*Balancing privacy and accessibility
*When are written orders necessary for radiologic services?
*Beware: New compliance hot spot

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Compliance Hot Topics: Billing and Coding, EMTALA, Stark, HIPAA

Question of the Week

Welcome to Compliance Monitor Q&A!

Our mission is to answer your difficult compliance questions-and your simple ones, too. To submit a question, send it to Compliance Monitor Q & A editor Kate Alvarez at kalvarez@hcpro.com. We hope you enjoy this service and we welcome your feedback.

This week's questions

• Balancing privacy and accessibility
• When are written orders necessary for radiologic services?

• Beware: New compliance hot spot

• How does your organization handle patient financial issues?

Q: In a clinical area, is it acceptable to keep medical records in a closed cabinet or does the Health Insurance Portability and Accountability Act (HIPAA) require charts to be under lock and key at all times?

A: HIPAA requires "reasonable safeguards" to protect the privacy of health information, but guidance on this regulation specifically states that it is not intended to place undue burden on the patient care process. Charts can remain accessible and unhidden without revealing patients' records. They can be in a rack on or beside the exam room door or left at a nursing station, but should remain closed or covered except when in use. Caregivers should use low voices and avoid using the patient's name when discussing a medical record. They can also call patients from the waiting area by name and use sign-in sheets, provided there is no request for information on the purpose of the visit.

Of course, certain types of disclosures may take place: others in the waiting room will hear names called, catch a glance of the sign-in sheet or a chart, or overhear a conversation about a patient as they walk down the hall. Provided that reasonable safeguards are in place, the Department of Health and Human Services has stated specifically that these types of disclosures are "incidental," and therefore not violations.

This question was answered by Marion Neal, President of HIPAASimple.com.

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Click here to take our quick survey on your financial policies and procedures!

Improving outpatient documentation

Did you know that four types of encounters account for over 90% of the facility-based outpatient visits? If your facility is busy with emergency department, diagnostic testing, ambulatory surgery, and observation visits, there are plenty of opportunities to miss appropriate reimbursement due to documentation errors, not to mention chances to fail to meet compliance standards.

You need the new book, "Guide to Outpatient Clinical Documentation Improvement: The First Step in Revenue Cycle Management" by Ruthann Russo, JD, MPH, RHIT.

For more information, CLICK HERE and save 10% when you order on line. You may also call our Customer Service Team at 800-650-6787. Please mention source code EB23108A when you call.

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JOIN THE COMPLIANCE MONITOR TEAM!

Are you a compliance expert? We're looking for compliance experts in coding, billing, documentation, HIPAA, EMTALA, Stark, laboratories, and many other areas of compliance. If you are interested in answering questions from your peers, please e-mail Compliance Monitor editor Kate Alvarez.

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To find out how to bill appropriately using the 21 new diagnosis-related groups, order the pay-per-view article "Beware: New compliance hot spot." The cost is $10. Subscribers to the online Briefings on Coding Compliance Strategies have free access to this article. Subscribers to the printe edition can find it in their September issues.

A $30 Steal!
You can read this article--and much more--in the September issue of Briefings on Coding Compliance Strategies. Your cost: Five stories for only $30! You'll also learn about training requirements for the new ICD-9 diagnosis codes, accurate stroke coding without costly work-ups, understanding anatomy that can cause coding errors, as well as coding Q&A.

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IMPROVE REIMBURSEMENT AND DOCUMENTATION

Get an EASY, STEP-BY-STEP KIT to increase medical records accuracy; improve reimbursement, reduce staff work time; and get all physicians, clinical staff, HIM personnel, and administrators on the same page with documentation improvement to comply with Medicare and other federal regulations.

Order the CDI (CLINICAL DOCUMENTATION IMPROVEMENT) SYSTEM FOR INPATIENT CARE(TM). Just call HCPro's customer service at 1 (800) 650-6787 (please mention source code EB22607B) or click here.

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A: To read the answer to this question, click here.

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To submit your answer, go to the Question of the Week at Complianceinfo.com.

Here are the answers to the last survey:

When will your organization begin auditing its HIPAA compliance program?

• Within the next six months: 68%
• In 7-12 months: 17%
• In 12+ months: 9%
• We do not plan to audit: 6%

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Network with your audit colleagues

"Audit Talk" is a new, moderated chat forum that members can use to post messages or questions for their peers 24-hours-a-day. "Audit Talk" offers a free forum to network, share ideas, and solve problems for those in the audit industry. Getting involved is easy. To subscribe, just send your request to this e-mail: owner-audit_talk@hcpro.com.

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Send your comments and questions about Compliance Monitor Q&A to:

Kate Alvarez
Editorial Assistant
kalvarez@hcpro.com