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HIM Connection

Keep up to date with weekly advice on issues such as coding and reimbursement, medical record documentation, Joint Commission IM standards, and more.

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HIM Connection

Issue 22, May 29, 2012

• CMS issuing National Coverage Determinations with ICD-10 translations

  CMS recently issued National Coverage Determination and Claims Manual transmittals on the coverage...

• Q&A: Coding for dry skin due to cold weather

  Q: Should I report ICD-9-CM code 701.1 (keratoderma, acquired) or 706.8 (other specified diseases...

• Privacy, security concerns high in HIEs

  A Boston resident is at a New York Yankees game in the Bronx cheering on his beloved Boston Red...

Issue 21, May 22, 2012

• OIG reports critique on CMS’ processes and programs

  In recent months there has been a number of Office of Inspector General (OIG) reports released that...

• Q&A: Acute respiratory failure diagnosis does not require intubation

  Q: Our pulmonologists are not comfortable documenting acute respiratory failure unless the patient...

• Convince leaders to invest their dollars to protect PHI

  Sure, you understand the value of investing in improvements that will better protect your...

• Continue ICD-10 preparations despite proposed delay

  CMS has proposed delaying ICD-10 implementation until October 1, 2014, but coders shouldn't delay...

Issue 20, May 15, 2012

• ONC releases privacy, security guide

  The Office of the National Coordinator for Health IT (ONC) released its “Guide to Privacy...

• Stage 2 Meaningful Use requirements: What you need to know

  If your hospital doesn't plan to take advantage of government financial incentives for those who...

• Stage 2 Meaningful Use requirements: What you need to know

  If your hospital doesn't plan to take advantage of government financial incentives for those who...

• TIP: Don't delay ICD-10 physician education

  CMS’ proposed year-long delay in ICD-10 compliance to October 1, 2014, shouldn't affect when...

• Nurse posts picture of athlete/patient on Facebook

  I have a friend who is a Facebook friend of a nurse in a hospital in another state. This nurse...

Issue 19, May 8, 2012

• Manage EHR access and audit controls

  HIPAA requires covered entities (CEs) to implement technical policies and procedures for...

• Identity theft case in South Carolina leads to heightened repercussions

  South Carolina government enforcement officials are cracking down on state agency security systems...

• HIPAA Q&A: PHI definition

  A hospital sends a patient a letter that includes the patient’s name and address, patient...

• Compliance stories from HCCA? Let us know!

  Editors here at HCPro, Inc., the company that distributes this e-newsletter, attended the Health...

Issue 18, May 1, 2012

• CMS issues IPPS proposed rule for FY 2013

  Inpatient acute care hospitals could see a 2.3% increase in payment rates under the fiscal year...

• Q&A: Sheet on patient's wall

  Q. A nurse in a skilled nursing facility asked if she could post a paper form called “Turn...

• Comply with CMS’ CoP for order authentication

  In November 2006, CMS published a final rule on the Conditions of Participation (CoP) for...

• TIP: Planning can maximize benefits of internal coding audits

  If you're going to spend time and resources to conduct a coding audit, you certainly want to...

Issue 17, April 24, 2012

• Data breach update: 780,000 affected in Utah data breach

  The Utah Department of Health (UDOH) released an update April 9 regarding a data breach caused by...

• Q&A: ICD-10-CM documentation

  Q. Can you please provide an example in which physicians must provide additional documentation so...

• Transitioning to an EHR: Three steps to consensus building

  2012 is upon us, and for many healthcare organization leaders, the ticking clock of healthcare...

• Tip: Conduct security risk analysis to comply with Stage 2 meaningful use

  Those wondering whether the proposed meaningful use Stage 2 measures would increase HIPAA...

Issue 16, April 17, 2012

• Code freeze to extend through ICD-10 implementation

  After HHS proposed a year-long delay of ICD-10-CM/PCS, questions emerged regarding the current...

• Q&A: Encryption levels

  Q. Can you please explain in an understandable way for nontechnical individuals what level of...

• Avoid burnout and ease stress: Strategies every HIM director and manager should know

  As you run down your mental to-do list for the rest of the afternoon, you realize you're...

• Take the 2012 HIM director and manager salary survey

  Medical Records Briefing is conducting its annual HIM Director and Manager salary survey, and we...

Issue 15, April 10, 2012

• Data breach in Utah compromises thousands of Medicaid claims

  The Utah Department of Technology Services (DTS) reported March 30 a patient information breach...

• Q&A: Deducting push time from infusions

  Q. If a nurse administers an IV push without a stop time at the same time hydration is running...

• Tip for engaging physicians

  Here is a tip that might provide some direction and insight into your physician engagement and...

• Identify potential Medicaid RAC target areas

  The Medicaid RAC program kicked off January 1, and experts say that although the program got off...

Issue 14, April 3, 2012

• HIPAA/HITECH final rules in the hands of the Office of Management & Budget

  OCR took the final step before publishing final rules on HIPAA/HITECH, sending its rules to the...

• Q&A: Using patient PHI in work force disciplinary procedures

  Q. A covered entity is required to impose sanctions against workforce members who violate the...

• Coders need to understand their role in the process

  Coding isn't just about reading documentation and selecting codes based on certain words. It's...

Issue 13, March 27, 2012

• Take the 2012 HIM director and manager salary survey

  Medical Records Briefing is conducting its annual HIM Director and Manager salary survey, and we...

• OIG examines CMS' CERT improper payment error rate estimations

  On March 9, the OIG published the report, “Review of CERT Errors Overturned Through the...

• Q&A: HIPAA privacy and HIV information

  Q: Must we keep HIV information separately in the medical record?

• Avoid burnout and ease stress: Strategies every HIM director and manager should know

  From researching and implementing EHR systems to developing training and education plans for...

• Strive for specificity now and in preparation for ICD-10

  ICD-10 will allow coders to report nonspecific, unspecified, or not otherwise specified (NOS...

Issue 12, March 20, 2012

• CMS targets April for release of new ICD-10-CM/PCS implementation date

  CMS expects to release a new ICD-10-CM/PCS implementation date sometime in April. That date will be...

• CMS delays HIPAA Version 5010 enforcement date--again

  CMS announced March 15 that it will not enforce the January 1, 2012 HIPAA Version 5010 compliance...

• Blue Cross Blue Shield of Tennessee reaches $1.5 million settlement over HIPAA breach

  HIPAA compliance 101—policies, training, monitoring, and risk assessments—may have...

• Q&A: Coding for pneumonia with malnutrition secondary to feeding difficulties of the elderly

  Q: A physician admitted a patient with pneumonia, which was the first diagnosis. The second...

Issue 11, March 13, 2012

• Submit comments on meaningful use Stage 2 proposed rules

  On March 7, the two proposed rules related to Stage 2 of the meaningful use program appeared in the...

• Q&A: Documentation for hydration

  QUESTION: We have a question in regards to hydration that we are trying to figure out. Does the...

• Stay on top of post-op pain coding

  ICD-9 guidelines indicate that coders should not report routine or expected postoperative pain that...

• Manage privacy, security, and mobile devices. Really.

  Mobile devices are here to stay-so now you have to manage the risks. "Hang on a minute,"...

Issue 10, March 6, 2012

• Revenue Cycle Institute releases '2011 Recovery Audit Benchmarking Report'

  The Revenue Cycle Institute has released a new white paper, “2011 Recovery Auditor...

• Q&A: HIM director access to colleague's medical records

  Q: Is it permissible for the HIM director to access the medical records of a colleague who is...

• Respond effectively to data breaches

  How your organization responds when breaches happen can make all the difference. If a breach...

• Know how inpatient coders can ensure compliance

  The three-day payment window requires hospitals to include the following information on inpatient...

Issue 9, February 28, 2012

• Stage 2 meaningful use requirements announced by CMS

  HHS Secretary Kathleen Sebelius announced the proposed Stage 2 meaningful use requirements for...

• Q&A: Compliant coding for hospital-owned freestanding clinics

  Q: I’ve heard that freestanding clinics that are wholly owned or operated by a hospital must...

• Ensure quality data through administrative monitoring

  Monitoring administrative and clerical errors can help ensure that the medical record contains...

• Latest study shows major increase in data breaches

  If you thought the healthcare industry was doing a better job protecting patients' PHI, think...

Issue 8, February 21, 2012

• HHS confirms ICD-10 delay: What does it mean for you?

  It’s no longer a mere possibility; HHS has confirmed its intent to delay the ICD-10...

• Q&A: Cameras in patient rooms

  Q: The nursing department in my facility wants to install cameras in a few of the patient rooms. It...

• Ensure proper inpatient coding of outpatient services

  Although it may seem counterintuitive, inpatient coders need to be aware of certain outpatient...

• Take note of second-generation tracers

  Normal 0 false false false EN-US X-NONE X-NONE...

Issue 7, February 14, 2012

• CMS posts year-end improper payment figures, top issues by region

  On February 9, CMS posted its latest recovery auditor update. The results show a continuing trend...

• Q&A: Compliant coding for kidney disease secondary to malignant hypertension

  Q: A patient presents with end-stage renal disease and chronic kidney disease secondary to...

• Understand ICD-10-CM excludes notes

  ICD-9-CM incorporates only one type of excludes note—which, confusingly, can mean two...

• A tight time frame for compliance audits

  When Mac McMillan, CISSP, CEO of CynergisTek in Austin, TX, picked up the phone recently, he had a...

• JustCoding Virtual Summit offers AAPC, AHIMA, CCDS credits

  We are now offering up to 12 AAPC, 12 AHIMA, and 12 CCDS credits for attendees of the JustCoding...

Issue 6, February 7, 2012

• CMS announces potential start date for recovery auditor prepayment review demonstration

  On November 15, 2011, CMS unveiled three demonstration projects aimed at reducing improper payments...

• Top 10 reasons to attend the JustCoding Virtual Summit: ICD-10-CM and ICD-10-PCS

  Here are the top 10 reasons you should attend the JustCoding Virtual Summit: ICD-10-CM and...

• Q&A: Incidental disclosures and patient privacy

  Q: Our phlebotomy area has two drawing chairs and is divided by a curtain. Is it a HIPAA violation...

• Know how pain justifies medical necessity

  Generally speaking, coders are taught not to code signs and symptoms that are integral to a disease...

• Reinvigorate EHR quality monitors for the new year

  HIM directors must renew efforts in the new year to ensure the effectiveness of EHR quality...

Issue 5, January 31, 2012

• Meaningful use appeals process guidance released

  The CMS Office of Clinical Standards and Quality (OCSQ) introduced a new appeals process, last...

• LAST CHANCE to participate in our 2012 Scanning Productivity Benchmarking Survey

  Dear reader, Medical Records Briefing is conducting a benchmarking survey on scanning productivity...

• Q&A: Documentation for admitting a newly discharged patient

  Q: A patient is discharged from our hospital so he can be transferred by helicopter to another...

• DESIGN an effective HIM department

  Elizabeth Layman, PhD, RHIA, CCS, FAHIMA, professor in the Department of Health Services and...

• How to improve your privacy and security training program

  It's 2012, and that means it's time to make some resolutions to kick off the new year. "This...

Issue 4, January 24, 2012

• Participate in our 2012 Scanning Productivity Benchmarking Survey

  Dear reader, Medical Records Briefing is conducting a benchmarking survey on scanning...

• Congratulations to our MRB contest winner!

  Carolyn Taggett, RHIT, director of health information services at Northern Maine Medical Center in...

• Q&A: Tracking e-mails with PHI

  Q: The draft accounting of disclosures rule may require tracking e-mails sent between healthcare...

• Be aware of cloned documentation

  In addition to confirming the validity of diagnoses, RACs and other auditors are reviewing...

• Apply a risk analysis to an EHR environment: It's not just HIPAA and meaningful use

  The death of an infant at an Illinois hospital made national news in June 2011. Genesis Burkett...

Issue 3, January 17, 2012

• JustCoding Virtual Summit: ICD-10-CM and ICD-10-PCS

  Get three days of ICD-10 training without the travel. This online event, February 29-March 2, 2012...

• Q&A: Querying for acute confusion

  Q: Can a patient have encephalopathy after surgery? For example, a patient post-surgery becomes...

• HIM role in quality initiatives

  Quality initiatives are here to stay, and there are new ones popping up all the time. Ignoring them...

• Bundled payment plan aims to improve care, lower costs

  Hospitals have long lamented the difficulty of obtaining physician buy-in for various quality...

Issue 2, January 10, 2012

• Expansion of the multiple procedure payment reduction

  CMS plans to expand the Multiple Procedure Payment Reduction (MPPR) for 2012. While the increase is...

• Q&A: Potential PHI breach from found medical records

  Q We found medical records about one of our patients in our parking lot. Is this a breach? What...

• Focus on DRGs with one MCC

  Coders must pay close attention to records that include only one MCC, says Glenn Krauss, BBA, RHIA...

• Survey shows many organizations experience HIPAA breaches, remain unprepared for an audit

  At the start of 2012, the healthcare industry still has a long way to go when it comes to the state...

Issue 1, January 3, 2012

• CMS releases details of recovery auditor prepayment review demonstration

  On November 15, CMS announced that it will launch a number of demonstration programs that are set...

• CMS to delay two out of three new demonstration projects aimed at reducing improper payments

  On December 29, CMS issued a notice announcing the delay of the recovery audit prepayment review...

• Q&A: Reporting new ICD-9-CM code V40.31

  Q. When may we report new ICD-9-CM code V40.31 (wandering in diseases classified elsewhere)? This...

• Make use of technology to help spot inappropriate record access

  Build triggers into your electronic system to identify aberrant and atypical user behavior, said...

• Manage the changing nature of HIM jobs

  Times are changing, and, most likely, so are the jobs of your HIM staff members. In some cases...

Issue 18, May 21, 2012

• OCR begins HIPAA compliance audits

  Mac McMillan, CISSM, has an insider’s look at what it’s like to undergo a HIPAA...