HIM Briefings

Editor's note: The commentary in this article was originally presented in the HCPro, Inc., February 7 audio conference, "The Pediatric Medical Record: Opportunities for Documentation Improvement." Learn more about the audio conference at http://tinyurl.com/bbh9yl5.

At the Association of Clinical Documentation Improvement Specialists (ACDIS), questions on physician queries are never few and far between. Although AHIMA has published a couple briefs on the topic over the last decade, questions have still remained about how to implement a compliant and effective query process.

The Joint Commission recently introduced the Focused Standards Assessment (FSA) tool and the risk icon (R) to identify:

What better time to gauge HIPAA compliance than now with the January publishing of HHS' major HIPAA omnibus final rule.

If the October 1, 2014, implementation date for ICD-10-CM and ICD-10-PCS is not altered by the time this is published, there will be 18 months left until the transition.

In the world of computer-assisted coding (CAC), things can get super competitive.

HIM directors must revisit and potentially refine processes for patient record restriction requests and requests for electronic copies of medical records ­because of the HHS HIPAA omnibus final rule.

Everyone knows that CCs and MCCs are under scrutiny these days. However, that doesn't mean hospitals should err on the side of caution when reporting these conditions. William E. Haik, MD, FCCP, CDIP, director of DRG Review, Inc., in Fort Walton Beach, Fla., provides several tips that coders can employ to look for clinical evidence in the record before querying for these targeted conditions.