Many organizations develop physician documentation tip sheets based on the clinical topics appropriate to their specific facility. Some handouts are a simple piece of paper developed by a clinical documentation improvement team, whereas others are laminated, elaborately formatted cards from consulting companies distributed as part of the initial implementation program. Several samples donated by members of the Association of Clinical Documentation Improvement Specialists (ACDIS) are available on its website at www.hcpro.com/acdis. (See p. 11 for a sample.)
“In my opinion, [ICD-10 implementation] is the biggest change in healthcare since the implementation of DRGs back in the early ’80s,” said Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, director of HIM and coding at HCPro, Inc., in Danvers, MA. McCall and Lolita M. Jones, RHIA, CCS, independent consultant in Fort Washington, MD, spoke during HCPro’s November 18 audio conference, “ICD-10-PCS Surgery Coding: Understand and Apply Five Medical Surgical Root Operations.”
The last thing you need is more to do, but when it comes to preparing your HIM department for EHR go-live, an ounce of prevention is worth a pound of cure.
Many of the nation’s hospitals now have clinical documentation improvement (CDI), management, or integrity programs. They are designed to help physicians improve the documentation of diagnostic or procedural information in inpatient medical records so that the documentation meets the needs of the coding process. There are good things that can come out of these programs, but there can also be bad things.
HIPAA privacy officers don’t have eyes in the back of their heads. Nor can they be everywhere at once. But they can increase their ability to monitor compliance by sharing the responsibility with other staff members.
The frequency of CMS surveys seems to be on the rise. With that in mind, I thought I would address three of the top medical record concerns that might plague you if CMS comes knocking on your HIM department’s door. We have covered these in past columns, but it never hurts to take another look at the big three: verbal orders, history and physical reports (H&P), and post-anesthesia evaluation.
