HIM Briefings

For many people, the new year brings the promise of a fresh start, which is one of the reasons why we often make New Year's resolutions. These resolutions date back to ancient Babylonian times, when people would make resolutions to gods during the vernal equinox. But for HIM professionals, a New Year's resolution often means establishing and abiding by organizational timelines, training your workforce, and updating technology.

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.

The release of CMS' 2014 inpatient prospective payment system (IPPS) final rule was a major game changer for hospitals. While you may be caught up in understanding and applying the 2-midnight rule for inpatient admissions, it's important to remember that the final rule also brings about significant changes to quality of care. We discussed these issues and their impact on the hospital landscape during HCPro's September 10 audio conference "2014 IPPS Final Rule Explained."

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.

The top finding in Joint Commission surveys for the first half of 2013 should be no surprise for HIM professionals. For the last three years, RC.01.01.01 has been No. 1 on the top 10 list of most frequently cited standards in Joint Commission surveys. The good news is that RC.01.01.01 is the only standard from the Record of Care, Treatment and Services (RC) chapter to make the list. The bad news is that this standard and some of its EPs will most likely continue to be a challenge.

Coding for sepsis is often easier said than done. Obstacles range from difficulty distinguishing between documentation for sepsis and related conditions to trouble with physician queries.

Editor's note: This is the first in a two-part series that analyzes the 2014 inpatient prospective payment system (IPPS) final rule. This month we discuss the final rule's impact on inpatient status criteria. We will address quality-of-care changes in the next issue of MRB.

Using a credentialed coder with computer-assisted coding (CAC) can ­increase coder productivity and lead to more accurate inpatient ­coding than ­using CAC alone, according to a study conducted by the AHIMA ­Foundation in collaboration with Cleveland Clinic and 3M Health ­Information Systems.

Time is of the essence. With less than a year until the ICD-10 deadline, there are many items that organizations need to cross off their checklists as we get ready to go live. Unfortunately, organizations aren't all in the same place when it comes to ICD-10 readiness.