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HIM-HIPAA Insider

Issue 14, May 31, 2011

• Minimize verbal and telephone orders

  There are some Joint Commission EPs with which ¬almost all hospital HIM departments struggle...

Issue 14, May 17, 2011

• CMS announces three-day payment window clarification in IPPS proposed rule

  The three-day payment window regulation has been the source of much confusion over the years...

Issue 14, April 26, 2011

• The lost art of data integrity

  Somewhere between the third urgent item on your to-do list, getting your budgets prepared, and...

Issue 52, December 23, 2011

• Final rule updating MLR to factor in ICD-10 conversion costs

  CMS released a final rule to address the medical loss ratio (MLR) by including provisions for...

• Q&A: Attorney requests and authorization expiration

  Q. A patient signed an authorization form eight months ago, and her attorney is now submitting it...

• Cardiomyopathy: Know intent of codes reported

  Cardiomyopathy (CMP), a disease that affects the heart muscle, is an example of a diagnosis that is...

• How one HIM director turned his department around - and saved big bucks in the process

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Issue 51, December 20, 2011

• Happy Holidays from HCPro

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• Large breach reporting nears 400 mark

  The Office for Civil Rights (OCR), which began posting entities reporting breaches of unsecured...

• Q&A: Querying for systemic inflammatory response syndrome (SIRS)

  Q: How should I query for systemic inflammatory response syndrome (SIRS) if SIRS codes to sepsis? I...

• Incorporate remote staff in ICD-10 training sessions

  Training coordinators must find ways of integrating remote staff members into the training...

• Learn why the discharge summary is worth the wait

  Coding without a complete medical record could put your facility at risk during a RAC audit...

Issue 50, December 13, 2011

• HHS revises meaningful use deadline

  HHS recently extended the EHR meaningful use deadline to allow entities to adopt EHR systems this...

• CMS alerts providers about HIPAA 5010 transition

  On December 1, CMS posted a Special Edition MLN Matters article alerting providers that...

• HIPAA Q&A: Media requests

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• What inpatient coders need to know about billing for replacement devices

  Compliant billing for replacement devices requires that coders and billers have the following...

• A no-cost way to prove your competency in HIT

  The need for qualified health information technology (HIT) professionals will increase...

Issue 49, December 6, 2011

• CMS releases 2012 Medicare Physician Fee Schedule final rule

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• Q&A: Coding for arthroscopic patellofemoral resurfacing

  Q: How should we code arthroscopic patellofemoral resurfacing? Some physicians want to code this as...

• Address handwriting legibility with your physicians

  Legibility is one of the five main reasons coders and CDI professionals should query physicians...

• Consider the threats "insiders" pose to your security

  HIPAA privacy and security officers often spend a lot of time and effort protecting their...

Issue 48, November 29, 2011

• Sutter Health breach includes medical diagnoses

  On November 16, Sutter Health in Sacramento, CA, reported on its website the theft of an...

• Q&A: Therapy patients that receive phone calls during appointments

  Q: I need advice for two scenarios in our small outpatient physical therapy clinic. First, what is...

• Understand the implication of coding on readmission data and cohort selection

  CMS is starting to crack down on readmissions, and hospitals may soon feel the effects from a...

• A year's worth of Joint Commission compliance

  As we begin to close out the year, it seems to be a good time to reflect on some of the challenging...

Issue 47, November 22, 2011

• CMS delays HIPAA 5010 enforcement

  CMS’ Office of E-Health Standards and Services (OESS) won’t enforce compliance with the...

• CMS announces new initiatives including RAC prepayment audits and Part B rebilling changes

  As part of the ongoing effort to reduce improper payments in Medicare and Medicaid, CMS announced...

• Q&A: Addenda to discharge summaries

  Q: Some of our physicians are uncomfortable making addenda to the discharge summary to include...

• Understand how learning styles can affect ICD-10 training

  As hospitals begin to develop more intensive training programs in preparation for ICD-10...

• Six best practices to survive increased enforcement

  Before HITECH, covered entities (CE) could pretty much say the government was all bark and no bite...

Issue 46, November 15, 2011

• OCR officially launches privacy, security audits

  The Office for Civil Rights (OCR) formally released its plans for HITECH-required HIPAA privacy and...

• CMS to hold ICD-10 implementation strategies and planning call

  Representatives from the American Hospital Association (AHA), the American Health Information...

• Q&A: Is a written warning for a HIPAA violation considered retaliation?

  Q: We have a nurse who has twice mailed test results to the wrong patient. Both times the nurse...

• Understand the proposed regulation requires HIPAA-covered labs to release test results directly to patients

  Patients may have easier access to laboratory results under an HHS proposed rule, "CLIA...

• Don’t fall prey to coding information overload

  Becoming inundated with coding information is easy in this fast-paced world of interconnectedness...

Issue 45, November 8, 2011

• Changes to cancer centers, separately payable drug payments in 2012 OPPS final rule

  The 2012 OPPS final rule contains some significant wins, including changes to cancer center...

• Q&A: Coding for surgical debridement of devitalized tissue with scalpel

  Q: One of our podiatrists documents “surgical debridement of devitalized tissue with...

• Look to the past for a hint of what's ahead with HIPAA audits

  With potential audits looming, smart healthcare organizations should waste no time ensuring HIPAA...

• Pneumonia with a negative chest x-ray: Clinical diagnoses, physician documentation, and coding guidelines

  As the weather cools, the heat is on coders to properly report the high number of pneumonia cases...

Issue 44, November 1, 2011

• Participate in our 2011 HIPAA compliance benchmark survey

  Dear reader, HCPro is conducting a benchmarking survey on HIPAA compliance efforts and we would...

• Q&A: HIPAA and historical records

  Q: I have a box of patient records that date from 1917 when our hospital first opened through 1934...

• Monitor diagnoses targeted for readmission reduction

  CMS will implement a program to reduce hospital readmissions for certain hospitals with excessive...

• Six ways to make the EHR meaningful use incentive program work for you

  The Medicare and Medicaid EHR incentive programs are well under way at this point. The federal...

Issue 43, October 25, 2011

• AHA to host November conference calls with CMS and RAC representatives

  The American Hospital Association (AHA) will host four members-only conference calls—one for...

• Q&A: Does a faxing error need to be included in an accounting of disclosures?

  Q: A fax containing protected health information (PHI) is sent to an incorrect fax number. Did the...

• Evaluate CAC and software expenses

  Gloryanne Bryant, RHIA, CCS, CCDS, regional managing director of HIM (Northern California Revenue...

• New ICD-9-CM diagnosis codes offer hint of what future holds

  Variety is often the spice of life, and this year's 168 new ICD-9-CM diagnosis codes seem to...

• Prepare for ICD-10

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

Issue 42, October 18, 2011

• OIG releases HIPAA compliance target areas

  The Office of Inspector General (OIG) plans to focus on HIPAA compliance reviews of security...

• Q&A: Release of information authorization forms

  Q: A patient signed an authorization form in February permitting release of personal health...

• Carefully examine syncope and collapse denials

  Hospitals reported syncope and collapse (MS-DRG 312) as the top MS-DRG with respect to financial...

• A port in a storm: Benefits of an EHR when disaster hits

  St. John's Regional Medical Center's EHR went live May 1. On May 22, a deadly tornado struck the...

• Coming soon in MRB

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

Issue 41, October 11, 2011

• Revised RAC statement of work: Impact on providers

  CMS released a revised RAC statement of work (SOW) September 12 that contains several revisions and...

• Q&A: Coding emaciation without documented malnutrituion

  Q: A physician documents emaciation without noting malnutrition. ICD-9-CM indexes emaciation to...

• The four steps of HIPAA policy creation

  HIPAA policy creation is ultimately a four-step process, says Phyllis A. Patrick, MBA, FACHE, CHC...

• EHR best practices from A to Z

  by Darice M. Grzybowski, MA, RHIA, FAHIMA. Over the course of 30 years in the HIM field, I have...

Issue 40, October 4, 2011

• New white paper available on selecting a principal diagnosis

  The Revenue Cycle Institute has released a new white paper, “Principal Diagnosis Selection...

• Q&A: Physicians and patient privacy

  Q: One of the physicians in our practice frequently speaks about patients in the hallway and even...

• Take steps to minimize the security risk for wireless devices

  Healthcare organizations can protect sensitive patient data in a variety of ways as increasing...

• Know how to identify, understand RAC compliance risks

  It shouldn't come as a surprise that RACs use the Common Working File (CWF) to ensure that...

Issue 39, September 27, 2011

• HHS announces new lab/HIPAA rules, new OCR director

  Patients may have easier access to lab results under a proposed rule announced by HHS Secretary...

• Q&A: Are poison control agencies covered entities?

  Q: Should I report ICD-9-CM code V71.5 (observation following alleged rape or seduction) after an...

• Prepare for a HIPAA audit

  How can organizations begin to prepare for a possible HIPAA audit? Recognize that it's all about...

• What color is your PEPPER?

  The Program for Evaluating Payment Patterns Electronic Report (PEPPER), distributed either...

• Prepare for ICD-10

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

Issue 38, September 20, 2011

• CMS releases Medicaid RACs final rule

  In February, the Centers for Medicare and Medicaid Services (CMS) delayed its expected April 1...

• Happy Clinical Documentation Improvement Week!

  The first ever Clinical Documentation Improvement Week is being held this week, Sept. 18–24...

• Q&A: Are colleges sending students to our facility for rotations business associates?

  Q: Should we obtain business associate agreements with colleges that send students to our hospital...

• EHR implementation: Plan wisely

  When working toward an EHR implementation, leave plenty of time for planning the most important...

• FY 2012 IPPS final rule includes some surprises

  The FY 2012 IPPS final rule is out, and hospitals that are bracing for changes effective October 1...

• Coming soon in Medical Records Briefing

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

Issue 37, September 13, 2011

• OCR submits HITECH HIPAA reports to Congress

  HHS submitted two reports to Congress as required by the HITECH Act—one on breaches of HIPAA...

• Q&A: Are poison control agencies covered entities?

  Q: Are poison control agencies considered healthcare providers? Their staff members usually make...

• When, and how, to 'fess up

  Let's face it. It's not human nature to rush to confess our sins. But when it comes to compliance...

• Are you ready for the patient-centered communication standards?

  Don't let the new Joint Commission patient-centered communication standards catch you up...

Issue 36, September 6, 2011

• CMS raises limits for RAC additional documentation for certain providers

  As of August 22, recovery auditors can request up to 35 records per 45 days from non-supplier and...

• CMS announces new initiative to lower costs and improve coordination of services during an episode of care

  On August 23, CMS announced a new initiative to lower costs and help physicians, hospitals, and...

• Q&A: HIPAA and discarded PHI found on-site

  Q: As a hospital employee, I found a patient wristband on the sidewalk outside the emergency...

• Remote coding: The good, the bad, and the productivity

  According to a survey on coder productivity published in the May edition of MRB, 83% of those with...

Issue 35, August 30, 2011

• CMS releases revised ABN, mandatory as of November 1

  During the July 13 Hospital Open Door Forum call, CMS announced the release of a revised ABN form...

• Q&A: Coding based on a note dated after the discharge date

  Q: Some of our physicians are uncomfortable making addendums to the discharge summary to include...

• Understand the difference between an accounting of disclosures and an access report

  The long-awaited notice of proposed rulemaking (NPRM) required by HITECH for accounting of...

• Include physicians during transition to ICD-10: Three tips to help open the lines of communication

  As coders sharpen their knowledge of anatomy and physiology and hone their ICD-10-CM/PCS skills...

Issue 34, August 23, 2011

• RAC demand letter responsibility shifted to MACs

  RACs previously had been responsible for issuing demand letters to providers, but a July 29...

• Q&A: Coding for palliative care

  Q: I am auditing records that include diagnosis code V66.7 (palliative care) for patients...

• Conduct a global HIPAA policy review

  If you're looking for a reason to review your organization's policies and procedures, look no...

• Decisions, decisions, decisions: Appealing denials, addressing interest, and making a case

  Denied claims got you down? An upper-level appeal may be the answer.

• Prepare for ICD-10

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

Issue 33, August 16, 2011

• HIPAA disclosure rule comments highlight provider opposition

  The proposed HIPAA privacy disclosures rule would be an administrative and financial burden for...

• Q&A: Accounting of disclosures

  Q: Must a covered entity (CE) provide an accounting of the following disclosures? A CE...

• Start preparing for ICD-10-CM by comparing differences in diabetes mellitus coding

  In ICD-10-CM, the diabetes mellitus codes are combination codes that include the type of...

• Don’t remain silent if you observe a pattern of fraudulent conduct

  It started with two courageous coders who knew the query process at Johns Hopkins Bayview Medical...

• Coming soon in MRB

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

Issue 32, August 9, 2011

• CMS releases 2012 IPPS final rule

  CMS released its final rule for the FY 2012 Inpatient Prospective Payment System integral to...

• Q&A: Coding for chronic lower back pain from spinal stenosis

  Q: A patient has chronic lower back pain from spinal stenosis. Should I code chronic lower back...

• Use social media cautiously: Tips to help prevent PHI breaches

  Healthcare organizations can protect themselves from PHI breaches associated with the use of social...

• Make sense of the accounting of disclosures proposed rule

  HHS has released the long-awaited notice of proposed rulemaking (NPRM) on the changes to the HIPAA...

Issue 31, August 2, 2011

• AHIMA says HIPAA access report requirement is a 'significant burden'

  The proposed new right for patients to request information on who accessed their health record...

• Q&A: Can staff access their own PHI?

  Q: Is it permissible to allow hospital employees who have been granted access to PHI through the...

• Review HIV coding to ensure compliance

  Coding and sequencing HIV can be challenging for coders, so it's no surprise that CMS identified it...

• Are your ICD-10 educational efforts under way?

  When it comes to ICD-10 education, a day late may mean you're more than a few dollars short. The...

Issue 30, July 26, 2011

• UCLA Health System settles HIPAA violations for $865,500

  HHS entered into its third largest settlement for potential HIPAA privacy and security rule...

• Q&A: Are staffing agencies business associates?

  Q: If a covered entity needs to contract with a staffing agency to provide temporary staff (e.g...

• Jump-start ICD-10 efforts with coding and documentation assessments

  There’s no time like the present to conduct a coding and documentation assessment in...

• ICD-10-CM/PCS: Assess coder productivity and clinical knowledge

  Coding productivity will decrease at least initially with the switch to ICD-10-CM/PCS. Coders will...

• Take our 2011 ICD-10 benchmarking survey!

  Medical Records Briefing is conducting a benchmarking survey on ICD-10-CM/PCS implementation...

• Prepare for ICD-10

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

Issue 29, July 19, 2011

• Take our 2011 ICD-10 benchmarking survey!

  Medical Records Briefing is conducting a benchmarking survey on ICD-10-CM/PCS implementation...

• Q&A: 'Friending' patients on Facebook

  Q: One of our nurses has “friended” one of our patients on Facebook. Is this allowed?

• Best practices to ensure appropriate patient access to their medical records and PHI

  Lou Ann Wiedemann, MS, RHIA, FAHIMA, CPEHR, director of professional practice resources at AHIMA in...

• Take small steps to prepare for ICD-10-CM

  The descriptions of diagnosis codes in ICD-10-CM may be very different than what coders have become...

• Coming soon in MRB!

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

Issue 28, July 12, 2011

• CMS proposes to rescind lab requisition signature requirement

  After 10 years, the requirements for signatures on lab requisitions are still in flux. CMS now...

• CMS releases 2012 OPPS proposed rule

  CMS released the 2012 outpatient prospective payment system (OPPS) proposed rule July 1. The...

• Q&A: Coding conflicting documentation

  Q: Many of our orthopedic surgeons are documenting open reduction internal fixation (ORIF...

• Consider sample data management tracer questions

  Jean S. Clark, RHIA, CSHA, director for accreditation at Roper St. Francis Healthcare in...

• The top five gaps in HIPAA compliance

  When Raj Chaudhary, MS, PE, CGEIT, goes into hospitals, he typically finds five HIPAA privacy and...

Issue 27, July 5, 2011

• Special editions MLN articles highlight inpatient coding vulnerabilities and admit date issues

  CMS released two special edition MLN articles last week. One article, SE1121, highlights some of...

• Q&A: Requests for copies of lab reports

  Q: After meeting with physicians to review lab reports, patients often request a copy of their...

• Prepare for Medicaid RACs

  Providers are currently waiting for CMS to announce a formal start date for the Medicaid RAC...

• Full team ahead: Think outside the department for a comprehensive approach to ICD-10 education

  The staff at St. Francis Hospital-the Heart Center in Roslyn, NY, recognize that the transition to...

Issue 26, June 28, 2011

• Provider-friendly change to tracking observation hours

  In the July OPPS update, CMS made a manual change to the section on counting observation hours that...

• Q&A: Coding 'aspiration without pneumonia'

  Q: Some of our physicians have started documenting “aspiration without pneumonia.” When...

• Keep EHR security in mind

  Don’t forget about protecting security when moving to an EHR. “Electronic health...

• Involve HIM in Joint Commission survey preparations

  Does HIM play a role in Joint Commission survey readiness at your hospital?

Issue 25, June 21, 2011

• 2011 EHR meaningful use deadline looms

  Eligible hospitals and critical access hospitals must begin their 90-day reporting period by July 3...

• Q&A: Coding patellofemoral chondrosis in ICD-9-CM and ICD-10-CM

  Q: How should I report patellofemoral chondrosis?

• Encryption: It's a no-brainer

  Encryption is a very simple solution that can help healthcare organizations avoid some of the major...

• Use PEPPER to enhance your RAC readiness

  Not sure where to focus your RAC preparations these days? Look no further than the Program for...

• Coming soon in MRB!

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

Issue 24, June 14, 2011

• CMS releases final rule on Medicaid HCACs

  Provider-preventable conditions (PPC), including health care-acquired conditions (HCAC), are now...

• Q&A: Surgery schedule posting vs. HIPAA privacy

  Q: Posting the surgery schedule has been a recent topic of discussion at our hospital. Who should...

• Tips from the trenches

  In honor of MRB's 25th year we reached out to some long-time readers who have been on board since...

• 2012 IPPS proposed rule: What you need to know

  CMS has released its fiscal year (FY) 2012 IPPS proposed rule, and coders need to note various...

• Prepare for ICD-10

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

Issue 23, June 7, 2011

• HITECH accounting of disclosures proposed rule released

  On May 27 HHS released a display copy of the Accounting of Disclosures proposed rule as required by...

• Q&A: Notice of Privacy Practices changes

  Q: We were very familiar with Notice of Privacy Practices (NPP) requirements before the enactment...

• Note details when drafting physician queries

  Coders should be mindful of the words they choose when drafting physician queries. Certain...

• Five assessments critical to ICD-10 implementation

  ICD-10 will affect every system within your hospital. So said Mary Rita Hyland, RN, BS, MBA...

Issue 22, May 31, 2011

• Comment on the IPPS proposed rule

  CMS published the 2012 Inpatient Prospective Payment System (IPPS) proposed rule May 5 in the...

• Q&A: BA contract amendments, HITECH requirements, and indemnification clauses

  Q: A covered entity encounters difficulty when executing updated business associate contracts...

• HAC data goes public: Is your hospital ready?

  If you haven't already heard, HAC data is now publicly available on CMS' website, and as of April...

Issue 21, May 24, 2011

• First Medicare and Medicaid EHR incentive payments issued, attestation assistance available

  CMS issued the first set of incentive payments for the Medicare EHR meaningful use program the week...

• OIG reports cite weakness in OCR and ONC efforts to protect ePHI

  The Office of the Inspector General released two reports May 17 questioning the efforts of the...

• Q&A: ICD-10-CM/PCS and ICD-9-CM dual systems

  Q: In what instances would a dual system be necessary after ICD-10 takes effect?

• A winning game plan if OCR launches an investigation

  Healthcare organizations can learn some important lessons from Cignet Health about how not to...

• Prepare for ICD-10

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

Issue 20, May 17, 2011

• CMS holds HIPAA 5010 National Testing Day

  With the January 1, 2012 HIPAA version 5010 compliance deadline approaching quickly, CMS and the...

• Q&A: Coding a coccyx pressure ulcer

  Q: Members of our coding department disagree regarding how to code a coccyx pressure ulcer.Some...

• HIM’s top 10 problematic Joint Commission EPs

  Almost all hospital HIM departments struggle with some Joint Commission EPs.. Surveyors continue to...

• Reminder: Vote now in AHIMA's annual election

  HIM professionals will face many challenges during the next few years. You can help your...

• Coming soon in MRB!

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

Issue 19, May 10, 2011

• CMS issues latest quarterly provider compliance newsletter

  CMS and the Medicare Learning Network (MLN) released the third Medicare Quarterly Provider...

• Q&A: ICD-10-CM/PCS' effect on transcription

  Q: What impact, if any, will the switch to ICD-10-CM/PCS have on transcription?

• Understand how HIPAA and meaningful use could collide

  One possible fallout from an Office for Civil Rights (OCR) increasing HIPAA enforcement action is...

• Inpatient-only procedures: Ensure compliance, avoid RAC recoupments

  Inpatient coders may lack familiarity with the ¬inpatient-only procedure list because CMS...

Issue 18, May 3, 2011

• CMS identifies total improper payment figures, top RAC issue per region

  CMS released a short but useful Recovery Audit Contractor (RAC) update on its website last week...

• Q&A: PHI faxed to the incorrect phone number

  Q: A private individual notified a clinic that he has been receiving faxed protected health...

• Improve moral without spending a lot of money

  Even with today's tight budgets, you can still find ways to brighten the faces of your staff...

• Know how ICD-10 could affect your bottom line

  Exactly how will ICD-10 affect MS-DRG assignment? As coders began learning the intricacies of...

Issue 17, April 26, 2011

• CMS proposes IPPS changes for 2012 and beyond

  The Centers for Medicare & Medicaid Services (CMS) plans limited changes to complications and...

• Q&A: Who needs to learn ICD-10-PCS coding?

  Q: Do I need to learn ICD-10-PCS?

• Learn about CMS proposes value-based purchasing incentives

  Healthcare quality continues to take center stage, and now it could play an important role in...

• Prepare for ICD-10

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

Issue 16, April 19, 2011

• ACDIS submits comments to CDC about proposed ICD-9-CM changes

  The Association of Clinical Documentation Improvement Specialists (ACDIS) submitted comments March...

• Q&A: Percutaneous vs. trocar cholecystostomies

  Q: The following procedures are performed in the radiology department: 51.01 (percutaneous...

• Create a policy for sharing patient information with law enforcement

  Law enforcement officials must follow an established process to acquire information about patients...

• Kick off your ICD-10 implementation the right way

  Managing the changeover to ICD-10 may be so completely overwhelming for some HIM directors and...

• 2011 HIM Director and Manager Salary Survey

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

• Coming soon in MRB

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

Issue 15, April 12, 2011

• RACs using 'semi-automated' claims review

  Providers familiar with automated claims reviews and complex claims reviews by the recovery RACs...

• Q&A: Lewy body dementia and Parkinson?s disease

  Q: May I report Lewy body dementia (LBD) for a patient who has Parkinson’s disease with...

• Spread the word about physician legibility

  Patti Reisinger, RHIT, CCS, HIM director at Community Medical Center in Missoula, MT, is taking a...

• As patients get more savvy, address privacy concerns

  Here's one trend industry observers say healthcare organizations can expect to see now and in the...

• 2011 HIM Director and Manager Salary Survey

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

Issue 14, April 5, 2011

• 2011 HIM Director and Manager Salary Survey

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

• CMS rulemaking on lab requisition signatures at the OMB

  Those of us who have wondered what the outcome will be of CMS’ three-month delay in enforcing...

• Q&A: Does a skin graft code include debridement?

  Q: I have been trying to determine whether a skin graft includes debridement. Based on what I have...

• Tips to help improve physician queries

  Physician queries are a predictable part of any coder's job. Coders may pose hundreds—even...

• Kick off your ICD-10 implementation the right way

  Managing the changeover to ICD-10 may be so ¬completely overwhelming for some HIM directors and...

Issue 13, March 29, 2011

• ICD-10 assessment survey

  HCPro is conducting research into how organizations are assessing their ICD-10 readiness.

• Stay on top of EHR incentive program updates and payments

  CMS announced that it is holding conference calls for eligible professionals and hospitals on April...

• Q&A: Lab requisitions and orders

  Q: What is the difference between a requisition and an order?

• Catch up on Coding Clinic guidance

  Be sure to take a look at Coding Clinic, 3rd and 4th quarters 2010, if you haven't already...

• HITECH promises, but does it deliver?

  With newfound authority, some state attorneys general (AG) are beginning to take aim at covered...

Issue 12, March 22, 2011

• HIPAA enforcement actions take center stage as breaches, violations, and penalties pile up

  HIPAA enforcement actions have been all over the news in the last month. It began with the Office...

• Q&A: Privacy of minors with documented substance abuse

  Q: A 16-year-old patient has admitted to extensive substance abuse, which is documented in his...

• Increased coding compliance, improved productivity: The benefits of computer-assisted coding

  If you haven't already considered adopting computer-assisted coding (CAC) software, there's no time...

• Share your ideas and win a prize!

  What did you do in 2010 that was new, innovative, or otherwise went above and beyond? Share your...

• Prepare for ICD-10

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

Issue 11, March 15, 2011

• CMS raises documentation request limits for certain hospitals

  CMS recently increased the number of medical records that recovery audit contractors (RAC) can...

• CMS updates RAC underpayment instructions

  CMS updated the instructions related to processing underpayments indentified by RACs in Transmittal...

• Tips to help ensure HIPAA compliance

  As healthcare organizations look to the future, they should focus on ensuring HIPAA compliance...

• Comply with MM.04.01.01 documentation requirements

  Jean S. Clark, RHIA, CSHA addresses Joint Commission standard MM.04.01.01 (orders for medication...

• Coming soon in MRB

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

Issue 10, March 8, 2011

• CMS delays Medicaid RAC implementation, issues RAC map

  CMS has officially delayed the proposed April 1 deadline for states to implement their Medicaid RAC...

• AHA weighs in on Part C RACs

  On February 23, the American Hospital Association sent a letter to CMS regarding the expansion of...

• First civil money penalty for HIPAA Privacy Rule violations

  The Office for Civil Rights (OCR), HIPAA privacy and security enforcer, issued its first civil...

• Q&A: Privacy and surgery observation

  Q. What are the requirements for observing surgery? The observer is neither an employee, family...

• Dig deeply into documentation whenever you assign the POA indicator

  You’re coding a record, and the documentation of a patient’s stage III pressure ulcer...

• Share your best work and win a prize!

  What did you do in 2010 that was new, innovative, or otherwise went above and beyond? Share your...

Issue 9, March 1, 2011

• CMS announces electronic data submission tool for providers

  Currently, providers respond to documentation requests from review contractors such RACs and...

• CMS proposes Medicaid payment reductions for provider-preventable conditions

  Provider-preventable conditions would receive a payment reduction under Medicaid, similar to the...

• CHIME recommends delaying meaningful use stage 2

  The College of Healthcare Information Management Executives has recommended that the federal...

• Q&A: Is discussing the health of nonpatient relatives a HIPAA violation?

  Q. I work in patient financial services at a hospital. Like me, several of my coworkers have aging...

• Comply with the new signature requirements for lab requisitions: How HIM can help

  After 10 years, the requirements for signatures on lab requisitions are still in flux; CMS...

Issue 8, February 22, 2011

• CMS forms EHR listserv, posts RAC ADR limits for physicians

  On February 10, CMS announced a new listserv for the Medicare and Medicaid EHR incentive programs...

• Q&A: Coding for follow-up visit after surgical rod insertion

  Q. A patient presents for a follow-up visit after undergoing surgery for insertion of a rod. The...

• Focus on people to address security concerns

  End users—the people in your organization who handle protected health information...

• ICD-10-PCS root operations: A case study approach

  The codes, they are a-changin’. “In my opinion, [ICD-10 implementation] is the biggest...

Issue 7, February 15, 2011

• Contractors to deny claim line items with -GZ modifier

  In two recently issued transmittals, CMS ordered all contractors – MACs, CERTs, RACs...

• Q&A: What information needs to be compromised to constitute a HIPAA breach?

  Q. The Code of Federal Regulations, specifically 45 CFR 160.103, defines protected health...

• Don't forget about your physical space when moving to an EHR

  Take a good look around you. Is your physical environment as ready for your move to an electronic...

• Know when to report secondary diagnoses

  A patient’s medical record could include a laundry list of diagnoses, but not all of these...

• Coder productivity survey prize winners announced

  MRB recently conducted its 2010 coder productivity benchmarking report. (Stay tuned for the...

• Coming soon in MRB

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

Issue 6, February 8, 2011

• CMS talks EHRs, the three-day rule, value-based purchasing program and more

  During the January 12 Hospital & Hospital Quality Open Door Forum, CMS representatives...

• Q&A: Coding for a DPOAE hearing test for a newborn

  Q: What code should I report for a distortion product otoacoustic emissions (DPOAE) hearing test...

• Take ICD-10 tasks off your plate: Bring an HIM intern on board

  Healthcare providers should strongly consider using HIT/HIM student interns for ICD-10-CM/PCS...

• Your training checkup: How to comply with ongoing HIPAA workforce training requirements

  In a November 2010 benchmark study by the Ponemon Institute, 49% of 65 respondents identified lack...

Issue 5, February 1, 2011

• CMS releases RAC FAQ regarding 60-day determination requirement

  On January 13, CMS released a new recovery audit contractor (RAC) FAQ regarding the requirement for...

• Review your policies to ensure compliance with new, revised Joint Commission RC standard EPs

  Are you questioning your readiness for the recently approved Joint Commission patient-provider...

• An ounce of prevention: Keep HIM and coding running smoothly during EHR go-live

  The last thing you need is more to do, but when it comes to preparing your HIM department for EHR...

• Q&A: Next of kin breach notification

  Q. A covered entity received a business associate contract that included breach notification...

• Prepare for ICD-10

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

Issue 4, January 25, 2011

• ONC: 4 in 5 hospitals will claim EHR incentives

  Four-fifths of the nation's hospitals and 41% of office-based physicians plan to cash in on as much...

• Q&A: Consider privacy when leaving preadmission voice mail messages

  Q: May a preadmission nurse leave messages (e.g., “This is a reminder that your surgery is...

• Three tips for conducting coding audits

  With an ever-growing list of RAC-targeted MS-DRGs and a host of coding compliance traps that...

• When selecting an EHR vendor, don't forget the add-ons!

  I was recently working on an EHR project, and there was a deep and vibrant discussion about which...

• Last chance! Take the 2010 Coder productivity survey, win a prize!

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

Issue 3, January 18, 2011

• CMS asks for Part C and D RAC suggestions

  CMS published a notice in the Federal Register December 27 asking for comments on the RAC program...

• Q&A: Modifiers and ICD-10-CM

  Q: Since laterality will be identified in ICD-10-CM diagnosis codes, will we still need to use...

• New Year's resolutions for HIM directors and privacy officers

  HIM directors and privacy officers should consider making the following HIPAA-related New...

• Ensure thorough inpatient rehabilitation documentation

  Now that medical record audits are the rule rather than the exception, inpatient rehabilitation...

• 2010 Coder productivity survey

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

• Coming soon in Medical Records Briefing

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

Issue 2, January 11, 2011

• ONC issues EHR certification program final rule

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

• Q&A: Kaizen events and patient privacy

  Q: During a Kaizen event involving mental healthcare, how can we invite public members of the...

• Take note of the biggest Medicare changes in 2011

  I hope you had a wonderful holiday and started the new year in style! Things were pretty quiet at...

• Know which coding issues to include in your facility's 2011 audit plan

  With an ever-growing list of RAC-targeted MS-DRGs and a host of coding compliance traps that...

• 2010 Coder productivity survey

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

Issue 1, January 4, 2011

• CMS announces registration for EHR incentive program

  CMS and the Office of the National Coordinator for Health Information Technology (ONC) announced...

• Q&A: HIPAA and nurse intake and output sheets

  Q: Our nursing staff continues to tape patient intake and output sheets outside of patient rooms in...

• Coding tips from the experts

  Briefings on Coding Compliance Strategies recently asked advisory board members about the best...

• Release of information practices revealed

  The move to an electronic record affects all areas of the hospital, and the release of information...

• 2010 Coder productivity survey

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