In ICD-10-CM, defining, diagnosing, and documenting the various forms of altered mental status and their underlying causes remains an ongoing challenge for physicians and their facilities.
Accurate clinical documentation is the bedrock of the legal medical record, billing, and coding. It is also the most complex and vulnerable part of the revenue cycle.
When it comes to dealing with Medicare Recovery Auditors (RACs), there is never a dull moment for HIM professionals. Any shift in the RAC program quickly emerges as front-page news for HIM leaders.
Reimbursement for provider-based departments (PBD) can be complex, and regulations affecting it have changed frequently over the past year. Section 603 of the Bipartisan Budget Act of 2015, the 2017 outpatient prospective payment system (OPPS) final rule, and the 21st Century Cures Act changed the payment methodology and made multiple adjustments to the definition of excepted (on-campus or grandfathered off-campus) and non-excepted (off-campus) PBDs. Hospitals must know the regulations inside and out and understand how they apply to their PBDs and to avoid denials or noncompliance.
Regulatory compliance reforms have forced CMS to set the bar high for meeting evaluation and management (E/M) standards. This is especially true for clinical documentation improvement (CDI) performance for coding and billing level four and five patient visits in outpatient settings.
Data integrity and analytics, increased HIPAA enforcement, patient-generated health data, and information security emerged as the top four topics at the 2017 Health Information and Management Systems Society national conference.
Effective July 2016, as part of The Joint Commission’s Project REFRESH, the Medical Record Statistics form was retired for hospital accreditation surveys. Is it still important to monitor our medical records for presence, timeliness, legibility (paper or printed), accuracy, authentication, and completeness?
Payment reform is here to stay. Although reimbursement will continue to evolve over the next several years, it’s unlikely that payers, commercial or government, are going to abandon risk-based models and value-based purchasing and turn the clock back to fee-for-service and volume over value.
HIM Briefings’ 2017 EHR benchmark survey took a closer look at EHR implementation and use as well as the role of HIM in EHR management, including common challenges and benefits. Respondents shared experiences, discussed the impact of EHRs on data quality and security, and reflected on HIM’s role in ongoing EHR maintenance.
How we define, diagnose, and document diagnoses that predict morbidity and mortality is essential if we want our patient’s risk to be accurately portrayed.
