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.
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?
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.
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.
Although HIM professionals do not treat or diagnose patients, their role in managing all the moving parts in a healthcare organization affects overall quality of care.
Revenue cycle leaders, including HIM professionals, are aware that a patient billing or collection problem can destroy what had up to that point been an exceptionally positive clinical experience. With the ever-expanding reach of social media, a patient who is dissatisfied with a billing or collection problem may be more likely to share that problem with others rather than sharing private details about clinical problems.
In 2008, only 11% of respondents to an Association of Clinical Documentation Improvement Specialists (ACDIS) poll indicated their clinical documentation improvement (CDI) programs either reviewed outpatient records for documentation improvement opportunities or were looking to expand into outpatient areas (8% and 3% respectively).
