Medical Records Briefing (MRB) recently asked HIM, clinical documentation improvement (CDI), and coding professionals about their ICD-10 implementation efforts for our first quarterly benchmarking survey of the year.
Many resources are available to aid and reassure HIM professionals as they embark on the journey to create a paperless environment at their organizations. The Healthcare Information Management Systems Society (HIMSS) Analytics EMR Adoption Model (EMRAM) is one such resource.
As we listen to the tick-tock of the clock, and we approach a pivotal year in healthcare that is sure to be full of impactful changes, I’ve put together a top 10 list of tasks to which you can devote that precious work time.
Q . Are HIPAA policies and training required regardless of the number of employees at a facility? For example, must a three-provider clinic provide HIPAA training?
To accurately interpret and code physician documentation, the HIM department must employ a quality clinical documentation improvement (CDI) program and an effective query process. Building upon these programs is integral to the success of the HIM department, especially where ICD-10 is concerned, said Deborah Lantz, RHIA, during HCPro's audio conference "Auditing Documentation for ICD-10: Steps to Take Now to Prepare Physicians and Staff." Lantz is the director of HIM at St. Charles Hospital in Port Jefferson, N.Y., and an AHIMA-certified ICD-10 trainer.
It's no secret that ICD-10-CM allows for more specific coding of many diseases and conditions. However, your physician's current clinical documentation may not have enough detail to allow coders to take advantage of this increased specificity.
