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HIM-HIPAA Insider

Issue 51, December 28, 2010

• Happy Holidays from HCPro

  On behalf of HCPro, Inc., and HIM Connection, I would like to wish you a joyful holiday season and...

• 2010 Coder productivity survey

  HCPro is conducting in-depth research into coder productivity, and we value your input. The survey...

• Prepare for ICD-10

  ICD-10. The biggest change to happen in health information management in more than 20 years is on...

• Q&A: Coding for protein malnutrition

  Q: Our physician provided an illegible diagnosis of malnutrition, and when we queried him regarding...

• Keep tabs on digital cameras

  You worry about laptop computers and other portable devices being stolen. But what about digital...

• The complicated process of reporting complications

  As the Patient Protection and Affordable Care Act implementation progresses, the quality and...

Issue 50, December 21, 2010

• CMS now requiring ABN review as part of MAC, CERT, RAC, and ZPIC documentation requests

  On December 10 CMS released Transmittal 361, Change Request 6988 that MACs, CERT, RACs, and ZPICs...

• Q&A: Releasing records to APS

  Q. When is Adult Protective Services (APS) entitled to copies of a patient’s medical record...

• Make sense of Medicaid RACs

  Signs are pointing to the fact that Medicaid RACs might not be the stuff of unicorns or Santa...

• Let the OIG Work Plan inspire your auditing, compliance program

  Each year, the Office of Inspector General (OIG) Work Plan includes a host of inpatient-related...

• Coming soon in Medical Records Briefing

  In the January issue of MRB, you’ll find articles on the following topics and more!

Issue 49, December 14, 2010

• PCAST releases report on health information technology

  On December 8, the President's Council of Advisors on Science and Technology (PCAST) released a...

• Q&A: Keeping NPP receipt acknowledgments

  Q. Do we need to keep the acknowledgment form when we provide a Notice of Privacy Practices (NPP...

• Take time to understand acute kidney injury versus acute renal failure

  The language physicians use to create a patient’s clinical picture doesn’t always...

• Keep medical record retention rules in mind

  In what was perhaps an effort to remind providers to consider medical record retention as they move...

Issue 48, December 7, 2010

• HCPro releases free ICD-10 white paper

  HCPro’s Revenue Cycle Institute recently released a free downloadable white paper on...

• Q&A: Releasing records to an insurance company

  Q. An insurance company is requesting copies of medical records to review our CPT® coding...

• Understand the 'X' in ICD-10 coding

  What does “x” represent in ICD-10? What seemed like a fairly straightforward question...

• Strategies for performing staff evaluations: Five things to keep in mind when conducting your reviews

  With the end of the year approaching, you, along with many of your HIM director and manager...

Issue 47, November 30, 2010

• Data breaches cost hospitals $6B annually

  Hospitals spend $6 billion annually because of data breaches, and federal regulations enacted under...

• Address inadequate HIPAA Security Rule-required policies and procedures

  CMS detailed seven shortcomings, including old and inadequate policies and procedures, found in its...

• Q&A: Coding removal of a Bartholin's gland cyst catheter in the ED

  Q: What code should I report for a patient who presents to the ED for removal of a...

• Busted: 10 EHR myths and misconceptions: Minimize the bumps in your road to an electronic record

  An EHR will make all of your problems—well, except for the move to ICD-10—go away...

Issue 46, November 23, 2010

• CMS publishes 2011 RAC ADR limits for providers

  CMS has modified the additional documentation request (ADR) limits (i.e., medical record request...

• Q&A: Releasing PHI to a collection agency

  Q. We released protected health information (PHI) to a collection agency because a patient was...

• Involve coders in your RAC defense strategy

  Now that RAC medical necessity audits are well under way, the focus has shifted from anticipatory...

• Get "social," but address privacy concerns: Steps to get you on the social media bandwagon and ensure patient privacy

  When it comes to social networking websites, advocates say hospitals can have it both...

• Coming soon in Medical Records Briefing

  In the December issue of MRB, you’ll find articles on the following topics and more!

Issue 45, November 16, 2010

• CMS takes first step toward Medicaid RAC implementation

  CMS released the long-anticipated proposed rule for Medicaid RACs November 5, setting the stage for...

• Q&A: Using mobile phones and smartphones to communicate patient information

  Q. Can staff members communicate patient information via mobile and smartphones?

• New to your HIM managerial role? No problem

  MRB recently asked several advisory board members for crucial tips that new HIM managers and...

• Medical necessity audits: Involve coders in your RAC defense strategy

  Hospitals have waited with bated breath for RAC medical necessity audits to begin. Now that the...

Issue 44, November 9, 2010

• CMS announces physician supervision changes as part of 2011 OPPS final rule

  CMS finalized four changes to its physician supervision requirements as part of the 2011 OPPS final...

• Q&A: Assigning the correct DRG when a caregiver refuses a vaccination

  Q: I heard that code V64.05 (vaccination not carried out because of caregiver refusal) has been...

• Train your work force to be HIPAA ready

  To effectively train your staff on HIPAA, mix things up and be creative.

• Medical record documentation makes Joint Commission top 10 noncompliance list for first half of 2010

  It should come as no surprise that medical record documentation made the list for top standards...

Issue 43, November 2, 2010

• CMS issues new guidance for Medicaid integrity contractors

  On October 25, AHA News Now published information on a new CMS policy that prohibits Medicaid...

• Q&A: Sending unencrypted e-mail within a network

  Q. Would a covered entity or business associate violate the HIPAA Security Rule if it sends PHI in...

• Ready your CDI staff for ICD-10 implementation

  Three years. That’s how long you have to prepare for the implementation of the International...

• New to your HIM managerial role? No problem.

  MRB recently asked several advisory board members for crucial tips that new HIM managers and...

• Last chance! Release of Information survey

  Medical Records Briefing is conducting a survey on release of information (ROI) practices by...

Issue 42, October 26, 2010

• ONC publishes listing certified EHRs and EHR modules online

  The Office of the National Coordinator for Health IT (ONC) has published a new website (available...

• Q&A: Power of attorney and deceased individuals

  Q. Is a power of attorney still effective after a patient’s death? I was told that a woman...

• Avoid encoder overreliance

  As hospitals move toward ICD-10, an overreliance on encoders could become more of a problem as...

• Transition to ICD-10: The team, timeline, and tasks

  The transition to ICD-10 is not in any way the kind of transition we made from ICD-8 to ICD-9, nor...

• Release of Information survey

  Medical Records Briefing is conducting a survey on release of information (ROI) practices by...

Issue 41, October 19, 2010

• Release of Information survey

  Medical Records Briefing is conducting a survey on release of information (ROI) practices by...

• Q&A: Verifying admissions for internal staff

  Q: If an employee is hospitalized in the facility in which he or she works, does the manager of the...

• Review coding guidelines for inpatient wound debridement coding

  Coders and other HIM staff members can do several things to ensure that they report excisional...

• Five tips to ensure HAC, POA, and never event compliance

  The Present on Admission (POA) indicator, hospital-acquired conditions (HAC), and never events have...

• Coming soon in Medical Records Briefing

  In the November issue of MRB, you’ll find articles on the following topics and more!

Issue 40, October 12, 2010

• OIG releases 2011 Work Plan: EMTALA out, radiation therapy and medical devices in

  Medical devices, radiation therapy quality and safety, and an expanded focus on the three- and...

• Q&A: EHR incentive payments

  Q. When will the CMS begin to pay Medicare and Medicaid EHR incentives to eligible professionals...

• Tips to keep your information secure

  The list of breaches of unsecured PHI on the Office for Civil Rights (OCR) website continues to...

• Did you get an invite to the EHR table?

  As I work with various clients who are preparing for transition to EHRs, I often hear HIM staff...

Issue 39, October 5, 2010

• CMS publishes RAC improper payment vulnerabilities

  In an effort to propagate useful information on RAC high-dollar improper payment vulnerabilities...

• Q&A: HIPAA and video monitoring

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

• Address insufficient documentation to prepare for RACs

  As providers navigate their way through complex reviews and the newly approved medical necessity...

• What you need to know about the 2011 ICD-9-CM codes

  Every October 1, new ICD-9-CM codes take effect. Others are revised or deemed invalid. What do you...

Issue 38, September 28, 2010

• Revenue Cycle Institute offers free white papers

  Did you know that HCPro Revenue Cycle Institute offers free white papers on a variety of coding and...

• Q&A: Releasing information to law enforcement

  Q. A patient assaulted another patient while both were at our substance abuse treatment facility...

• Do some analysis to deal with the DCA

  The FY 2011 inpatient prospective payment system final rule released July 30 includes the usual...

• Accounting for disclosures from EHRs: What you need to know to comply with HITECH requirement

  When HITECH was signed into law February 17, 2009, privacy and security officers predicted the...

Issue 37, September 21, 2010

• Editor's note: Correction

  Editor’s note: In the previous issue of HIM Connection there was a typo in the fifth digit of...

• Healthcare News: ICD-9 code freeze finalized

  During the ICD-9-CM Coordination and Maintenance Committee meeting September 15, the committee...

• Q&A: H&P for patients undergoing moderate or deep sedation?

  Q: Is a history and physical (H&P) exam necessary for patients undergoing moderate or deep...

• As attention shifts to HITECH, don't forget about compliance with HIPAA basics

  Many HIPAA privacy and security officers now focus on meeting new regulatory requirements under...

• Don't bypass coding rules to get more money: Take a closer look to compare acute, chronic conditions

  Last month I discussed the importance of queries related to sepsis versus UTI due to an indwelling...

• Coming soon in Medical Records Briefing

  In the October issue of MRB, you’ll find articles on the following topics and more!

Issue 36, September 14, 2010

• CMS announces switch to PPS system for ESRD

  Effective January 1, 2011, CMS will replace the current basic case-mix adjusted composite payment...

• Q&A: Coding for chronic scapholutynate ligament tear

  Q: Which ICD-9-CM code denotes chronic scapholutynate ligament tear?

• Prepare for the HIPAA final rule by focusing on BA relationships

  Focus on working relationships with business associates (BA). Sometimes covered entities sign...

• Walking the path of ARRA, HIPAA compliance

  ARRA brought us an expanded version of HIPAA. Along with it came the clear message that if the last...

Issue 35, September 7, 2010

• ONC names first certifiers of EHR systems and technology

  The Chicago-based Certification Commission for Health Information Technology (CCHIT), and the...

• Q&A: HITECH changes to HIPAA Security Rule?

  Q: Did HITECH change any HIPAA Security Rule implementation specifications from addressable to...

• Tips for RAC appeal success

  According to a July HCPro survey of approximately 500 healthcare providers, 56% have already...

• Assigning the principal diagnosis: Four case studies

  The following four case studies test your knowledge of correct principal diagnosis (PDX...

Issue 34, August 31, 2010

• 5010 transaction standard testing to begin in January

  On August 24, CMS issued a press release to remind to healthcare providers, health plans...

• Q&A: Coding for dyspnea due to respiratory ciliary dyskinesia

  Q: Which code should I report for a patient who has dyspnea due to respiratory ciliary dyskinesia?

• Tip: Get the HIPAA job done, even if you're a solo act

  How can privacy and security officers perform their jobs when they don’t have enough hours in...

• Take advantage of nine tips for RAC appeal success

  According to a July HCPro survey of approximately 500 healthcare providers, 56% have already...

Issue 33, August 24, 2010

• Editor's Note: Correction: Coding Clinic vs. coding guidelines: Which takes precedence?

  Editor’s note: HIM Connection reprinted the following Q&A in our August 17 issue...

Issue 32, August 17, 2010

• CMS approves 18 medical necessity issues for RAC review

  The long wait for medical necessity RAC reviews will soon be over. CMS recently approved the first...

• Q&A: Coding Clinic vs. coding guidelines: Which takes precedence?

  Q: An auditor recently reviewed a chart for an inpatient stay. The patient was admitted due to an...

• Tip: Use your case-mix index to help measure the effectiveness of your CDI program

  Calculating a hospital’s case-mix index (CMI) is one way to gauge a CDI program’s...

• Manage misplaced documents in an EDMS

  Regardless of the safeguards in place in any electronic document management system (EDMS...

Issue 31, August 10, 2010

• ONC releases EHR fact sheets, CMS holds conference calls on incentive programs

  The Office of the National Coordinator of Health IT (ONC) has released tip sheets for Medicare...

• Q&A: Release of information when a child is in DHS custody

  Q: Can a parent access his or her child’s PHI when the child is in the custody of the...

• Tip: Consider outsourcing your PHI disposal

  Healthcare organizations need to worry about more than just the disposal of paper records. Covered...

• Don't fall into avoidable V code traps

  V codes play an important role in painting an accurate picture of an admission and facilitating...

Issue 30, August 3, 2010

• CMS proceeds with documentation 2.9% payment cut in FY 2011 IPPS final rule

  On July 30, CMS issued the inpatient prospective payment system (IPPS) final rule to update...

• Rite Aid to pay $1 million for potential patient privacy breaches

  Rite Aid Corporation could have avoided a $1 million fine by simply enforcing its HIPAA policies...

• Q&A: Inpatient consultation codes

  Q: Will you provide more information about inpatient consultation codes? Please explain how to...

• Tip: Consider security of electronic releases of information

  Harry B. Rhodes, MBA, RHIA, CHPS, CPHIMS, FAHIMA, director of practice leadership at AHIMA in...

• Report card helps track timing and dating success

  Shelia Hull, RN, Joint Commission specialist at Pikeville (KY) Medical Center, was with the...

Issue 29, July 27, 2010

• OCR releases final guidance on risk analysis

  On July 15 the Office for Civil Rights posted its annual guidance on conducting risk...

• Q&A: Notice of privacy practice posting

  Q. If we provide laminated copies of our privacy notice on the registration counters, must we post...

• Tip: Reduce RAC denials with targeted auditing

  Providers can make a great impact in terms of reducing RAC denials at their facilities with...

• Should coders wait for the discharge summary before coding?

  A coder may delay sending a claim for many reasons, but should a missing discharge summary be one...

• MRB 2010 EHR benchmark survey: Last chance!

  Medical Records Briefing is conducting a survey on hospital EHR use and implementation, and we are...

• Coming soon in Medical Records Briefing

  In the August issue of MRB, you’ll find articles on the following topics and more!

Issue 28, July 20, 2010

• HHS eases requirements for initial phase of EHR 'meaningful use'

  HHS softened some of its proposed requirements for healthcare entities to become meaningful users...

• HHS proposes 'significant' changes to HIPAA privacy, security, and enforcement

  On July 8 HHS released a proposed rule to modify the HIPAA privacy, security, and enforcement...

• Q&A: RAC MLN Matters article

  Q: What should providers know about CMS’ new RAC MLN Matters article?

• The times they are a-changin?: HIM in an EHR world

  EHR implementation is a “big, hairy animal,” according to Meg McElroy, RHIA, MBA, HIM...

• MRB 2010 EHR benchmark survey

  Medical Records Briefing is conducting a survey on hospital EHR use and implementation, and we...

Issue 27, July 13, 2010

• MRB 2010 EHR benchmark survey

  Medical Records Briefing is conducting a survey on hospital EHR use and implementation, and we...

• CMS releases 2011 OPPS proposed rule

  CMS continues to refine the physician supervision requirements for diagnostic and therapeutic...

• Q&A: HIPAA and attorney requests for records

  Q. When an attorney requests records and asks that all records be released, must we comply and send...

• The 2010 HIM director and manager salary survey

  The annual Medical Records Briefing salary survey for HIM directors and managers has come to a...

Issue 26, July 6, 2010

• Hospitals face three-day payment window changes

  Hospitals clamoring for guidance from CMS about the three-day payment window must now grapple with...

• Q&A: HIPAA and on-campus education for minors

  Q: We have a medical unit for a pediatric population. This campus includes a school for educating...

• Understand clinical indicators of CHF before querying physicians

  Congestive heart failure (CHF) is one example of a condition for which coders and clinical...

• Prevent RAC DRG validation and complex coding denials

  Medically unnecessary services and incorrectly coded items had the highest amounts of RAC...

• Correction: Q&A on coding for signs and symptoms

  Editor’s note: There was an error in the last sentence of the Q&A on coding for signs and...

Issue 25, June 29, 2010

• HHS releases final rule for temporary EHR certification program

  The HHS Office of the National Coordinator for Health Information Technology (ONC) released a final...

• Q&A: Coding for signs and symptoms

  Q: My question pertains to inpatient admissions during which the conditions are resolved at the...

• Make HIPAA a top priority with upper management

  Privacy and security officers may face varying challenges to get buy-in from top leaders for HIPAA...

• The times they are a-changin': HIM in an EHR world

  With many HIM directors being intimately involved in many of the various elements that go into a...

Issue 24, June 22, 2010

• Large patient information breach list nears century mark

  The Office for Civil Rights' (OCR) list of entities reporting major patient information breaches...

• Q&A: HIPAA and requests for report results

  Q. We are an MRI facility, and our services are referral-based. We fax MRI reports to referring...

• Consider non-monetary incentives to motivate your HIM staff members

  Motivating staff to produce more when recognition of superior performance is limited or nonexistent...

• FY 2011 IPPS proposed rule spurs discussions about regulatory hot topics

  The fiscal year (FY) 2011 IPPS proposed rule released April 19 addresses several highly debated...

• Coming soon in Medical Records Briefing

  In the July issue of MRB, you’ll find the following articles and more!

Issue 23, June 15, 2010

• Update Medicare Advantage patient information needed to determine Medicare DSH payments for FYs 2007, 2008 by August

  In the May 5 transmittal R696OTN CMS reminded hospitals of the importance of submitting...

• Q&A: Determining the principal diagnosis for hernia with bowel obstruction

  Q: A patient who has had multiple previous abdominal surgeries now presents with a small bowel...

• Protect PHI when staff members leave

  Establish a procedure to protect PHI when clinical staff members leave your organization. This is...

• Don't let improper discharge disposition codes fly under the radar at your facility

  You may think the discharge disposition codes you assign are correct, but discharge plans often...

Issue 22, June 8, 2010

• FTC delays Red Flags Rule enforcement

  The Federal Trade Commission (FTC) delayed enforcement of the Red Flags Rule for a fifth time, this...

• Q&A: HIPAA-compliant sign-in sheets

  Q. Do patient sign-in sheets violate the HIPAA privacy rule? If they don’t, does a...

• Retroactively audit discharge disposition codes to find missed reimbursement

  Coders and billers should audit claims retrospectively to ensure correct discharge disposition...

• Master HCPCS level II and anatomical modifiers

  Certain modifiers are well-known as being difficult for coders. (Modifier -59, anyone?) Others...

Issue 21, June 1, 2010

• CMS says medical necessity, physician complex audits on their way

  On the May 12 RAC 101 call for physicians, a caller asked CMS specific information about when...

• Q&A: ICD-10 implementation timeline

  Q: Where should our hospital be in terms of the ICD-10 implementation process in 2010?

• Understand individual needs to effectively motivate your team

  Motivation HIM department staff members is important because it affects performance. It is the...

• Establish a robust coding auditing program

  Many reasons justify establishing an internal auditing program. An organization may have a...

Issue 20, May 25, 2010

• OCR issues guidance on risk analysis

  On May 7 the Office for Civil Rights (OCR) issued a series of guidance documents dealing with risk...

• Q&A: Required inpatient length of stay

  Q: I’ve always heard that inpatient status requires a specific time frame. For example, must...

• Understand the difference between modifiers -73 and -74

  Coders should use modifiers -73 and -74 to report discontinued outpatient procedures. Modifier -73...

• Seven steps to comply with the Red Flags Rule

  If you don’t have an identity theft prevention program in place, take action now. The Federal...

• Coming soon in Medical Records Briefing

  In the June issue of MRB, you’ll find the following articles.Click here for more information...

Issue 19, May 18, 2010

• CMS addresses medical necessity reviews, RAC expansion in RAC 101 call

  CMS representatives addressed two developing recovery audit contractor (RAC) areas during the May 5...

• Q&A: Accidental sharing of PHI with other healthcare providers

  Q: We inadvertently sent a clinical note to the wrong healthcare provider. Must we conduct a risk...

• Help ensure compliance when reporting cirrhosis and alcoholic hepatitis with an MCC

  MS-DRG 432 (cirrhosis and alcoholic hepatitis with MCC) is one of many MS-DRGs slated for RAC...

• Considering additional EHR technologies? Early adopter shares advice

  Upcoming EHR meaningful use subsidies may give many hospitals the additional incentive necessary to...

Issue 18, May 11, 2010

• AHIMA addresses physician queries in guidance for CDI programs

  On April 29, AHIMA issued a practice brief, “Guidance for Clinical Documentation Improvement...

• Q&A: HITECH vs. third-party payer policies: Who wins?

  Q. Does HITECH supersede our contracts with third-party health insurance policies if the patient...

• Master ongoing record review for survey success

  Although The Joint Commission has not focused on the ongoing record review (ORR) process during...

• Use PEPPER to improve coding compliance

  Aside from being a catchy acronym, PEPPER (Program for Evaluating Payment Patterns Electronic...

Issue 17, May 4, 2010

• HHS: HIPAA regulations to come this month

  The timing of the release of proposed HIPAA regulations per the HITECH Act became a little clearer...

• Q&A: Improving physician documentation in preparation for ICD-10

  Q. What should HIM staff members communicate to physicians now about the level of specificity...

• Take advantage of free RAC tools available from the Revenue Cycle Institute

  Did you know that the HCPro Revenue Cycle Institute is a great source for free tools for those in...

• Cost-effective ways to ensure HIPAA compliance

  Jaspinder Grewal is a self-described “techie” who knows that developing cost-effective...

Issue 16, April 27, 2010

• CMS releases FY 2011 IPPS proposed rule

  In the fiscal year (FY) 2011 Inpatient Prospective Payment System (IPPS) proposed rule, CMS...

• Q&A: Processing claims during the ICD-10 transition

  Q. If an outpatient has a service on September 10, September 20, October 1, and October 15, 2013...

• Prepare for RAC audits by exercising caution with septicemia codes

  Overcoding and coding based on insufficient documentation may be one reason why RACs are auditing...

• Cascade official shares lessons learned from CMS HIPAA security audit

  Ten covered entities (CE) found themselves in CMS’ crosshairs when the federal government...

• Reminder: Last day to take 2010 HIM Director/Manager salary survey

  Medical Records Briefing is conducting its annual HIM director and manager salary survey, and we...

Issue 15, April 20, 2010

• CMS issues new RAC FAQ, video

  On April 13, CMS released the following new RAC FAQ: Can the RAC do a medical necessity review on a...

• Q&A: Coder documentation in the medical record

  Q: May coders document in the medical record?

• Heal the divide between HIM and CDI

  Divisions between HIM and clinical documentation improvement (CDI) staff members are common. But in...

• HCPro survey: Breach notification requirements are top HITECH challenge; BA contracts also a concern

  Have you wondered what has been the biggest challenge for healthcare providers since enactment of...

• Coming soon in Medical Records Briefing

  In the May issue of MRB, you’ll find the following articles, and more!

Issue 14, April 13, 2010

• CMS announces upcoming RAC calls

  On April 6 CMS announced a series of upcoming RAC calls for different provider types.

• Q&A: HIPAA and friendly follow-ups

  Q. An emergency department (ED) nurse at a hospital and trauma center saw the name of an...

• Coding postop or post-traumatic infections with OR procedures

  RACs already are validating countless MS-DRGs in hospitals nationwide, and the number of eligible...

• When work flow becomes ’worry’ flow

  One of the most common questions I am asked when doing EHR implementation consulting is, “Can...

• 2010 HIM Director and Manager Salary Survey

  Medical Records Briefing is conducting its annual HIM director and manager salary survey, and we...

Issue 13, April 6, 2010

• Audit for signatures: New transmittal clarifies assessment requirements

  In the current regulatory environment many contractors review claims and medical documentation...

• Q&A: HIPAA and media

  Q. Which HIPAA requirements are applicable with respect to notifying the media about a...

• Consider internal auditing options

  Coding managers often conduct internal audits, but other alternatives exist. Some organizations...

• Know the coder's role in accurate portrayal of readmission data

  The statistic is striking. Nearly 18% of admissions result in readmissions within 30 days of...

Issue 12, March 30, 2010

• Changes coming for HIM in wake of healthcare reform bill

  Now that the Senate and House have put the finishing touches on the newly signed...

• New members needed for Provider Roundtable

  In 2003, HCPro, Inc., Nimitt Consulting, Inc., and 3M Health Information Systems joined forces to...

• Q&A: HIPAA and census data

  Q. Census workers are requesting information about the residents of our group homes to conduct an...

• Don't let work flow become 'worry flow'

  To avoid having work flow become “worry” flow, start planning out work flow needs well...

• Audit present-on-admission indicators to ensure compliance, data accuracy

  Was it present on admission (POA) or did it develop during the patient’s stay? These...

Issue 11, March 23, 2010

• AHA Recommends Changes to EHR Standards, Implementation

  Adding its voice to the EHR standards debate, the American Hospital Association asked for changes...

• CMS delays enforcement of physician supervision for CAHs

  Critical access hospitals (CAH) have received a reprieve of sorts from CMS. CMS will not evaluate...

• Q&A: Coding capillary leak syndrome secondary to biochemotherapy

  Q: How should I code capillary leak syndrome secondary to biochemotherapy? Can you provide coding...

• Consider centralizing your HIM department: Unexpected benefits may await you

  Memorial Hermann Healthcare System (MHHS) in Houston includes nine acute care hospitals, one...

Issue 10, March 16, 2010

• White House memorandum mandates additional recovery audits

  A March 10 White House memorandum on finding and recapturing improper payments has mandated...

• Q&A: Notification requirements when a privacy breach occurs involving a minor

  Q. Whom should we notify if a minor’s record is breached? For example, a grandparent who...

• Tips to keep your coding compliance program fresh

  Just because your coding compliance program is in place doesn’t mean it’s doing its job...

• Heal the divide between HIM and CDI

  Divisions between HIM and clinical documentation improvement (CDI) staff members are common. But in...

• Coming soon in Medical Records Briefing

  In the April issue of MRB, you’ll find the following articles, and more! EHR beat...

Issue 9, March 9, 2010

• HHS releases proposed rule for EHR certification: Certification to ensure functionality, security necessary to meet meaningful use criteria

  Is your EHR meaningful use–compliant? Healthcare providers may soon be able to find out for...

• Q&A: Coding for Delleman syndrome

  Q: What code should I use to report for Delleman syndrome?

• Don't succumb to off-site, out-of-mind record storage

  Space is at a premium for many hospitals. Most campuses simply don’t have enough space to...

• Adapt HIPAA internal sanctions policy to comply with HITECH

  Providers know that HIPAA requires them, as covered entities, to impose sanctions consistently...

Issue 8, March 2, 2010

• CMS posts HIPAA version 5010 fact sheets and checklists

  CMS posted fact sheets and checklists on its Web site to help guide providers through the...

• Q&A: HITECH enforcement delays

  Q: Has HITECH enforcement been delayed?

• Tips to help providers meet new IRF documentation and coverage requirements

  CMS is taking a closer look at admissions to inpatient rehabilitation facilities (IRF) thanks to...

• Find out what meaningful use means for you now

  On December 30, 2009, the Office of the National Coordinator for Health Information Technology...

Issue 7, February 23, 2010

• Federal committee recommends changes to EHR meaningful use rule

  The conversation continues regarding the effectiveness, appropriateness, and reasonableness of the...

• Q&A: Coding for gastric lap band erosion with infection

  Q: How should I code gastric lap band erosion with infection? The ICD-9-CM Manual instructs coders...

• Tips for revising your HIPAA internal sanctions policy

  As healthcare organizations begin adapting their HIPAA internal sanctions policies to comply with...

• Cope with confusing Medicare consultation code payment changes

  The start of the new year typically ushers in a multitude of code changes. But for 2010, hospitals...

Issue 6, February 16, 2010

• Draft senate bill expands EHR incentives to hospital-based outpatient physicians

  Many hospital-based physicians puzzled by their apparent exclusion from EHR meaningful use...

• Q&A: HITECH requirements for business associate contracts

  Q: Are covered entities and BAs required to revise their BA contracts? Do contracts executed prior...

• Strategies for managing an understaffed HIM department

  Flu season. Layoffs. Natural disasters. Vacations. You may find your HIM department suddenly down a...

• Think twice before assigning codes for surgical complications

  CDI programs can greatly enhance documentation, but what happens when a hospital's risk-adjusted...

Issue 5, February 9, 2010

• Business associates could pay for breaches

  Business associates can be directly liable for a breach of unsecured protected health information...

• Q&A: EHR audit log retention

  Q. We use numeric patient account numbers that cannot be tied back to a patient except by a...

• Use PEPPER reports to stay on top of common coding errors

  HIM directors can evaluate their hospital’s potential risk for overcoding and unnecessary...

• Brush up on sequencing as RAC complex reviews get under way

  As RACs begin to roll out complex reviews and request medical record documentation, compliant...

• Coming soon in Medical Records Briefing

  In the March issue of MRB, you’ll find the following articles, and more! EHR beat...

Issue 5, February 2, 2010

• Survey shows RAC activity is on the rise

  Nearly 20% of healthcare providers have already received Recovery Audit Contractor (RAC...

• Q&A: EHR audit log retention

  Q. Does any regulation define the retention period for EHR or electronic medical record audit logs?

• Tips to help ensure effective EHR implementation

  Just getting started with your transition to an EHR? Consider tips from experts in the field...

• Find capital now, gain stimulus funds later

  Healthcare providers still have time to implement EHRs before they start losing out on federal...

Issue 4, January 26, 2010

• New Joint Commission survey process takes into account hospitals’ time demands

  Relief will come to facilities waiting for their unannounced survey by The Joint Commission...

• Q&A: Querying for principal diagnosis

  Q: Is querying a physician for the principal diagnosis appropriate? For example, is this query...

• Integrate identity theft into staff member training

  Educate your patients about playing an active role in fighting medical identity theft, make your...

• Coding corner: Cope with confusing Medicare consultation code payment changes

  The start of the new year typically ushers in a multitude of code changes. But for 2010, Medicare...

Issue 3, January 19, 2010

• RAC posts dozens of new issues for under- and overpayment DRG-validation complex review

  In recent weeks, HealthDataInsights (HDI) has added dozens of new issues to its CMS-approved list...

• Q&A: HIPAA-compliant fundraising

  Q: A large specialty medical group with a nonprofit research foundation allows the foundation to...

• Use PEPPER reports to stay on top of common coding errors

  CMS has once again contracted with the TMF Health Quality Institute to release Program for...

• Know when to report uncertain diagnoses

  Coders may often wish they could read physicians’ minds when clinical documentation is...

Issue 2, January 12, 2010

• AHA offers comments on Congress healthcare reform bills

  The American Hospital Association (AHA) offered comments and suggestions on the Senate and House...

• Q&A: Qualifying for the EHR incentive program under Medicare and Medicaid

  Q: Can eligible hospitals qualify for payments from both the Medicare and Medicaid EHR incentive...

• Renal failure coding tips

  Chronic kidney disease (CKD) affects 26 million Americans, according to the National Kidney...

• Hybrid is a healthy state for vegetables, but not for an EHR

  Throughout the past five years, I have written many articles on topics related to the transitioning...

Issue 1, January 5, 2010

• HHS announces SHARP health IT program, funding

  HHS is making $60 million available to support the development of Strategic Health IT Advanced...

• Q&A: Coding for influenza type A

  Q: How should we code a diagnosis of influenza type A? Should we report ICD-9-CM code 487.1?

• Tip: Assess privacy vulnerabilities for social networking sites

  Trendy social networking sites such as Facebook, TwitterTM, MySpaceTM, and blogs pose enough of a...

• Manage information beyond the EHR

  HIM professionals should no longer think of a record as just a paper form. Records now include...

Issue 13, August 24, 2010

• Coming soon in Medical Records Briefing

  In the September issue of MRB, you’ll find articles on the following topics and more!

Issue 13, August 24, 2010

• Two EHR challenges: Access management and auditing

  Electronic health records (EHR) have their advantages, but they also create challenges for...

Issue 13, August 24, 2010

• Tip: Spice up your PEPPER-related meetings

  The electronic Program for Evaluating Payment Patterns Electronic Report (PEPPER) contains data for...

Issue 13, August 24, 2010

• Q&A: Coding for diagnosis of pregnancy-elevated primary glucose tolerance test

  Q: Which code should I report for a diagnosis of pregnancy-elevated primary glucose tolerance test...

Issue 13, August 24, 2010

• CMS revises POA instructions

  On August 13 CMS issued Transmittal 756, Change Request 7024, to instruct providers on...