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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 51, December 30, 2008

• Understand how the new Advance Beneficiary Notice will affect patient access and clinical department staff members

  On March 3, 2008, CMS released a new Advance Beneficiary Notice (ABN) of Noncoverage (ABN-R-131...

• Coding oxygen therapy

  Q: I am new to the inpatient coding world and looking for information about when to code oxygen...

• Form a discovery response team to effectively implement legal holds

  The first step in creating a legal hold plan is the formation of a discovery response team.

Issue 50, December 23, 2008

• Revenue Cycle Institute releases new, updated white papers

  The Revenue Cycle Institute announces new and updated white papers available for download.

• What are the costs of release of information?

  Ask the expert: What are the costs of release of information?

• Target these RAC focus areas

  Kathy M. Johnson, RHIA, director of coding services at Care Communications in Chicago, says the RAC...

• Honeypots--A sweet tool you can use to monitor snooping staff members

  It doesn’t matter whether a staff member peeks at the medical record of Tiger Woods, John...

Issue 49, December 16, 2008

• Joint Commission Sentinel Event Alert addresses technology-related healthcare errors

  Computerized provider order entry and EHRs are just two of the many technologies that could lead to...

• Coding a sprained ankle

  Q: A patient is walking quickly on an icy, unsalted sidewalk so she doesn’t miss her bus. The...

• Read Joint Commission report about 'hospitals of the future'

  On November 20, The Joint Commission issued a report, "Health Care at the Crossroads: Guiding...

• Work with physicians to obtain clear-cut documentation for pressure ulcers

  Applying present-on-admission (POA) indicators to pressure ulcers is no easy task. Coders often...

Issue 48, December 9, 2008

• Understand payment implications of the POA indicator

  In Medlearn Matters SE0841, CMS outlines payment implications for each of the present on admission...

• Certifying records when outsourcing the ROI function

  Q: We outsource our release of information (ROI) function. The company that we use scans the...

• Read new Joint Commission FAQ regarding acceptable abbreviations

  The Joint Commission posted an FAQ November 24 that pertains to acceptable abbreviations

• AHIMA's final query practice brief reflects growing CDI efforts

  On September 29, AHIMA published "Managing an Effective Query Process," which continues...

Issue 47, December 2, 2008

• CCHIT announces new certified inpatient EHR product

  In a November 12 press release, the Certification Commission for Health Information Technology...

• Diagnosis code for rejection of a kidney transplant

  Q: A physician admits a patient for rejection of a kidney transplant the physician performed four...

• Know what to expect as your FI or carrier transitions to a MAC

  On November 12, CMS released Special Edition Medlearn Matters article SE0837 to assist providers...

• AHIMA's final query practice brief reflects growing CDI efforts

  Coders and others who perform queries have waited seven years for AHIMA to update its 2001 practice...

Issue 46, November 25, 2008

• CMS selects PHR vendors for pilot program in Arizona, Utah

  CMS announced the four personal health record (PHR) vendors it has chosen to participate in the...

• Where can I find the medical record delinquency form on The Joint Commission Web site?

  Ask the expert: Where can I find the medical record delinquency form on The Joint Commission Web...

• Review new CITL publication on the value of PHRs

  On November 12, the Center for Information Technology Leadership (CITL) released a 144-page...

• Discipline with the intent to educate when responding to HIPAA violations to minimize future incidents

  Despite the thoroughness of your policies and procedures, the effectiveness of your training, and...

Issue 45, November 18, 2008

• Understand RAC medical record request limitations

  Regardless of the fact that CMS announced November 3 that it would delay all recovery audit...

• Assigning a POA indicator for pressure ulcers that progress from one stage to the next during a hospital stay

  Q: What present on admission (POA) indicator should we assign when a patient presents to the...

• Consider AHA-endorsed tools to protect against medical identity theft

  The American Hospital Association (AHA) announced in a November 4 press release that it has...

• One-day stays--Evaluate your Medicare admits and denials before RAC reviewers do

  Forty percent of Medicare admission denials relate to improper one-day stays.

Issue 44, November 11, 2008

• MRB benchmarking survey: Personal health records

  We want your input! MRB is gathering data on implementation of personal health records and...

• CMS delays RAC permanent program

  CMS announced on November 3 that it has delayed the Medicare Recovery Audit Contractor (RAC...

• May we use standing orders for drugs and biologicals?

  Ask the expert: May we use standing orders for drugs and biologicals?

• Protect ePHI in light of new OIG report

  The Office of Inspector General (OIG) issued a final report October 27 reviewing CMS’ HIPAA...

• Flag identity theft as federal rule takes effect

  Although identity theft is often associated with exploited credit cards, patients can also be...

Issue 43, November 4, 2008

• AHIMA urges HHS to delay ICD-10 implementation until 2012

  In a letter to Michael Leavitt, secretary of the U.S. Department of Health and Human Services...

• What steps must we follow when disciplining employees involved in a privacy breach?

  Ask the expert: What steps must we follow when disciplining employees involved in a privacy breach?

• Use AHA sample policy to jump start compliance with red flag rules

  On October 24 the American Hospital Association (AHA) published a sample policy hospitals can use...

• Examine postoperative condition coding and don't assume complications

  Just because a physician documents a condition during the postoperative period doesn’t mean...

Issue 42, October 28, 2008

• Topic: Consider federal, state, and healthcare facility requirements when determining record retention timeframe

  When contemplating a record retention timeframe, you must understand federal, state, and facility...

• Ask the expert: Assigning ICD-9 codes for pressure ulcers that progress from one stage to another

  Q: An admitting physician in an acute care facility documents that a patient has a pressure ulcer...

• Tip of the week: Help your facility maintain compliance with the red flag medical identity theft rules

  The American Hospital Association (AHA) hosted two audio conferences—on October 7 and October...

• PPV: Understand the details of personal health records to serve as a valuable patient resource

  This scenario is becoming increasingly common: A patient presents to the HIM department and...

Issue 41, October 21, 2008

• Topic: National e-prescribing conference sparks conversation on healthcare delivery improvement

  More than 1,400 healthcare professionals and industry leaders convened earlier this month in Boston...

• Ask the expert: Where can I find more information about HIEs?

  Ask the expert: Where can I find more information about HIEs?

• Tip of the week: Revisit query forms in light of AHIMA final physician query practice brief

  The American Health Information Management Association (AHIMA) on Sept. 29 released its...

• PPV: Keep your staff members' e-mail private and secure

  In an era of instant connectivity, many physicians find that sending PHI and other confidential...

Issue 40, October 14, 2008

• Topic: CMS announces permanent RACs, increases estimate of appeals

  In an October 6 press release, CMS announced four permanent national recovery audit contractors...

• Ask the expert: A physician diagnoses a patient with ventilator-associated pneumonia (VAP) caused by pseudomonas aeruginosa. What ICD-9-CM diagnosis code should I report?

  Ask the expert: A physician diagnoses a patient with ventilator-associated pneumonia (VAP) caused...

• Tip of the week: Familiarize yourself with the new CMS-approved hospital accreditation program

  Hospitals now have three options to receive accreditation to participate in Medicare and Medicaid...

• PPV: Avoid the trap of probable diagnoses

  Most inpatient coders are accustomed to seeing "probable," "suspected,"...

Issue 39, October 7, 2008

• Topic: Flag identity theft before federal rule takes effect

  Effective November 1, hospitals must have a plan in place to detect, mitigate, and prevent red...

• Ask the expert: Can the physicians in our hospital use rubber stamp signatures?

  Ask the expert: Can the physicians in our hospital use rubber stamp signatures?

• Tip of the week: Use CMS resources to brush up on ICD-10

  Not sure where to turn to begin an ICD-10 implementation? Start with the special edition Medlearn...

• PPV: Develop a plan for system downtime, slowness, and glitches

  "The system is down" are four words no HIM director ever wants to hear. But system...

Issue 38, September 30, 2008

• Topic: CCHIT launches certification program for HIEs

  On October 1, the Certification Commission for Healthcare Information Technology (CCHIT) will...

• Ask the expert: New HIPAA resources

  Ask the expert: Where can I find a resource that explains when a provider may share a...

• Tip of the week: Brush up on PHRs by listening to free CCHIT town hall teleconference

  CCHIT will host a special free town hall teleconference on October 10 at 4 p.m. ET that will...

• PPV: Minimize mistakes when responding to the media

  It doesn’t matter whether your facility is located in the largest U.S. metropolitan area or a...

Issue 37, September 23, 2008

• Topic: CMS revises timeline for national RAC rollout

  CMS announced a revised timeline for the national rollout of the recovery audit contractor (RAC...

• Ask the expert: Application of condition code 44

  Q: It is my understanding that we should apply condition code 44 when the physician does not agree...

• Tip of the week: Learn from your mistakes during a CMS survey

  Think you have no control when a CMS surveyor is conducting an onsite survey? Think again. Surveys...

• PPV: Ensure your place at the EHR decision-making table

  There are leaders and there are followers. And during the labor-intensive process of an EHR...

Issue 36, September 16, 2008

• Topic: Consider these pointers when rolling out a clinical documentation improvement educational session

  When rolling out a documentation improvement education plan, perform a baseline assessment to...

• Ask the expert: Can a healthcare provider release protected health information to the media?

  Patients may release any protected health information (PHI) they choose. But written patient...

• Tip of the week: Encourage coders to research causes of secondary diabetes

  Effective October 1, coders will be able to report a code from the 249 category to denote secondary...

• PPV: Avoid inappropriate physician queries

  Since the implementation of Medicare Severity DRGs in October 2007, the volume of physician queries...

Issue 35, September 9, 2008

• Topic: Correct duplicate numbers before embarking on an EHR transition

  Correcting duplicate numbers should be an ongoing effort, but this task becomes increasingly...

• Ask the expert: May a provider who believes a patient may not be capable of driving due to a physical problem inform authorities?

  Ask the expert: May a provider who believes a patient may not be capable of driving due to a...

• Tip of the week: Advocate for a debriefing session subsequent to an EHR implementation

  Reviewing what did and did not go smoothly during an EHR implementation may seem like putting salt...

• PPV: Avoid the 'dirty little secret' in healthcare--Stop staff members from snooping

  Curiosity. Malice. Efficiency. Rivalry. To be helpful. To be hurtful. Because they have a brief...

Issue 34, September 2, 2008

• Topic: Consumers to gain greater insight into local hospital performance on enhanced Hospital Compare Web site

  If you want information on mortality measures for pneumonia or measures for hospital care of...

• Ask the expert: Where can I find more information on personal health records (PHR), specifically the new Medicare pilot program?

  Ask the expert: Where can I find more information on personal health records (PHR), specifically...

• Tip of the week: Have a physician advisor help your coders interpret clinical information

  A physician advisor can help coders interpret unique clinical aspects of cases.

• PPV: Avoid inappropriate physician queries

  Since the implementation of Medicare Severity DRGs in October 2007, the volume of physician queries...

Issue 33, August 26, 2008

• Topic: HHS proposed rule sets ICD-10-CM implementation date for October 1, 2011

  The United States will be one step closer to implementing ICD-10-CM if the Department of Health and...

• Ask the expert: When our hospital treats inmates from the local jail, may we provide information to jail officials if the patient is in custody?

  Ask the expert: When our hospital treats inmates from the local jail, may we provide information to...

• Tip of the week: Prepare physicians for detailed documentation requirements in 2009 by opening the lines of communication now

  There are several new codes that will take effect October 1 that will require physicians to provide...

• PPV: Salary survey reveals more responsibilities with little to no extra pay

  "Overworked and underpaid" is the lament of many HIM directors who participated in...

Issue 32, August 19, 2008

• Topic: Focus on documentation for new ICD-9-CM codes denoting secondary diabetes

  Some of the code sets that were finalized for 2009 could present particularly difficult...

• Ask the expert: Where can I find more information on hospital acquired conditions for FY 2009?

  Q: Where can I find more information on hospital acquired conditions for FY 2009?

• Tip of the week: Encourage coders to review the new ICD-9-CM Official Coding Guidelines that take effect October 1

  CMS released its new ICD-9-CM coding guidelines on August 6. The guidelines, which discuss...

• PPV: Keep DNFB low in light of MS-DRGs, POA

  Most HIM directors probably cringe when they think about their discharge-not-final-billed (DNFB...

Issue 31, August 12, 2008

• Topic: Understand how MCC capture affects reimbursement

  It is important that a physician document all relevant major complications/comorbidities (MCC) to...

• Ask the expert: Can you explain the role that coders play in educating physicians about the present on admission indicator?

  With their understanding of the present on admission (POA) guidelines as published in Coding Clinic...

• Tip of the week: Prepare for 2009 ICD-9-CM code changes for carcinoid tumors

  Prior to the release of the 2009 ICD-9-CM codes that will take effect October 1, codes for...

• PPV: See your privacy program through a new set of eyes: Hospital shares its unique approach to accounting of disclosures

  HIPAA didn’t come with a step-by-step guide that explains how to implement the privacy rule...

Issue 30, August 5, 2008

• Topic: CCHIT to launch PHR certification program in 2009

  The Certification Commission for Healthcare Information Technology (CCHIT) plans to certify...

• Ask the expert: Assigning a principal diagnosis code for patient with cholelithiasis and gallstone pancreatitis

  A physician diagnoses a patient with cholelithiasis with gallstone pancreatitis. Coding Clinic...

• Tip of the week: Draft policy that outlines how often staff members should change their passwords

  Changing your password is addressable under the HIPAA security rule. Your organization must perform...

• PPV: Presidential election casts uncertainty on HIPAA: HIT adoption, enforcement at stake

  The presidential election is still months away, and presumptive nominees John McCain and Barack...

• Joint Commission survey brings positive insight to hospital's policies and procedures

  When Joint Commission surveyors came to St. Luke’s Hospital in Chesterfield, MO, the morning...

Issue 29, July 29, 2008

• Topic: Providence Health & Services enters Resolution Agreement with HHS to settle potential HIPAA violations

  Seattle-based Providence Health & Services entered into a Resolution Agreement with the U.S...

• Ask the expert: Coding a wound due to a cat bite

  Q: How should I code the following scenario?   History: A 52-year-old female presents as a new...

• Tip of the week: Look for flexibility, adaptability when hiring a CDI specialist

  CMS publishes new regulations every year that take effect each October. Although the changes may be...

• PPV: Medical identity theft an increasing challenge: Educate your staff members to protect your patients and yourself

  It’s a hot topic everywhere—in television commercials, movies, and on the nightly news...

Issue 28, July 22, 2008

• HIM preparedness for Recovery Audit Contractors

  Recovery Audit Contractors will soon make their way into every state nationwide by 2010. We’d...

• Topic: RAC demonstration recoups $992.7 million in overpayments

  Medicare Recovery Audit Contractors (RAC) corrected more than $1 billion of Medicare improper...

• Ask the expert: Where can I find more information about CCHIT criteria for inpatient EHR products?

  The Certification Commission for Healthcare Information Technology (CCHIT) has published its 2008...

• Tip of the week: Ensure round-the-clock registry staff coverage to reduce backlogs

  Backlogs occur because understaffing makes it impossible to provide coverage when someone is out...

• PPV: The IPPS PC Pricer: Make the most of this helpful software

  Do you work in the finance department or business office at your facility? Are you part of a...

Issue 27, July 15, 2008

• Topic: 2009 Joint Commission standards revised for ease of use

  On July 1, The Joint Commission announced that it has revised its standards, rationales, and...

• HCPro provides analysis on 2009 OPPS/ASC proposed rule

  CMS released its 2009 OPPS/ASC proposed rule, and HCPro has spoken with several industry experts to...

• Ask the expert: Coding a side-to-side anastomosis

  Q: Should coders report side-to-side anastomosis as an end-to-end functional anastomosis...

• Tip of the week: Brush up on the newly released 2009 OPPS/ASC proposed rule

  CMS released its Outpatient Prospective Payment System (OPPS) and ambulatory surgery center (ASC...

• PPV: HIPAA and the modern blended, extended family

  Protecting patient information has always been challenging. But these days, it’s downright...

Issue 26, July 8, 2008

• HIM director salary survey

  Notice: If you haven’t already taken our annual HIM director salary survey, be sure to do so...

• Topic: New PHR framework to enhance public trust

  Several technology companies, healthcare providers, insurers, and consumers groups endorsed a...

• Ask the expert: Where can I find more information online about Recovery Audit Contractors (RACs)?

  Ask the expert: Where can I find more information online about Recovery Audit Contractors (RACs)?

• Tip of the week: Understand new code category for secondary diabetes

  One of the most important ICD-9 code changes that will take effect October 1 is the addition of a...

• PPV: CMS launches demonstration project to bundle payment for physician and hospital services

  Those in the HIM world know that hospital and physician incentives have never been completely...

Issue 25, July 1, 2008

• Topic: New ICD-9 codes available on National Center for Healthcare Statistics Web site

  The National Center for Healthcare Statistics has released its annual ICD-9-CM update to the index...

• Ask the expert: Has CMS updated the Fiscal Intermediary Shared System (FISS) to recognize hospitals that are exempt from present on admission (POA) reporting?

  Ask the expert: Has CMS updated the Fiscal Intermediary Shared System (FISS) to recognize hospitals...

• Tip of the week: Perform a thorough systems inventory when drafting a disaster recovery plan

  When drafting a disaster recovery plan, it’s important to know where data is stored, says...

• PPV: AHIMA’s draft query practice brief leaves many questions unanswered

  The American Health Information Management Association (AHIMA) requires coders to query when...

Issue 24, June 24, 2008

• Topic: First-ever EHR demonstration project to launch in 12 communities, according to HHS press release

  Twelve communities will participate in a first-ever national Medicare demonstration project that...

• Ask the expert: What is the most recent development regarding Medicare Administrative Contractors?

  A: CMS announced June 11 that it has selected Pinnacle Business Solutions, Inc. (PBSI) as the...

• Tip of the week: Implement a quality improvement program at your hospital

  The Robert Wood Johnson Foundation has spearheaded a program called Transforming Care at the...

• PPV: Ask these questions to define your legal health record

  Unlike clothing, “one size fits all” is not an option when defining a legal health...

Issue 23, June 17, 2008

• Topic: American Hospital Association questions proposed quality measures

  In a June 9 letter to CMS Acting Administrator Kerry Weems, the American Hospital Association (AHA...

• Ask the expert: Has CMS indicated that it will challenge any successfully appealed Recovery Audit Contractor (RAC) denials?

  The AHA recently announced in its June 6 issue of AHA News Now that CMS plans to challenge certain...

• Tip of the week: Focus on top six coding changes in the fiscal year 2009 IPPS proposed rule

  According to Sue Bowman, RHIA, CCS, director of coding policy and compliance at American Health...

• PPV: Prepare for the worst, hope for the best--Draft a disaster recovery plan and keep it up to date

  Most HIM directors think a disaster will never occur at their hospitals. And although channeling...

Issue 22, June 10, 2008

• Topic: Assign POA carefully based on treating practitioner's documentation involved in patient's care

  In the CDI and coding community a number of questions continue to exist regarding CMS&rsquo...

• Ask the expert: Agreement for communicating PHI via unencrypted e-mail messages

  Q: Many physicians and patients are interested in communicating information that includes PHI via...

• Tip of the week: Understand clinical descriptions of pressure ulcer stages

  Pressure ulcers, a condition that CMS designates as preventable, occupy center stage in hospital...

• PPV: OIG questions short-stay outlier trends for LTCHs

  According to a report the Office of Inspector General (OIG) issued in late March, short-stay...

Issue 21, June 3, 2008

• Topic: AHIMA releases new query practice brief for comment

  On May 14, AHIMA issued a practice brief entitled “Queries as a tool for clinical...

• Ask the expert: How do I code a second degree sunburn?

  Ask the expert: A patient presents to the ER for severe sunburn on the back. The patient’s...

• Tip of the week: Understand record retrieval and copy fees

  The HIPAA privacy rule does not allow you to charge individuals or their personal representatives a...

• PPV: Prepare to be dazzled by the more than 300 proposed ICD-9 code changes

  Coders may face the largest number of code changes in more than a decade if CMS finalizes the...

Issue 20, May 27, 2008

• Topic: CMS launches demonstration project to bundle physician and hospital services

  Hospitals in Texas, Oklahoma, New Mexico, and Colorado may be able to bundle their payments with...

• Ask the expert: In a situation involving hybrid medical records, how can we amend protected health information (PHI) that is maintained only in an electronic format?

  Ask the expert: In a situation involving hybrid medical records, how can we amend protected health...

• Tip of the week: Query for definitive diagnoses under MS-DRGs

  The general rule regarding queries under MS-DRGs is that when a physician determines a more...

• PPV: Don't make a hasty decision when selecting an EHR vendor

  A hasty EHR vendor selection can lead to frustration at best or a failed implementation at worst...

Issue 19, May 20, 2008

• Topic: New pilot project puts Medicare beneficiaries in the driving seat of their own personal health records

  CMS announced a new pilot project in which it will give Medicare beneficiaries in South Carolina...

• Ask the expert: What resources can help me define the legal health record?

  A: Be sure to revisit HIPAA rules and regulations, state-specific general laws, CMS requirements...

• Tip of the week: Consider referral bonuses when recruiting transcriptionists

  Consider extending bonuses to employees who refer a qualified applicant who is subsequently hired...

• PPV: Don't take RAC medical necessity denials laying down

  By now, almost everyone knows the results of the three-state recovery audit contractor (RAC...

Issue 18, May 13, 2008

• Topic: Know how to query physicians for specific pneumonia diagnoses

  Hospital-acquired and community-acquired pneumonias do not translate directly to medical codes...

• Ask the expert: Where can I find more information about the Medicare Claims Review Program?

  Ask the expert: Are there any resources available to learn more about the Medicare Claims Review...

• Tip of the week: Involve legal counsel when transitioning to EHRs

  The initial investment in legal counsel up front outweighs the risk of misunderstanding conflicting...

• PPV: Recovery Audit Contractors--Learn from your peers

  As your HIM department prepares for the national expansion of the Recovery Audit Contractor (RAC...

Issue 17, May 6, 2008

• Topic: AAHAM supports one-year moratorium on RAC program

  On April 22, the American Association of Healthcare Administrative Management (AAHAM) sent out a...

• Ask the expert: How can I access the RAND report that analyzes the six alternative methods to MS-DRGs?

  Ask the expert: How can I access the RAND report that analyzes the six alternative methods to...

• Tip of the week: Ask open-ended questions during employee evaluations

  HIM directors should ask open-ended questions to encourage dialogue during an employee...

• PPV: Follow five rules to make your HIPAA training program shine

  When Community Health and Counseling Services (CHCS) assigned her the title of chief privacy...

Issue 16, April 29, 2008

• Topic: AHIMA roundtable focuses on protecting patient privacy

  In observance of the American Health Information Management Association’s (AHIMA) Privacy and...

• Ask the expert: Where can I find more information about the FY 2009 inpatient rehabilitation proposed rule?

  Ask the expert: Where can I find more information about the FY 2009 inpatient rehabilitation...

• Tip of the week: Develop a plan to capture postanesthesia evaluations

  CMS addresses postanesthesia evaluations in section 482.52(b)(3) of the Interpretive Guidelines...

• PPV: Solicit detailed documentation to improve your hospital's profile for stroke patients

  By Robert S. Gold, MD It has been quite a while since I’ve written about stroke...

Issue 15, April 22, 2008

• Topic: ICD-9-CM Coordination and Maintenance Committee announces several proposed ICD-9 changes (part two)

  Last week, we looked at several changes that the ICD-9-CM Coordination and Maintenance Committee...

• Ask the expert: What are some of the major highlights of the 2009 IPPS proposed rule?

  Ask the expert: What are some of the major highlights of the 2009 IPPS proposed rule?

• Tip of the week: Familiarize yourself with how CMS intends to treat the U POA indicator

  Since POA indicators came on the scene last October, providers have wondered how CMS will treat the...

• PPV: Consider these 10 tips for conducting employee evaluations

  For new HIM directors, conducting employee evaluations may be the most daunting task. Unlike...

Issue 14, April 15, 2008

• Topic: ICD-9-CM Coordination and Maintenance Committee announces several proposed ICD-9 changes (part one)

  The ICD-9-CM Coordination and Maintenance Committee Meeting took place March 19-20, and coders...

• Ask the expert: POA for UTI

  Ask the expert: A physician admits a patient who already has a urinary catheter in place. After...

• Tip of the week: Provide HIPAA training to new employees before granting access

  If you're going to grant new hires access to protected health information before training them...

• PPV: Improve documentation and coding now before recovery audit contractors go national in 2010

  Recovery audit contractors (RAC) have identified certain target DRGs and compliance areas as part...

Issue 13, April 8, 2008

• Topic: CMS announces MAC contracts for CT and NY

  On March 18, CMS issued a press release announcing that it has awarded National Government Services...

• Ask the expert: A physician admits a patient because of Staph A pneumonia. The patient's medical history includes hypertension, Parkinson's disease, and degenerative joint disease. A physician administers several medications during the admission, including Rocephin®, Lotensin®, Sinemet,® and Fosamax®. The history and physical includes documentation that the patient had a fever of 102.5ºF, was disoriented, and had tachycardia. On day two of the admission, the physician documents that the patient has sepsis due to pneumonia. Is it appropriate to query the physician regarding whether the sepsis due to pneumonia was POA, or can you simply report a POA indicator based on the documentation? If you can report an indicator, which one should you report?

  Ask the expert: A physician admits a patient because of Staph A pneumonia. The patient's medical...

• Tip: Don't let your encoder do all of the work for you

  Relying on an encoder can potentially result in an increased prevalence and incidence of...

• PPV: A look at postanesthesia evaluations as related to CMS guidelines

  CMS published federal regulations in the Federal Register that were effective...

Issue 12, April 1, 2008

• Topic: Understand April 2008 pricer changes for the Inpatient Rehabilitation Prospective Payment System

  CMS released Medlearn Matters article MM5965, effective April 7, 2008, which instructs Medicare...

• Ask the expert: A patient presents with dizziness and brief myoclonic jerks. After study, the provider determined that the patient has a left temporal mass. In this case, is it correct to code the myoclonic jerks (code 333.2) in addition to the lesion? I feel that the myoclonic jerks are a symptom of the brain lesion, but others have said that I should code them separately.

  Ask the expert: A patient presents with dizziness and brief myoclonic jerks. After study, the...

• Tip: Know your hospital's responsibility for responding to amendments

  HIPAA requires covered entities (CE) to respond to a request for a medical record amendment within...

• PPV: Drug administration challenges continue

  Despite the fact that the 2008 OPPS final rule did not make any major drug administration changes...

Issue 11, March 25, 2008

• HCPro, Inc. launches new logo and tagline as part of its new corporate branding initiative

  HCPro, Inc. is launching a new corporate branding campaign designed to reflect the company's focus...

• Topic: Don't miss the opportunity to submit feedback on proposed Joint Commission Documentation of Care chapter

  If you haven't already provided feedback on the Joint Commission's proposal to implement a...

• Ask the expert: Where can I find information about the most recent update to the inpatient prospective payment system (PPS) PC pricer?

  Ask the expert: Where can I find information about the most recent update to the inpatient...

• Tip of the week: Check references when choosing an electronic health record vendor

  Checking references is an important step in determining which electronic health record (EHR) vendor...

• PPV: Maintain compliance when coding from the medical record

  You might think that everything between the first and last page of a medical record is fair game...

Issue 10, March 18, 2008

• Announcement: Attention HIM Connection subscribers!

  We are looking for forms and/or tools related to release-of-information to include in an upcoming...

• Topic: RAC fiscal year 2007 status document cites $371.5 million in improper payments

  CMS collected $371.5 million in improper Medicare payments during fiscal year (FY) 2007 as part of...

• Ask the expert: May we release patient information that originated from other facilities?

  Ask the expert: May we release patient information that originated from other facilities?

• Tip: Learn from your mistakes when it comes to Joint Commission survey preparedness

  Don't be too hard on yourselves if everything did not go exactly as planned during an unannounced...

• Pay-per-view: Expect increased patient-driven amendments with EHRs

  The HIPAA privacy rule (section 164.526) permits patients to amend their medical records, and as...

Issue 9, March 11, 2008

• Topic: CMS, OESS post new security compliance review information, checklist

  On February 20, the Office of E-Health Standards and Services (OESS) posted new information on the...

• Ask the expert: Which information management (IM) standards has The Joint Commission identified as being the most challenging for the first half of 2007?

  A: The Joint Commission has identified the following IM standards as being the most challenging...

• Tip: Beware of remark code N363 for the POA indicator

  Hospitals that don't submit proper present on admission (POA) information will begin to...

• PPV: Fundraising, marketing, and the privacy rule

  <p>Healthcare providers that remain ignorant of HIPAA's rules regarding fundraising and...

Issue 8, March 4, 2008

• Topic: Recognize the risks of remote access

  When rolling out remote access to a segment of your work force, first define your needs. You must...

• Ask the expert: A patient whom we cared for on our unit last week has been readmitted to another unit in the hospital. Can we access the patient's information through our EMR system to get an update on her condition?

  Ask the expert: A patient whom we cared for on our unit last week has been readmitted to another...

• Tip of the week: Run reports to eliminate duplicate medical record numbers

  Cleaning up the master patient index (MPI) and eliminating duplicate numbers helps...

• PPV: Report hospital quality measures to ensure an accurate public profile and full reimbursement

  For the past several years, hospitals nationwide have been becoming familiar with inpatient quality...

Issue 7, February 25, 2008

• Topic: Recognize common HIPAA myths and misconceptions

  Working proactively to maintain HIPAA compliance and patient privacy is essential. However, some of...

• Tip: Look for confirming diagnoses when reporting the POA indicator

  Before you report a present on admission (POA) indicator, look for confirming diagnoses.

• Ask the expert: What is the timeline for POA implementation?

  Ask the expert: What is the timeline for POA implementation?

• Pay-per-view: Privacy and LTC--Common problems, effective solutions

  The enactment of the HIPAA privacy rule forced covered entities to examine their privacy practices...

Issue 6, February 19, 2008

• Topic: CMS issues revised interpretive guidelines relating to Hospital Conditions of Participation (CoPs)

  On February 8, CMS issued revised interpretive guidelines reflecting the most recent changes to the...

• Ask the expert: A patient was admitted for a laminectomy. During the time in which the patient received anesthesia and was positioned for the surgery, she developed extreme bradycardia. Should the degeneration of the disc or the bradycardia be listed as the principal diagnosis?

  Ask the expert: A patient was admitted for a laminectomy. During the time in which the patient...

• Tip of the week: Encourage physicians to provide detailed heart failure documentation

  Physicians must describe heart failure (HF) as systolic, diastolic, or both on every admission or...

• Pay-per-view: Know critical care billing, documentation requirements

  Physicians who take chances by skirting ethics to increase their revenue risk massive financial...

Issue 5, February 12, 2008

• Topic: Develop a late entry policy to ensure compliance

  A key point to address in your late entry policy is the proper format and notation to indicate that...

• Ask the expert: A patient presents to a cardiologist, who makes a final diagnosis of "history of fen-phen exposure" and "mild mitral regurgitation, not hemodynamically significant." Which codes should I assign in this scenario?

  Ask the expert: A patient presents to a cardiologist, who makes a final diagnosis of "history of...

• Tip of the week: Understand how to amend PHI

  Amending protected health information (PHI) means adding new information to the individual's...

• PPV: Hospitals experience POA snags due to systems problems, insufficient documentation

  Although present-on-admission (POA) indicator assignment is going smoothly for most hospitals...

Issue 4, January 29, 2008

• Topic: Consider front-end speech recognition to reduce transcription turnaround time, improve documentation quality

  Topic: Consider front-end speech recognition to reduce transcription turnaround time, improve...

• Topic: Consider these steps to achieve workflow process improvement

  Once you've cultivated the need for workflow process improvement associated with EHR...

• Ask the expert: Does a physician have to specify a seizure as petit mal or grand mal, or can the term "seizure" stand alone to count as a major complication/comorbidity (MCC)?

  Ask the expert: Does a physician have to specify a seizure as petit mal or grand mal, or can the...

• Ask the expert: A patient has an echocardiogram on day four and is proven to have mitral valve regurgitation (MVR). This is a condition that the physician did not detect or prove through diagnostic testing until four days post-admission. Should we report the MVR as being present on admission (POA)?

  Ask the expert: A patient has an echocardiogram on day four and is proven to have mitral valve...

• Tip of the week: Ask the right questions when choosing an off-site storage facility

  Tip of the week: Ask the right questions when choosing an off-site storage facility

• Tip of the week: Perform regular security checkups to prepare for potential audits

  There are several benefits to the security checkup, says Kate Borten, CISSP, CISM. First, the main...

• PPV: Recognize common HIPAA myths and misconceptions

  PPV: Recognize common HIPAA myths and misconceptions

• PPV: One hospital monitors its H&Ps to set benchmarks, significantly reduce the delinquency rate

  Many hospitals will admit that obtaining timely history and physicals (H&P) is no easy task...

Issue 3, January 22, 2008

• Topic: CMS discusses documentation for H&Ps during recent ODF call

  Topic: CMS discusses documentation for H&Ps during recent ODF call

• Ask the expert: If a third party, such as an insurance company, requests that we release patient information, should we deny sending patient records if the request doesn't include the following statement required by HIPAA?

  Ask the expert: If a third party, such as an insurance company, requests that we release patient...

• Tip of the week: Uncover the hidden clues in physician documentation

  Tip of the week: Uncover the hidden clues in physician documentation

• PPV: What's in a name: Healthcare IT's addiction to acronyms

  PPV: What's in a name: Healthcare IT's addiction to acronyms

Issue 2, January 15, 2008

• Topic: HIPAA will heat up in 2008

  Topic: HIPAA will heat up in 2008

• Ask the expert: It is my understanding that atherosclerosis of bypass grafts is considered a complication/comorbidity (CC). What about vessels that have stents or a stented vessel that restenosed?

  Ask the expert: It is my understanding that atherosclerosis of bypass grafts is considered a...

• Tip of the week: Prevent ED revenue loss by educating or retraining your coding and clinical staff

  Tip of the week: Prevent ED revenue loss by educating or retraining your coding and clinical staff

• PPV: OIG Work Plan to investigate CMS’ policies regarding The Joint Commission hospital accreditation process

  PPV: OIG Work Plan to investigate CMS’ policies regarding The Joint Commission hospital...

Issue 1, January 8, 2008

• Editor's note

  Editor's note

• Topic: Physician queries-Ask the right questions to improve coding accuracy, obtain detailed documentation

  Topic: Physician queries-Ask the right questions to improve coding accuracy, obtain detailed...

• Ask the expert: When we transfer a patient from one unit to another, is it acceptable for staff members from the first unit to continue accessing the transferred patient's protected health information PHI)?

  Ask the expert: When we transfer a patient from one unit to another, is it acceptable for staff...

• Tip of the week: Improve your patients' safety through EHR technology

  Tip of the week: Improve your patients' safety through EHR technology

• PPV: Health information exchanges on the rise to share data, improve care

  PPV: Health information exchanges on the rise to share data, improve care