In what was perhaps an effort to remind providers to consider medical record retention as they move to EHRs, CMS released MLN Matters SE1022, which addresses medical record retention limits and media formats.
With the end of the year approaching, you, along with many of your HIM director and manager colleagues, may soon be tasked with conducting annual staff evaluations. Chances are it isn’t your favorite task of the year. But it needs to be done.
You receive a RAC demand letter for repayment. But wait a minute before you pay up—you might want to take a close look to make sure your facility was really in the wrong. Karen Sagen, managed care leader at Bellin Health System in Green Bay, WI, who has worked in revenue cycle management for the past six years, has developed a step-by-step list of things to consider before pulling out your hospital’s checkbook.
It’s the end of the year, and many of us have been on the fast track to EHRs and EDMS installation, so we pause this month for a little levity and to honor all those working so hard behind the scenes. Happy holidays to all the brave health information professionals continuing to blaze the paths of progress in automated medical record documentation!
We went to medical school. We studied, and many of us learned about pathogenesis of diseases. We were encouraged by our attendings and throttled by our chief residents to be able to spout off the causes of conditions. It wasn’t enough to name the condition; we had to know the myriad possible etiologies. Being quizzed made us sharp. We started to learn patterns and became better diagnosticians because we could digest the complexities of a patient while we did the history and physical. And we knew, even before lab tests came back, what was going on with the patient and how it got there.
Present-on-admission (POA) indicators, hospital-acquired conditions (HAC), and never events have been around for a while. However, they still seem to cause compliance conundrums, says Shannon McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CCDS, director of HIM and coding at HCPro, Inc., in Marblehead, MA.
