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Medical Records Briefing

Issue 12, December 1, 2010 - VIEW THE FULL ISSUE

• Busted: 10 EHR myths and misconceptions

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

• Step-by-step: What to do when you receive a RAC denial

  You receive a RAC demand letter for repayment. But wait a minute before you pay up—you might...

• Medicaid RACs: Myth or reality?

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

• Strategies for performing staff evaluations

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

• Test your knowledge of anatomy and physiology

  Test your staff members’ knowledge of anatomy and physiology with the following quiz.

• Keep medical record retention rules in mind

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

• 'Twas the night before Go-Live

  It’s the end of the year, and many of us have been on the fast track to EHRs and EDMS...

• The complicated process of reporting complications

  Dear colleagues: As the Patient Protection and Affordable Care Act implementation progresses, the...

Issue 11, November 1, 2010 - VIEW THE FULL ISSUE

• Monitor external audit activity via a review dashboard

  In the past year or so, many hospitals have seen a dramatic rise in external audit activity from a...

• HIPAA refresher: Privacy and family members, collection efforts, and accidental disclosures

  Use this Q&A to test staff members’ knowledge of HIPAA privacy.

• Revise your Notice of Privacy Practices

  HHS released a notice of proposed rulemaking in July modifying the HIPAA Privacy, Security, and...

• Certified EHR systems and technology: Another step toward meaningful use incentives

  The Office of the National Coordinator of Health Information Technology (ONC) approved the...

• New to your HIM managerial role? No problem.

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

• 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...

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

  Present-on-admission (POA) indicators, hospital-acquired conditions (HAC), and never events have...

• Pathogenesis is not a thing of the past

  We went to medical school. We studied, and many of us learned about pathogenesis of diseases. We...

Issue 10, October 1, 2010 - VIEW THE FULL ISSUE

• EHR implementation 2010 survey results: What you have and where you’re headed

  Where is the healthcare community at in terms of EHR implementation, and where is it going from...

• Take a look at inpatient wound debridement coding to help reduce RAC audits and denials

  RACs are looking at excisional debridement coding, and it’s no wonder. There are plenty of...

• ’MRB Talk’: Because you’re not the only one

  It comes up every other day now, it seems. It’s the question with no good answer...

• 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...

• Make sure your EHR measures up: Meet meaningful use standards to qualify for Medicare incentives

  Qualifying for EHR meaningful use incentive dollars is no easy feat. A provider needs to be an...

• 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...

• Quiz: How well do you know the new, revised, and deleted 2011 ICD-9-CM diagnosis codes?

  Test staff members’ knowledge of the new codes with this quiz

• 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...

• Reflect severity through diagnoses and documentation

  Now that fall is in the air, hospitals may feel a chill as Medicare implements the Patient...

Issue 9, September 1, 2010 - VIEW THE FULL ISSUE

• EHR meaningful use: Final rules revealed

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

• Take advantage of nine tips for RAC appeal success

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

• Take a look at the proposed modifications to HIPAA privacy, security, and enforcement

  On July 8, HHS released a proposed rule to modify the HIPAA Privacy, Security, and Enforcement...

• History and physical reports clarified

  I have received several questions related to my “Standards of the month” column about...

• HIPAA refresher: Privacy and release of information

  Use this Q&A to test staff members’ HIPAA knowledge.

• 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...

• Strategies for spicing up your PEPPER-related meetings

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

• Coder speak: It’s almost a different language

  One of the most important aspects of documenting your evaluation and treatment of inpatients in...

Issue 8, August 1, 2010 - VIEW THE FULL ISSUE

• Stay on top of release of information in light of new ARRA, HITECH provisions

  When it comes to release of information (ROI), it may seem that exceptions are the rule. But you...

• EHR beat: Manage misplaced documents in an EDMS

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

• Become familiar with the organization, structure, and unique features of new ICD-10-CM codes

  It may be too early to start intensive ICD-10-CM training for your coding team, but now is a good...

• Take another look at transcription

  If you’ve been outsourcing your transcription but think there might be a better way to meet...

• Acute kidney injury: The crossroads of ICD-9-CM and medical literature

  Dear colleagues: In severity and risk adjustment, defining acute kidney disease, specifically...

Issue 7, July 1, 2010 - VIEW THE FULL ISSUE

• The 2010 HIM director and manager salary survey

  The annual MRB salary survey for HIM directors and managers has come to a close and the results...

• 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...

• Business ethics and the EHR

  Those of us who work in clinical settings are familiar with situations involving medical ethics...

• HIPAA refresher: Privacy and consent for care, ROI

  Test staff knowledge of HIPAA with these questions.

• History and physicals continue to be a challenge

  There is good news, but also a little bad news, about history and physical (H&P) reports...

• Prevent RAC DRG validation and complex coding denials

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

• Ten questions for ICD-10 implementation

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

• Document all elements of disease for cancer patients

  As physicians, we are quite aware of the severity of illness of the cancer patients we treat...

Issue 6, June 1, 2010 - VIEW THE FULL ISSUE

• Changes coming for HIM in wake of healthcare reform

  The Affordable Health Care for America Act, passed in late March, may leave many HIM directors...

• Learn how to motivate your HIM staff members

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

• A multifaceted approach to eliminating H&P deficiencies

  Many hospitals seem to struggle with inconsistencies in the quality of their physicians&rsquo...

• Master HCPCS level II and anatomical modifiers

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

• Quiz: Master surgical root operations to prepare for ICD-10-PCS

  Editor’s note: Use this quiz to prepare staff members for ICD-10-PCS by expanding their...

• How to grow coders: 10 stages to a successful program

  For years the demand for coders has exceeded supply, and for many possible reasons. This may be...

• Red flag update: June enforcement deadline looms

  HIM staff members have a lot on their plates right now, but one more looming deadline needs to be...

• Cardiovascular bundled DRG payments: Healthcare reform’s ACE in the hole

  Most agree that the passage of the Patient Protection and Affordable Care Act will be a...

Issue 5, May 1, 2010 - VIEW THE FULL ISSUE

• Coding corner: Become a modifier master

  The many CPT and HCPCS modifiers can leave coders dazed and confused when it comes to appropriately...

• Answers to your ICD-10 frequently asked questions

  Are you where you should be in terms of the ICD-10 implementation process? If you aren't sure...

• It's time: Find out where your hospital should be in terms of the ICD-10 implementation process

  Are you where you should be in terms of the ICD-10 implementation process? If you aren't sure...

• Considering additional EHR technologies?

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

• Proposed EHR certifying program seeks to balance needs

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

• Master ongoing record review for survey success

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

• This month's idea: Help ensure physician order legibility

  Despite the numerous jokes on the subject, physician illegibility is no laughing matter, and Kaweah...

Issue 4, April 1, 2010 - VIEW THE FULL ISSUE

• HIM central to surviving RACs as auditing activity is on the rise

  Recovery audit contractor (RAC) activity is picking up, but many healthcare providers are still...

• Heal the divide between HIM and CDI

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

• When work flow becomes 'worry' flow

  What is work flow? One of the most common questions I am asked when doing EHR implementation...

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

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

• Quiz: E code extravaganza

  This month's training tool is a quiz HIM directors can use to test staff members' knowledge of E...

• Brush up on sequencing as RAC complex audits begin

  As recovery audit contractors (RAC) begin to roll out complex reviews and request medical record...

Issue 3, March 1, 2010 - VIEW THE FULL ISSUE

• Find out what meaningful use means for you now

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

• Consider implementing a productivity incentive plan for coders and transcriptionists

  Sarah Bush Lincoln Health Center in Mattoon, IL developed a productivity incentive plan for their...

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

  Enter into a off-site record storage contracts carefully to protect against hidden costs and other...

• Survival when you’re thinnest: Tips, tricks, and strategies for managing an understaffed HIM department

  MRB experts share strategies for running an understaffed HIM department.

• Prepare for 2010 based on 2009 hot survey topics

  Jean S. Clark, RHIA, CSHA lists the top noncompliant Joint Commission standards for 2009 and...

Issue 2, February 1, 2010 - VIEW THE FULL ISSUE

• 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, there is...

• Comply with the HHS breach notification interim final rule

  On August 19, 2009, HHS released its interim final rule on breach notification of unsecure...

• Five tips to help ensure effective EHR implementation

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

• Who needs what now? Make sense of the multitude of auditor requests for medical record documentation

  You receive a letter in the mail requesting copies of medical records for an audit. It looks much...

• This month’s training tool: Know the new HCPCS G and J codes

  The AMA added many new HCPCS G and J codes for 2010. Use this quiz to test staff members&rsquo...

• This month’s idea: 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...

Issue 1, January 1, 2010 - VIEW THE FULL ISSUE

• HCPro releases RAC preparedness benchmarking survey results

  HCPro’s “RAC Preparedness Benchmarking Report” shows that HIM directors play a...

• ICD-10 conversion presents opportunities, challenges

  Learn to take advantage of opportunities the conversion to ICD-10 will present, and meet the...

• Manage information beyond the EHR

  Learn how to capture and manage unstructured electronic health information that needs to be part of...

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

  Despite common knowledge that hybrid systems are worse than either fully paper or electronic...

• HIPAA refresher: Protecting privacy when using social networking sites, working with minors, and more

  Encourage staff members to review HIPAA privacy guidelines by testing them with several questions.

• Medical Records Briefing 2009 index

  This index of MRB articles provides readers with the date and page of each story in the newsletter...