I have recently heard questions and discussion about the use of abbreviations within the medical record. With that in mind, this quarter's Joint Commission column will outline the requirements for abbreviations and provide guidance regarding the pros and cons of expanding the limited "do-not-use" list
Perhaps it's because I reside in Chicago?home of both Oprah Winfrey and the American Health Information Management Association?but lately I have been thinking about "aha moments" for HIM professionals.
CMS' fiscal year 2015 IPPS final rule focuses on quality initiatives mandated by the Affordable Care Act, including updates to the Hospital Value-Based Purchasing Program, the Hospital Readmissions Reduction Program, and the Hospital-Acquired Condition Reduction Program. This quality focus creates a need for increased interdisciplinary collaboration across quality, HIM, risk management, revenue cycle, compliance, and technology.
There has been a fair amount of coverage on the documentation requirements needed to assign ICD-10-CM diagnosis codes. While changes in documentation requirements for pregnancy, coma, diabetes, fractures, and pressure ulcers are frequently cited, less information is available regarding the documentation requirements for procedures.
A team of researchers may have uncovered what many involved in the transition to ICD-10 have feared all along: Disruption of data and financials is on the horizon.
CMS' 2014 IPPS final rule redefined inpatient admissions when it implemented the 2-midnight rule, which requires a validated physician order, documentation of medical necessity, and the expectation of a stay crossing two or more midnights.
Q: Are there any penalties for sending an unencrypted email containing PHI to the intended recipient? Would this just be a violation of the CE's policy and not a privacy breach under HITECH?
The HIPAA Security Rule requires implementing risk management tools and techniques to adequately and effectively safeguard ePHI. Risk analysis and management provides the foundation for an organization's Security Rule compliance efforts, and reinforces its strategy to protect the confidentiality, integrity, and availability of vital information.
