HIM Briefings

I first attended a lecture on the "upcoming" ICD-10 changes that were expected in 1991 (when the rest of the world started transitioning). On October 1, 2015, a mere 24 years and countless lectures later, the U.S. finally adopted ICD-10 (via ICD-10-CM and PCS, which are both unique to the U.S. at this time). 

Q: What is the recommendation for retaining hard copies of medical records once they have been transferred to an EMR system?

A: This varies quite a bit depending on your storage capabilities and state retention laws. I am aware of some organizations that keep these records for 3?6 years (until the statute of limitations has run out), but this is a very conservative approach. I have also seen six months and one month. I would suggest ensuring you have a rigorous scanning quality control process to reassure yourself that you in fact have the scanned documents and they are readable. I would recommend that you keep the hard copies for at least one month after scanning. You might also want to consult legal counsel on this matter.

Editor's note: Simons, director of health information and privacy officer at Maine General Medical Center in Augusta, answered these questions. She is also a HIM Briefings advisory board member. This information does not constitute legal advice. Consult legal counsel for answers to specific privacy and security questions. Send your questions related to HIPAA compliance to Editor Jaclyn Fitzgerald at jfitzgerald@hcpro.com.

CMS and the Office of the National Coordinator (ONC) released final rules October 6 with the intention of simplifying EHR requirements and allowing providers and consumers to exchange health information with greater flexibility. This includes the final rule with comment period for the EHR incentive programs and final rule for the 2015 edition health IT certification criteria.

Regulations adopted in October 2013 allow hospitals to bill Part B for inpatient cases that are internally reviewed and "self-denied" within one year of the date of service. But utilization review staff are unsure when to use the old condition code 44 process and when to opt for the new process using condition code W2. Operationalizing these rules can prove to be challenging, causing recoding, rebilling, and expensive slowdowns in the revenue cycle.

Physicians are constantly reminded that healthcare is undergoing significant change. October 2015 marked one more landmark change: the shift to ICD-10. Many physicians have worried about the transition and likely dreaded the loss of familiar terms, efficiency, or income. How can coders, HIM professionals, or clinical documentation improvement (CDI) specialists engage with physicians to help them now that ICD-10 has been implemented? Let's explore some strategies.

With the transition to ICD-10, some documentation issues have required the capture of new information while others involve updated, modified, and otherwise expanded documentation needs. As we gain experience with ICD-10 and more questions are answered, physicians, coding professionals, and other clinical staff must continue training in clinical documentation improvement (CDI) and ICD-10. Now comes the hard work: ensuring consistency and reliability of ICD-10 coded accounts and the analytics that will be the outcome of ICD-10 data.

The utilization review (UR) process is a required process to determine if the care a physician provides the patient is medically necessary and reimbursable by the payer source. While the exact definition of medical necessity varies amongst insurers and government agencies, section 1862 (a)(1)(a) of the Social Security Act provides the basic groundwork, stating, "Notwithstanding any other provisions of this tile, no payment may be made … for any expenses incurred for items or services, which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member."

After several delays, ICD-10 implementation is finally upon us. The healthcare industry has spent years planning, training, and testing?and now the moment we have all been waiting for has arrived. But don't breathe a sigh of relief just yet.