HIM Briefings

HIM professionals are at the center of a shift from a paper-based to an electronic healthcare environment. As healthcare organizations work toward Meaningful Use attestation, there are standards that can help HIM professionals ensure that their electronic records are interoperable.

Even before ICD-10-CM was delayed until October 1, 2015, the quality of physician documentation to accommodate the new code set was a top concern for the healthcare industry.

Do your coders ever feel as if they work more hours than most coders? Or perhaps they think their compensation is lower than other coders across the country? Have you ever wondered how your coders compare to the average coder?

Q: I work in long-term care and I am familiar with the language in HIPAA regulations regarding requests for electronic copies of medical records for a reasonable fee according to community standards. However, my company does not maintain its medical records in electronic form, nor do we presently have the capability of converting our paper records into electronic format. Our state legislature addressed the issue of "reasonable charges and community standards" by state statute in 2006 by providing a formula for every medical provider to follow state-wide for copy charges regarding paper copies.

The ICD-10 delay forced many healthcare organizations to rethink their ICD-10 staffing and implementation plans. Baptist Health System in Birmingham, Alabama, devised a plan to prepare for the one-year delay of ICD-10 by revising its budget and relying on new graduates to fill coder positions.

In a concerted effort to move healthcare payments to a system of "quality over quantity," CMS finalized policies that greatly expanded packaging for outpatient providers in the 2015 OPPS final rule (www.gpo.gov/fdsys/pkg/FR-2014-11-10/pdf/2014-26146.pdf). It also introduced complexity adjustments with comprehensive ambulatory payment classifications (C-APCs).

CMS designates certain procedures as inpatient-only and identifies them using CPT codes. Hospitals normally only use CPT codes for outpatient coding, so this may be confusing for coders who use ICD-9-CM Volume 3 codes for inpatient procedures. Coders need to know which procedures are on the inpatient-only list to monitor compliance with this rule as they apply inpatient procedure codes.

Many hospitals and health systems include computer-assisted coding (CAC) systems as a strategic tool in their plan for ICD-10. CAC software is considered an antidote to the significant decrease in coder productivity anticipated with ICD-10.