HIM Briefings

More than ever before, HIM is being recognized as an enterprise profession important to ambulatory, acute, and postacute settings. A good example of the transformation is HIM's involvement in CMS' risk adjustment and Hierarchical Condition Category coding system.

While it can be challenging to define your organization's legal health record (LHR), one health system in Denver is proving that collaboration and perseverance can lead to an effective LHR and EHR.

Coding and documentation should tell a patient's complete story. With the greater specificity in ICD-10, organizations should be better able to capture these stories, and the respiratory codes, listed in Chapter 10: Diseases of the Respiratory System (J00?J99), are no exception.

Q: If someone calls a facility to schedule an appointment for a patient, is it a violation of HIPAA to admit the patient receives care at the practice? For example, the practice where I work often helps victims of domestic abuse.

The new ICD-10 implementation date is less than a year away, and CMS is gearing up its end-to-end testing process in preparation.

Although numerous privacy and security laws apply to healthcare entities, HIPAA rules and requirements tend to receive the most emphasis?and generate the most angst. The terms HIPAA-compliant vendor, HIPAA cop, and HIPAA disciplinary action are anathema to experienced and serious privacy and information security professionals. HIPAA, as has been noted, represents the floor of requirements intended to protect the privacy and security of patient information. More stringent privacy requirements have existed at the state and national levels for several years before the HIPAA Privacy Rule was implemented (e.g., state medical records laws and requirements). Notably, many organizations implement policies and procedures that are more stringent than that required by HIPAA. Some of this is due to misinformation or misunderstanding of the HIPAA rules.

With so much information available online, it has become common for professionals to use social media to network and conduct job searches.

The CMS EHR Incentive Program 2014 attestation deadlines for Medicare-eligible hospitals and professionals draw near (November 30 and December 31, respectively), so MRB asked healthcare professionals to reflect upon their successes and struggles associated with EHR implementation for benchmark survey.

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