HCPro.com - Medical Records Briefing

Stage 2 Meaningful Use requirements: What you need to know

Fri, 01 Jun 2012 04:00:00 GMT

Stage 2 Meaningful Use requirements: What you need to know

If your hospital doesn't plan to take advantage of government financial incentives for those who become "meaningful users" of EHRs, it is in the minority. According to HHS, 85% of hospitals plan to demonstrate meaningful use and earn incentives by 2015.

CMS and the Office of the National Coordinator for Health Information Technology (ONC) advanced the incentive program February 24 by publishing a proposed rule for the second of three stages of EHR meaningful use. Access the rule, Medicare and Medicaid Programs; Electronic Health Record Incentive Program-Stage 2, in the March 7 Federal Register at http://tinyurl.com/7ts3quv.

Providers will have to adhere to Stage 2 requirements in 2014 under the proposed rule, an extension of the original plan for compliance by 2013. Overall, it includes new standards for online access for patients to their health information and electronic health information exchange (HIE) between providers.

The proposed rule "emphasized the desire to increase health information exchange, increase patient and family engagement, and better align reporting requirements with other HHS programs," Farzad Mostashari, MD, ScM, national coordinator for health information technology, said in a February 24 HHS press release. "The proposed rules announced will continue down the path Stage 1 established by focusing on value-added ways in which EHR systems can help providers deliver care which is more coordinated, safer, patient-centered, and efficient."

HIM data mining skills

So where should HIM professionals focus now that the proposed rule is out? Clinical Quality Measures (CQM) reporting to start, says Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, chief operating officer at First Class Solutions, Inc., in Maryland Heights, Mo.

In the proposed rule, eligible providers (EP) and hospitals are still required to report CQMs to demonstrate meaningful use. "I think this stage of MU will be an opportunity for HIM professionals to demonstrate their formula design, data mining, and integrity skills," says Dunn. "The data required for compliance with the CQMs will require HIM expertise to develop complex formulae that will allow the convoluted data to be accurately captured for some of the very complex CQMs."

CMS proposes in the rule a set of CQMs beginning in 2014 that align with existing quality programs such as measures used for the Physician Quality Reporting System, CMS Shared Savings Program, and National Council for Quality Assurance for medical home accreditation.

The proposed rule outlines a process by which EPs, eligible hospitals, and critical access hospitals (CAH) would submit CQM data electronically, reducing the associated burden of reporting for providers; EPs would need to report 12 CQMs; hospitals and CAHs, 24.

What does a CQM look like?

Dunn points out CQM 0372 in the proposed rule:

VTE-2 Intensive Care Unit (ICU) VTE prophylaxis

Description: This measure assesses the number of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after the initial admission (or transfer) to the Intensive Care Unit or surgery end date for surgeries that start the day of or the day after ICU admission (or transfer).

"Just look at all the variables in this very complex sentence," Dunn says. "English grammar teachers who still teach sentence diagramming would have so much fun with this sentence."

In a reporting measure such as this, HIM professionals may need to dissect the components of the requirement to build simultaneous formulae. When programming a formula, they may need to search for an item to see whether it is present, search for another associated item, and then execute a process (add, delete, sum, etc.) to ensure:

Data is pulled from the correct source
Time frames are captured from entry into an ICU or following surgery
Positive and negative factors are checked before data is submitted

"Taking the latter, one must decide whether the 'number of patients' that qualify for reporting must have documentation that VTE prophylaxis occurred or documentation that none was given," Dunn says. "One will need to determine whether cases must be excluded that had documentation that prophylaxis was not given-but no documentation as to 'why' it was not given."

HIM professionals are known for ensuring data integrity, and have been doing so for decades. "2012 is a time for data integrity specialists to shine," Dunn says.

Changes from Stage 1

HIM professionals should target these key changes from Stage 1 criteria in this proposed rule:

Changes to the denominator of computerized provider order entry. Stage 1 optional, Stage 2 required.
Changes to the age limitations for vital signs. Stage 1 optional, Stage 2 required.
Elimination of the "exchange of key clinical information" core objective from Stage 1 in favor of a "transitions of care" core objective that requires electronic exchange of summary of care documents in Stage 2. Effective Stage 2.
Replacing "provide patients with an electronic copy of their health information" objective with a "view online, download, and transmit" core objective. Effective Stage 2.

Margret Amatayakul, RHIA, CHPS, CPHIT, CPEHR, FHIMSS, president of Margret\A Consulting, LLC, in Schaumburg, Ill., says she is surprised by the proposal of a threshold of more than 10% for patients to view, download, or transmit health information to a third party.

Hospitals can make this information available online by hosting a patient portal, contracting with a vendor to host a patient portal, connecting with an online PHR, or through other means.

As long as the patient can view, download, and transmit the information using a standard Web browser, it qualifies.

"I know [the government] wants to do more in this area, but it's the way they're doing it," says Amatayakul. "Instead of giving someone an electronic copy of their medical record, they need to send them to a portal and download it. And the 10%-that's an outcome you don't have any control over. How many [patients] will go online?"

HIE promotion

Stage 2 meaningful use requirements include "rigorous expectations" for HIE including:

More demanding requirements for e-prescribing
Incorporating structured laboratory results
Expectations that providers will electronically transmit patient care summaries to support transitions in care across unaffiliated providers, settings, and EHR systems

"Increasingly robust expectations for health information exchange in Stage 2 and Stage 3 will support the goal that information follows the patient," according to the proposed rule. "In addition, as we forecasted in the Stage 1 final rule, we now consider nearly every objective that was optional for Stage 1 to be required in Stage 2, and we reevaluated the thresholds and exclusions of all the measures."

The rulemakers say the government believes that meaningful use of EHRs must ultimately involve real and ongoing electronic HIE to support care coordination.

Action steps for HIM

Ultimately, HIM professionals should be concerned with everything related to patient access to their medical records, Amatayakul says.

In addition, they should get involved in the construction and any discussions concerning the "view online, download, and transmit" core objective in Stage 2.

"They should be proactive in getting involved in the patient portal construction and management of portal security," Amatayakul says.

Keep track of which patients are using the portal, and encourage patients to use it.

"In many cases, I've seen HIM departments not fully embrace the technology," Amatayakul says. "They need to find a way to have patients use the portals as opposed to saying, 'Oh, I will supply that for you.' I think they really have to embrace and recognize this could be a cost savings for their organizations."

Amatayakul suggests HIM professionals revise their release of information policies to allow them to indicate whether they suggested patients use their portals to retrieve their records. You'll be able to tell the government you offered the program to patients, she says.

Further, determine the most common pieces of information patients request from their records. It may be that a records summary in the patient portal may suffice, Amatayakul says.

"What are the most commonly requested pieces of information out of a patient's record?" Amatayakul says you should ask. "They should be able to click somewhere for summaries of their records."

Privacy, security concerns high in HIEs

Fri, 01 Jun 2012 04:00:00 GMT

Privacy, security concerns high in HIEs

A Boston resident is at a New York Yankees game in the Bronx cheering on his beloved Boston Red Sox. Despite his best efforts to catch a foul ball coming into the stands, he misses, and the ball bounces off his head. He's woozy, and ballpark officials suggest he get to a hospital for precautionary reasons.

At the hospital, instead of filling out multiple forms, the attending physician logs on to a computer in the patient's room and pulls up his medical record and complete history in seconds. That's because the fan's hospital in Massachusetts and the New York facility participate in an interoperable health information exchange (HIE).

HIE advocates use a scenario like this to promote hospitals joining an exchange program, which is defined as the mobilization of healthcare information electronically across organizations within a region, community, or hospital system. But HIE programs do not come concern-free. For HIM professionals whose hospitals have signed on to participate in such a program and for those that are considering it, they must do some due diligence in:

Privacy and security, especially related to other HIE participants
Patient rights to opt in or opt out
Audit logs documenting the transmission of medical records through HIE
Accounts for stored protected health information if the HIE stores data transmitted through the network
Maintenance of the HIE Master Patient Index
Business associate (BA) contract negotiations

"HIM professionals need to understand what an HIE is all about," says Phyllis A. Patrick, MBA, FACHE, CHC, of Phyllis A. Patrick & Associates, LLC, in Purchase, N.Y., who recently coordinated a privacy and security task force for a new HIE in Nevada. "A lot of them are so busy in their days as they wear two or three hats ... Not a lot of them have knowledge and awareness of HIEs."

'Next phase in EHRs'

So why join an HIE? For one, it can improve efficiency of care through quicker and more accurate access to patient records from different providers-or save time and money on medical record requests from others.

"HIE is the next phase in EHRs," authors wrote in the April report by the National eHealth Collaborative, Health Information Exchange Roadmap: The Landscape and a Path Forward. "The benefits of HIE include better care coordination, the assurance that patients and providers have the right information available when needed, improved efficiency, improved quality, cost savings, fewer errors, avoidance of duplicate tests or procedures, improved population health, and more effective consumer and patient engagement."

The government, through the HITECH Act, signed into law by President Obama in February 2009, encourages states to participate in HIEs by offering incentives. HHS awarded agreements to develop and advance mechanisms for information sharing across healthcare. HITECH called for $564 million to support efforts to achieve widespread, sustainable HIE within and among states through the meaningful use of certified EHRs.

"HITECH made HIE a buzzword, but this concept has been around a lot longer," says Chris Apgar, CISSP, CEO and president of Apgar & Associates, LLC, in Portland, Ore. "It wasn't called HIE originally. It was Regional Health Information Organizations. MassShare in Massachusetts has a patient locator service and is just one of many operating HIEs. This all has just gained a lot of attention with HITECH with the government giving states big pots of money to participate."

Privacy and security concerns

Those who participate in HIEs should realize there are privacy and security concerns with sharing health information with providers participating in the HIE electronically. The government heard these concerns, and on March 22 the Office of the National Coordinator for Health Information Technology (ONC) released the Privacy and Security Framework Requirements and Guidance for the State Health Information Exchange Cooperative Agreement. It calls for state HIE participants who received incentive money to create robust privacy and security programs and policies. HIEs that didn't receive money can still use the framework (http://tinyurl.com/73vvrup).

The following tips can help ensure strong privacy and security when entering into and for sustaining an HIE:

"Privacy and security of information is only as strong as your weakest link," Apgar says. "If a member of the HIE does a bad job with protecting health information, that could be a breach of your health information."

"You need to determine what data elements are out there and how it needs to be treated," Apgar says. "You need to carefully examine the requirements for the HIE members as it relates to privacy and security." Apgar suggests working with legal counsel on this. "You want to make sure your patient information is protected."

"Document who is responsible for what," Apgar says. "If I'm transmitting data across an HIE pipeline, as soon as it gets into the pipeline and moves to another organization, it's their responsibility." Organizations must consider encryption information in HIEs, particularly at the "send and receive points," where hackers are likely to attack, according to Apgar. "You may have encryption in place but not at all the right places," he says.

More duties for HIM

HIM directors and managers need to determine which of their facility's patients will be included in the HIE. The industry now is buzzing about "opt-in" and "opt-out" requirements for HIEs.

The National eHealth Collaborative lists five models for defining patient consent to participate in an HIE:

The no-consent model, which doesn't require agreement from a patient to participate in an HIE
The opt-out model, which allows for a predetermined set of data to be automatically included in an HIE, but a patient may still deny access to information in the exchange
The opt-out with exceptions exchange, which enables the patient to selectively exclude data from an HIE, limit information to specific providers, or limit exchange of information to exchange only for specific purposes
The opt-in model, which requires patients to specifically affirm their desire to have their data made available for exchange within an HIE
The opt-in with restrictions model, which allows patients to make all or some defined amount of their data available for electronic exchange

"There is so much discussion about opt-in and opt-out. To me it's a smokescreen," Patrick says. "Eventually, most if not all exchanges will be the opt-in model. The patient should have the right to determine if they want to participate or not, and the healthcare system needs to respect their wishes regarding what will be shared and how."

Patrick says HIM professionals must look at the consent process. A lot of work is going to fall on HIM here.

"It is a tremendous amount of work in terms of getting a signature or getting something formal from a patient," she adds. "Patients will also look to HIM professionals to explain the process to them. As the guardian of the medical record, the HIM professional understands what is required more than most others in their facility or in the HIE. I think HIEs are underestimating this commitment."

Get involved early, Patrick says. HIM must participate up front to "help plan and orchestrate these rollouts and assure that consenting and privacy and security issues are properly and effectively addressed at the outset."

Ultimately, participating in an HIE can help hospitals and providers treat patients more effectively and at a higher quality. Providers may be able to better manage costs by saving money on faxing medical records and operating more smoothly with fewer redundant lab tests, Patrick says.

According to an internal study at Sushoo Health Information Exchange, the current method of exchanging patients' health information (e.g., printing, scanning, faxing, and phone calls) accounts for approximately $17,160 of expenses annually for a single-clinician practice.

If a facility were to go the route of an HIE, an HIM professional, as the guardian of the medical record, must be involved because of his or her knowledge of EHR technology and experience handling patient requests on medical records. "An HIM professional is a critical person to be at the discussion table when an HIE is being formed and when you're talking about patient consent," Patrick says. "And they can help determine what the medical record will look like in the HIE."

Bringing it all together: A Recovery Auditor checklist

Fri, 01 Jun 2012 04:00:00 GMT

Bringing it all together: A Recovery Auditor checklist

Managing Recovery Auditor preparation, requests, denials, and appeals entails the work of many staff members across many departments.

"It just can't be a stand-alone process," says Elizabeth Lamkin, MHA, CEO of PACE Healthcare Consulting, LLC, in Hilton Head, S.C. That's why she and her partner at PACE Healthcare, Amanda Berglund, created the following comprehensive checklist.

"The checklist is really aimed at getting the entire organization together toward a full comprehensive approach, and each department needs to play their part," Lamkin says. Marrying clinical and financial functions is something care management and HIMS has always done, she notes, and the checklist should help the department engage others to assist in managing the otherwise nightmarish logistical process.

To download a copy of the checklist, visit www.hcpro.com/downloads/140.

Quiz: How well do you know your ICD-10-CM chapters?

Fri, 01 Jun 2012 04:00:00 GMT

Quiz: How well do you know your ICD-10-CM chapters?

Use this quiz to test coding staff members.

1.Which ICD-10-CM code series contains neoplasm codes?

a.A series

b.C series

c.F series

d.P series

2.H codes are used to report diseases of which of the following?

a.Eyes

b.Ears

c.Nose

d.Throat

3.Diseases of the musculoskeletal system and connective tissue are found in which series of ICD-10-CM codes?

a.J series

b.K series

c.L series

d.M series

4.Certain conditions originating in the perinatal period are found in which series of ICD-10-CM codes?

a.O series

b.P series

c.Q series

d.R series

5.To report burns, coders would report T codes. Which chapter of the ICD-10-CM Manual contains these codes?

a.Certain Infections and Parasitic Diseases

b.External Cause of Morbidity

c.Injury, Poisoning, and Certain Other Consequences of External Causes

d.Symptoms, Signs, and Abnormal Clinical and Laboratory Findings

6.Mental and behavioral disorders are reported with which series of ICD-10-CM codes?

a.F series

b.G series

c.N series

d.V series

7.Coders will use I codes to report diseases of which system?

a.Circulatory

b.Digestive

c.Genitourinary

d.Respiratory

8.Symptoms, signs, and abnormal clinical and laboratory findings are reported with which series of ICD-10-CM codes?

a.A series

b.Q series

c.R series

d.T series

9.External causes of morbidity are found in which ICD-10-CM code series?

a.P series

b.S series

c.U series

d.V series

10.The ICD-10-CM D codes include which of the following?

a.Certain infections and parasitic diseases

b.Diseases of the blood and blood-forming organs

c.Diseases of the circulatory system

d.Endocrine, nutritional, and metabolic diseases

Answers: 1. b 2. a 3. d 4. b 5. c 6. a 7. a 8. c 9. d 10. b

Medicaid HCACs mean more conditions may go unpaid

Fri, 01 Jun 2012 04:00:00 GMT

Medicaid HCACs mean more conditions may go unpaid

Starting in July, hospitals can risk their reimbursement under the Medicaid program for conditions that CMS deems as "reasonably preventable."

CMS, building off its list of Medicare hospital-acquired conditions (HAC), mandates compliance with its rule, Payment Adjustment for Provider-Preventable Conditions Including Health Care-Acquired Conditions, by July 1. (Access the final rule in the June 6, 2011, Federal Register at www.gpo.gov/fdsys/pkg/FR-2011-06-06/pdf/2011-13819.pdf.)

The new Medicaid healthcare-acquired conditions (HCAC) program uses Medicare's preventable conditions in inpatient hospital settings as the base (adjusted for the differences in the Medicare and Medicaid populations) and provides states the flexibility to identify additional preventable conditions and settings for which Medicaid payment will be denied.

For your organization, that means failure to manage these conditions properly can risk revenue.

The good news for compliance? If your hospital's revenue cycle, quality, compliance, and safety departments already align to create a strong program to avoid Medicare preventable conditions and detect present-on-admission indicators, you're ahead of the game.

"While this is a new requirement, policies and procedures you've already established for Medicaid [HACs] may be easily utilized as a template for success in the Medicare law," William L. Malm, ND, RN, CMAS, senior data projects manager for Atlanta's Craneware, Inc., said in an HCPro November 2011 audio conference, "Medicaid Final Rule for Healthcare-Acquired Conditions: Critical Information You Need to Know in 90 Minutes."

"Medicare is really the baseline of the law," Malm added.

Breaking down the rule

The final rule introduces the new term "healthcare-acquired conditions." Ultimately, these conditions fall under Medicare's provider-preventable conditions (PPC) but expand beyond the Medicare inpatient setting and can include ancillary facilities outside of hospitals.

Some definitions that HIM professionals should know from Section 5001(c) of the Deficit Reduction Act, from which the rule emanates, are:

HACs: Conditions that:
- Are high cost, high volume, or both
- Result in the assignment of a case to a DRG that has a higher payment when present as a secondary diagnosis
- Could reasonably have been prevented through the application of evidenced-based guidelines
HCACs: Conditions that:
- Occur within any Medicaid inpatient hospital setting identified as a HAC by HHS, other than deep vein thrombosis (DVT)/pulmonary embolism (PE) as related to total knee replacement or hip replacement surgery in pediatric and obstetric patients
Other provider-preventable conditions (OPPC): Conditions occurring in any healthcare setting that meet the following criteria:
- Apply broadly to Medicaid inpatient and outpatient healthcare settings where these events may occur
- Are defined to include at a minimum, the three Medicare national coverage determinations (i.e., surgery on the wrong patient, wrong surgery on a patient, and wrong site surgery)
- Would allow states to expand to settings other than inpatient hospital with CMS approval by nature of identifying events that occur in other settings
- Would allow states to expand the conditions identified for nonpayment with CMS approval, based on criteria set forth in the regulation
PPCs: Conditions that:
- Meet the definition of an HCAC or any OPPC. PPC serves as an umbrella term for hospital and nonhospital conditions identified by the state for nonpayment to ensure the high quality of Medicaid services.

CMS excluded DVT and PE because those conditions are not typical within most Medicaid pediatric settings, Malm said.

CMS made another change in the Medicaid HCACs rule regarding never events. Hospitals in the Medicare HAC rule do not have to report for never events if they are not going to bill for them. Never events occur when a healthcare practitioner erroneously performs:

A different procedure altogether
The correct procedure but on the wrong body part
The correct procedure but on the wrong patient

Medicare does not cover a particular surgical or other invasive procedure to treat a particular medical condition when the practitioner commits one of these mistakes.

However, under the Medicaid HCAC final rule, providers must report to CMS never events regardless of whether they intends to bill for them.

"And these can occur in any situation and in any setting," Malm said. "Hospitals had been concerned about liability and malpractice and wouldn't include the never events. But regardless of your intent, you must report it now. The government has been emphasizing quality for many years, and the reason is dwindling funds. They want to make sure the taxpayers are funding the highest quality care and not paying for these adverse conditions."

Providers' homework

In order to be successful in preventing these conditions, Malm said, providers must include in their policies and procedures evidence-based medicine factors.

"We're starting to see it in RACs, and it's an absolute must in order to be successful down the line," he added.

Malm suggested providers preparing to comply with the new Medicaid HCAC final rule must:

Determine who will report conditions. With the new rule comes a new reporting requirement for Medicaid. Is the person doing the Medicare HAC reporting also going to do the HCAC reporting? Do you need to hire another FTE? Should you look to your Medicaid specialist to handle the new burden?
Prepare for multistate cases. Large healthcare systems with facilities in multiple states must be aware of the regulations for each state. "It's very possible some bigger health systems will have to monitor several states," Malm said. Ultimately, CMS said wherever the preventable condition occurred, the hospital must follow that state's reporting requirements.
Seek information from your state Medicaid program. Each state hospital association should have a specialist intimate with this knowledge, or you could go directly to your state's Medicaid website to see where it's at with its HCAC program.

Steps to take

Elizabeth Lamkin, MHA, CEO of PACE Healthcare Consulting, LLC, in Hilton Head, S.C., recommended during the audio conference that providers consider the following suggestions from the National Association of Public Hospitals and Health Systems in its March 2011 letter to CMS regarding the rule on preventable conditions:

Be limited to conditions for which there is clear scientific evidence and practical experience demonstrating that the HCAC is reasonably detectable, taking into account that safety net providers often treat vulnerable patients with multiple comorbidities
Include only conditions researched and vetted by experts, including the provider community
Does not reduce access by discouraging hospitals from taking the highest-risk patients or penalize the safety net hospitals that, by their missions, are dedicated to treating those patients
Be driven by patient safety and not a quest for cost savings

Lamkin said providers must be proactive in reporting and tracking Medicaid HCACs because there are a lot of patients with "so many comorbidities."

To build a robust quality and compliance program around Medicaid HCACs, Lamkin said providers should:

Ensure clinical quality staff trains clinical staff to assess and document potential HCACs
Utilize the education department as an infrastructure to reach all necessary staff
Use clinical criteria such as InterQual® or Milliman®
Create clear policies and procedures in the case of a "never event" and how it must be documented and managed according to the state regulations
Build a culture of transparency
Reward risk reporting
Establish a team to monitor the state's requirements and develop policies and procedures and reporting mechanisms to ensure success
Participate in associations and contact legislative representatives to influence outcome
Review healthcare reform and the Medicaid final rule on HCAC
Gather resources for implementation
Enact your quality performance improvement team to ensure successful implementation through a planned and measurable process
Integrate into current performance improvement systems such as core measure compliance using key performance indicators to measure compliance
Focus on front-end prevention and documentation
Measure results and report through committee structure

Your quality program starts with the board of directors, which must have in place an active Quality Assessment and Performance Improvement and compliance program.

"This program should be charged with identifying weaknesses in all aspects of compliance, including HACs, HCACs, and PPCs," Lamkin said. "The best way to monitor the process and ensure that weaknesses are identified are through a comprehensive quality system that proactively audits and inspects, then corrects."

Medicare HACs list

The following is Medicare's list for hospital-acquired conditions (HAC). Note that CMS eliminated the conditions in bold for the Medicaid healthcare-acquired conditions program:

Foreign object retained after surgery
Air embolism
Blood incompatibility
Stage III and IV pressure ulcers
Falls and trauma
- Fractures
- Dislocations
- Intracranial injuries
- Crushing injuries
- Burns
- Electric shock
Manifestations of poor glycemic control
Diabetic ketoacidosis
- Nonketotic hyperosmolar coma
- Hypoglycemic coma
- Secondary diabetes with ketoacidosis
- Secondary diabetes with hyperosmolarity
Catheter-associated urinary tract infection
Vascular catheter-associated infection
Surgical site infection following:
- Coronary artery bypass graft-mediastinitis
- Bariatric surgery
- Orthopedic procedures
Deep vein thrombosis/pulmonary embolism

Medical Records Briefing, June 2012

Fri, 01 Jun 2012 04:00:00 GMT

Stage 2 Meaningful Use requirements: What you need to know

HIM data mining skills

What does a CQM look like?

Dunn points out CQM 0372 in the proposed rule:

VTE-2 Intensive Care Unit (ICU) VTE prophylaxis

"Just look at all the variables in this very complex sentence," Dunn says. "English grammar teachers who still teach sentence diagramming would have so much fun with this sentence."

Data is pulled from the correct source
Time frames are captured from entry into an ICU or following surgery
Positive and negative factors are checked before data is submitted

HIM professionals are known for ensuring data integrity, and have been doing so for decades. "2012 is a time for data integrity specialists to shine," Dunn says.

Changes from Stage 1

HIM professionals should target these key changes from Stage 1 criteria in this proposed rule:

Changes to the denominator of computerized provider order entry. Stage 1 optional, Stage 2 required.
Changes to the age limitations for vital signs. Stage 1 optional, Stage 2 required.
Elimination of the "exchange of key clinical information" core objective from Stage 1 in favor of a "transitions of care" core objective that requires electronic exchange of summary of care documents in Stage 2. Effective Stage 2.
Replacing "provide patients with an electronic copy of their health information" objective with a "view online, download, and transmit" core objective. Effective Stage 2.

Hospitals can make this information available online by hosting a patient portal, contracting with a vendor to host a patient portal, connecting with an online PHR, or through other means.

As long as the patient can view, download, and transmit the information using a standard Web browser, it qualifies.

HIE promotion

Stage 2 meaningful use requirements include "rigorous expectations" for HIE including:

More demanding requirements for e-prescribing
Incorporating structured laboratory results
Expectations that providers will electronically transmit patient care summaries to support transitions in care across unaffiliated providers, settings, and EHR systems

The rulemakers say the government believes that meaningful use of EHRs must ultimately involve real and ongoing electronic HIE to support care coordination.

Action steps for HIM

Ultimately, HIM professionals should be concerned with everything related to patient access to their medical records, Amatayakul says.

In addition, they should get involved in the construction and any discussions concerning the "view online, download, and transmit" core objective in Stage 2.

"They should be proactive in getting involved in the patient portal construction and management of portal security," Amatayakul says.

Keep track of which patients are using the portal, and encourage patients to use it.

Further, determine the most common pieces of information patients request from their records. It may be that a records summary in the patient portal may suffice, Amatayakul says.

"What are the most commonly requested pieces of information out of a patient's record?" Amatayakul says you should ask. "They should be able to click somewhere for summaries of their records."

Privacy, security concerns high in HIEs

Privacy and security, especially related to other HIE participants
Patient rights to opt in or opt out
Audit logs documenting the transmission of medical records through HIE
Accounts for stored protected health information if the HIE stores data transmitted through the network
Maintenance of the HIE Master Patient Index
Business associate (BA) contract negotiations

'Next phase in EHRs'

Privacy and security concerns

The following tips can help ensure strong privacy and security when entering into and for sustaining an HIE:

More duties for HIM

HIM directors and managers need to determine which of their facility's patients will be included in the HIE. The industry now is buzzing about "opt-in" and "opt-out" requirements for HIEs.

The National eHealth Collaborative lists five models for defining patient consent to participate in an HIE:

The no-consent model, which doesn't require agreement from a patient to participate in an HIE
The opt-out model, which allows for a predetermined set of data to be automatically included in an HIE, but a patient may still deny access to information in the exchange
The opt-out with exceptions exchange, which enables the patient to selectively exclude data from an HIE, limit information to specific providers, or limit exchange of information to exchange only for specific purposes
The opt-in model, which requires patients to specifically affirm their desire to have their data made available for exchange within an HIE
The opt-in with restrictions model, which allows patients to make all or some defined amount of their data available for electronic exchange

Patrick says HIM professionals must look at the consent process. A lot of work is going to fall on HIM here.

Bringing it all together: A Recovery Auditor checklist

Managing Recovery Auditor preparation, requests, denials, and appeals entails the work of many staff members across many departments.

To download a copy of the checklist, visit www.hcpro.com/downloads/140.

Quiz: How well do you know your ICD-10-CM chapters?

Use this quiz to test coding staff members.

1.Which ICD-10-CM code series contains neoplasm codes?

a.A series

b.C series

c.F series

d.P series

2.H codes are used to report diseases of which of the following?

a.Eyes

b.Ears

c.Nose

d.Throat

3.Diseases of the musculoskeletal system and connective tissue are found in which series of ICD-10-CM codes?

a.J series

b.K series

c.L series

d.M series

4.Certain conditions originating in the perinatal period are found in which series of ICD-10-CM codes?

a.O series

b.P series

c.Q series

d.R series

5.To report burns, coders would report T codes. Which chapter of the ICD-10-CM Manual contains these codes?

a.Certain Infections and Parasitic Diseases

b.External Cause of Morbidity

c.Injury, Poisoning, and Certain Other Consequences of External Causes

d.Symptoms, Signs, and Abnormal Clinical and Laboratory Findings

6.Mental and behavioral disorders are reported with which series of ICD-10-CM codes?

a.F series

b.G series

c.N series

d.V series

7.Coders will use I codes to report diseases of which system?

a.Circulatory

b.Digestive

c.Genitourinary

d.Respiratory

8.Symptoms, signs, and abnormal clinical and laboratory findings are reported with which series of ICD-10-CM codes?

a.A series

b.Q series

c.R series

d.T series

9.External causes of morbidity are found in which ICD-10-CM code series?

a.P series

b.S series

c.U series

d.V series

10.The ICD-10-CM D codes include which of the following?

a.Certain infections and parasitic diseases

b.Diseases of the blood and blood-forming organs

c.Diseases of the circulatory system

d.Endocrine, nutritional, and metabolic diseases

Answers: 1. b 2. a 3. d 4. b 5. c 6. a 7. a 8. c 9. d 10. b

Medicaid HCACs mean more conditions may go unpaid

Starting in July, hospitals can risk their reimbursement under the Medicaid program for conditions that CMS deems as "reasonably preventable."

For your organization, that means failure to manage these conditions properly can risk revenue.

"Medicare is really the baseline of the law," Malm added.

Breaking down the rule

Some definitions that HIM professionals should know from Section 5001(c) of the Deficit Reduction Act, from which the rule emanates, are:

HACs: Conditions that:
- Are high cost, high volume, or both
- Result in the assignment of a case to a DRG that has a higher payment when present as a secondary diagnosis
- Could reasonably have been prevented through the application of evidenced-based guidelines
HCACs: Conditions that:
- Occur within any Medicaid inpatient hospital setting identified as a HAC by HHS, other than deep vein thrombosis (DVT)/pulmonary embolism (PE) as related to total knee replacement or hip replacement surgery in pediatric and obstetric patients
Other provider-preventable conditions (OPPC): Conditions occurring in any healthcare setting that meet the following criteria:
- Apply broadly to Medicaid inpatient and outpatient healthcare settings where these events may occur
- Are defined to include at a minimum, the three Medicare national coverage determinations (i.e., surgery on the wrong patient, wrong surgery on a patient, and wrong site surgery)
- Would allow states to expand to settings other than inpatient hospital with CMS approval by nature of identifying events that occur in other settings
- Would allow states to expand the conditions identified for nonpayment with CMS approval, based on criteria set forth in the regulation
PPCs: Conditions that:
- Meet the definition of an HCAC or any OPPC. PPC serves as an umbrella term for hospital and nonhospital conditions identified by the state for nonpayment to ensure the high quality of Medicaid services.

CMS excluded DVT and PE because those conditions are not typical within most Medicaid pediatric settings, Malm said.

A different procedure altogether
The correct procedure but on the wrong body part
The correct procedure but on the wrong patient

Medicare does not cover a particular surgical or other invasive procedure to treat a particular medical condition when the practitioner commits one of these mistakes.

However, under the Medicaid HCAC final rule, providers must report to CMS never events regardless of whether they intends to bill for them.

Providers' homework

In order to be successful in preventing these conditions, Malm said, providers must include in their policies and procedures evidence-based medicine factors.

"We're starting to see it in RACs, and it's an absolute must in order to be successful down the line," he added.

Malm suggested providers preparing to comply with the new

Feeling the heat: Providers share their experience with Recovery Audit Program and other auditors

Tue, 01 May 2012 04:00:00 GMT

Feeling the heat: Providers share their experience with Recovery Audit Program and other auditors

Editor's note: Each year HCPro's Revenue Cycle Institute reports on the experience of providers related to the Recovery Audit Program. The article below is adapted from the 2011 Recovery Auditor Benchmarking Report, released in early 2012. In addition, MRB has looked back at the changes in the program and provider experience since we began surveying providers in 2009, and you will also see that information included in the following pages. The summary of last year's results is by Kimberly Anderwood Hoy, JD, CPC, director of Medicare and compliance at HCPro. Readers can download their complimentary copy of the full report at www.revenuecycleinstitute.com.

This year's survey had 431 respondents representing hospitals of all sizes and from all four Recovery Auditor regions. Respondents were fairly evenly distributed among providers of different sizes, with 21% from small hospitals with less than 100 beds and 31% from larger hospitals with more than 400 beds. Region C had the most respondents, and there was an increased response from Regions A and D, although all regions were fairly well represented.

Survey respondents held the following positions within their facilities:

21%: Recovery audit coordinators
19%: Compliance officers and professionals
13%: HIM directors, managers, and staff
8%: Case managers and case management professionals
6%: Coding professionals

Others, in decreasing number, included clinical documentation specialists, revenue cycle managers and directors, internal auditors and audit professionals, appeals coordinators or professionals, nurses, and utilization review (UR) managers or directors.

Automated, semi-automated, and complex audits

The responses reflect a big uptick in Recovery Auditor activity with a large increase in respondents reporting both automated audits and records requests. Less than 50% of providers had received an automated audit recoupment in 2010, but this number is now up to 72% (see p. 2).

In addition, more than 80% of providers have received records requests for semi-automated or complex reviews over the course of 2011, as seen in the sidebar on p. 3.

This increase in audit activity has led to an increase in the number of respondents who have had money recouped. Seventy-six percent of respondents have experienced recoupment, and only 6% of providers who have received records requests have been left unscathed by recoupments.

Challenges with the Recovery Auditor Program

With the increase in activity of the Recovery Auditors, however, we have seen a corresponding decrease in problems with the operations of the Recovery Audit Program as issues have worked themselves out as predicted in last year's report. For example, the number of respondents having problems with records requests fell from 17% to 8%; other issues related to records requests, other than tracking, were also cited by fewer than 10% of respondents.

The most challenging issues cited by providers are demand letters (21%), tracking recoupments back to individual claims (17%), and the discussion period (16%), all of which CMS has taken steps to address. Beginning in January 2012, demand letters will be issued by the Medicare Administrative Contractor (MAC) rather than the Recovery Auditors to ensure the timing is accurate for recoupments related to the demand letter.

CMS also made changes to the discussion period in the new September 2011 scope of work for the Recovery Auditors, which is available on the CMS website.

Additional government auditors

Providers also saw substantial audit activity by other contractors in addition to Recovery Auditors. Thirty-five percent of respondents have seen audits from the CERT program.

The number of MAC probe audits seemed relatively low at 16%, but 16% of respondents have also had audits from the Office of Inspector General (OIG)-a relatively high number considering how focused OIG audits tend to be.

In addition to the Medicare arena, we are also seeing audit activity from Medicaid, with 16% of respondents having received Medicaid Integrity Contractor audits.

Despite the relatively recent addition of Medicaid Recovery Auditors to the scene, most respondents (57%) seem satisfied that their overall recovery audit preparation will be sufficient for Medicaid Recovery Auditors as well, though 32% are taking additional specific action, including:

Additional education
Internal audits
Strengthening existing processes

Surprisingly, 11% of respondents weren't sure whether their facility is taking a particular course of action. This may reflect the newness of the program or the relatively low level of audit activity experienced at the time of the survey.

Dealing with auditing activity

Most respondents (82%) now have a formal internal program dealing with recovery audits. However, programs are split fairly evenly between those dedicated to recovery audits (45%) and those that include other audits (49%). The trend may be toward unified programs, though, because some of the remaining 6% indicated they are working toward consolidating into one audit activity program.

As in 2010, survey results indicated that the staff members included on providers' Recovery Auditor teams encompassed a variety of positions. Respondents indicated that most teams include HIM, case management, compliance, coding, and patient accounting staff members. Rounding out the bottom five from highest to lowest are physicians, UR physician advisors, patient access, legal, and outside consultant staff members.

Also carrying over from 2010 is the fact that Recovery Auditor teams are once again composed of mostly director-level staff members-68% of respondents indicated that they are present on their team. In addition, as was the case last year, staff-level compliance members represent the smallest percentage for all positions, with only 11% of respondents indicating that they are members of a Recovery Auditor team.

Most facilities were employing or designating a dedicated recovery audit coordinator at the time of the survey; 67% of respondents indicated they have some form of coordinator on their staff. Of those who responded yes, a whopping 58% use a full-time employee for the position, as seen below. Those that indicated "Other" largely do have recovery audit coordinators, but those coordinators hold additional jobs/responsibilities within the facility.

The background of audit coordinators varied, with the largest percent indicating their professional background was in HIM, at 28%. Another 22% were from a case management/nursing background, and 18% had been involved in compliance.

Physician involvement

The overwhelming response from survey participants indicated that providers are generally using physicians on their Recovery Auditor teams-67% reported this-but the physicians' roles on the team vary largely.

Twenty-two percent of respondents use a physician to review denied inpatient cases, while 20% use their physician to help formulate appeals. In addition, 14% have their physician regularly attend Recovery Auditor team meetings, and 11% use him or her to help educate other physicians about denials.

Handling the appeals process

This number should surprise no one: In 2011, 90% of survey respondents indicated that they had a program in place to handle their appeals. This percentage has risen each year since the program began in 2009, as seen in below.

The vast majority of respondents are using at least some internal staff to handle their appeals, with 35% of respondents using a combination of internal staff and an external third party, 34% handling them internally through affected departments, and 23% handling them internally through a dedicated department. Only 5% are handling appeals entirely through a third party, as seen at right.

HIPAA Q&A: Facility directories, opt-outs, and discussing personal health information

Tue, 01 May 2012 04:00:00 GMT

HIPAA Q&A: Facility directories, opt-outs, and discussing personal health information

Test staff knowledge of HIPAA with these questions.

QIf a patient says he or she doesn't want to be in the facility directory, what does this mean?

APatients have the right, under most circumstances, to keep the fact that they are receiving care confidential. (Exceptions might include reporting to public health agencies, insurance companies that are paying for the care, etc.) Patients who choose not to be in the directory should not be listed; this means calls, visitors, mail, etc., would not be forwarded to the patient, nor would the patient's general condition be released to callers. In the event of an inquiry regarding these patients, the appropriate response is something to the effect of, "I am sorry, that patient is not listed in our facility directory. Perhaps you should contact the family."

QWhat is the difference between "opt out" and "opt in" strategies?

AThis question is coming up quite a bit given health information exchanges (HIE) and the beginnings of accountable care organizations. In some states, patients must sign a form indicating they are willing to participate in an HIE, and if they don't sign, they don't participate. This is what is meant by an "opt in" strategy. In other states, patients are assumed to be in the HIE unless they specifically say (usually in writing) that they do not want to participate. This is considered an "opt out" strategy-you are a participant unless you specifically indicate you don't want to be in. As might be expected, opt-out arrangements tend to have many more participants because the patient doesn't have to do anything to participate. Some privacy advocates say, however, that this arrangement does not represent true informed consent (although usually some sort of patient education is given) because patients may not realize their information is included in the HIE unless they take the time to learn the details.

QOne of my colleagues has been quite open about her health issues in the office. She is also a patient here. Is it a HIPAA violation if we discuss her health issues in the office?

AThis brings up the important distinction between HIPAA violations and plain old gossip. If you are talking about information you obtained during the course of business due to your access to PHI (either via medical records or from hearing others discuss it in the course of providing care), it is a HIPAA violation. However, if you are discussing information (even medical information) that a coworker shared, it is not a HIPAA violation as long as you didn't use your position to obtain that information. Put another way, two employees talking about a colleague's medical condition while working at a department store would not be committing a HIPAA violation; they would merely be talking about information they received from the colleague or others. While this sort of discussion could be considered gossip, and therefore probably not wise, it would not be a HIPAA violation.

Editor's note: Chris Simons, RHIA, director of health information and privacy officer at Cheshire Medical Center/Dartmouth-Hitchcock in Keene, NH, provided these questions and answers. This information does not constitute legal advice. Consult legal counsel for answers to specific privacy and security questions.

Prepare now for ICD-10 coding productivity challenges

Tue, 01 May 2012 04:00:00 GMT

Prepare now for ICD-10 coding productivity challenges

Many HIM directors and coding managers are aware of the decrease in productivity that is anticipated with the implementation of ICD-10.

That concern is a valid one, according to Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, chief operating officer of St. Louis-based First Class Solutions, Inc. Dunn presented the session "Coding Productivity: Preparation for ICD-10" at the JustCoding Virtual Summit: ICD-10-CM and ICD-10-PCS.

In ICD-9, coders are accustomed to using the numerical keypad for code entry because so few codes have an alphabetic character, but in ICD-10-CM, that's not the case, Dunn said. Consider the large category of codes for pregnancy and childbirth.

"The codes in this category start with an alphabetical O, so for a split second, our coders-especially our experienced coders-will need to question to make sure they didn't enter a zero instead of an alphabetical O," she said. The coder similarly has to be careful when reporting procedure codes, some of which begin with the number zero.

This might not sound like a significant problem, Dunn explained, but consider the advantage of the 5010 transaction set.

"We're now able to enter 25 diagnoses and 25 procedures, whereas before we were limited to nine and six," she said. "So that split second adds up to seconds and minutes."

In addition, flipping between the numerical and alphabetic keypads takes additional time. "Just think about the time you spend entering a text message on your cell phone and the need to flip back and forth between the letters and the numbers," Dunn pointed out. Additionally, many of the codes will be longer in ICD-10, and some people are anticipating a greater number of queries as a result of the increased documentation that may be necessary under the new coding system.

Predicted declines

The experience of Canadian healthcare organizations may be the best indicator of what's ahead in terms of productivity changes, Dunn said. Providers there experienced a six-month learning curve when they implemented ICD-10, which is the same length of time as HHS is predicting.

That said, given the longer time needed to enter codes and the potential increase in queries, Dunn doesn't believe coders will ever achieve today's level of productivity under ICD-10.

She also offered her own guesses at productivity changes providers might expect for different record types, based on the results of HCPro's 2011 Coder Productivity Survey. (To download a copy of the survey, visit www.hcpro.com/content/266165.pdf.) Dunn estimates the following:

Inpatient records could decrease from 3-3.5 records per hour to 2.5-3.
Ambulatory surgery records could drop from 6-7 records per hour to 5.5-6 records, assuming coders only code the surgeries in CPT® and not in ICD-10-PCS. However, if coders will be dual coding in both ICD-10-PCS and CPT, Dunn anticipates the rate will fall to 5 or fewer records per hour.
Noninterventional radiology tests (i.e., lab tests and outpatient diagnostic tests) may fall from 30 or more cases per hour down to 23-26 per hour because they are diagnosis based. Considering that many hospitals handle a high volume of these tests, it may be necessary to increase staffing to deal with the productivity decrease, Dunn noted.

Tips for minimizing the decreased productivity

Dunn provided the following tips for mitigating the expected decreases in productivity that will come with ICD-10 implementation:

Consider using coding assistants. These include clerical staff members who can help follow up on queries to reduce the double handling that coders currently do. This way coders only need to attend to an encounter when medical staff responds to a query, she explained.
Eliminate non-coding duties. "We no longer have that luxury," Dunn explained. It may also be necessary to consider having other staff members enter the codes into the billing system or perform abstracting, she said.
Reduce distractions for coders-both in the office and off-site. Consider conducting spot visits for remote coders to ensure they are free from distractions while working off-site.
Take a look at technology needs. Optimize connectivity for off-site staff and consider dual or triple screens for coders. Don't overlook the advantages that computer-aided coding applications may provide.
Consider dual coding as soon as ICD-10 education is complete, and be sure to provide feedback to coders based on their dual coding performance.
Emphasize that coders must take responsibility for their own professional development. "The point should be that the organization will provide some support, but that each team member is expected to do some preparation on their own," Dunn said. Encourage team members to work together with their colleagues and share what they learn with each other.
Use skills assessments to identify weaknesses. This includes assessing coders prior to educational refresher courses, such as on anatomy and physiology, and assessing them again after the courses are complete. Conduct assessments yet again after detailed ICD-10 education occurs.
If your coders have strong stomachs and could use some education on different procedures and surgeries, consider taking advantage of the free videos available on YouTube.
Consider supplemental staffing options, including cross-training coders, or backfilling with contracted staff so coders can participate in educational activities. Implementing an apprentice system may also be an option for "growing your own." Consider nurses or therapists who, due to a physical injury, may no longer be able to perform their job but have all the bioscience skills necessary to learn how to code, Dunn said.

And remember, if there are problems that exist today, they need to be fixed before getting to ICD-10, Dunn said.

Editor's note: For more information about this and other presentations from the JustCoding Virtual Summit, please visit www.hcmarketplace.com/JCSummit.

The 10 P's of ICD-10 coder productivity preparation

According to Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, chief operating officer of St. Louis-based First Class Solutions, Inc., the 10 P's of ICD-10 productivity preparation are:

?1.Capture a Point of reference

?2.Predict labor requirements

?3.Plan for sources of labor

?4.Product and tool considerations

?5.Take the Pulse on skill sets

?6.Polish the skill sets

?7.Prep coders, physicians, and others for ICD-10

?8.Practice ICD-10

?9.Adjust labor Predictions based on training and practice results

10.Be Poised for 10/1/2013?

Get to know the 2012 ICD-10-CM guideline changes

Tue, 01 May 2012 04:00:00 GMT

Get to know the 2012 ICD-10-CM guideline changes

The additions and revisions to the ICD-10-CM Official Guidelines for Coding and Reporting in 2012 include some new information that coders should be aware of in preparation for ICD-10 implementation.

"They've done a good job of taking the previous guidelines and reworking them for 2012," says Sandy Nicholson, MA, RHIA, vice president of health information services for DCBA, Inc., an Atlanta-based consulting company. Now coders just need to familiarize themselves with the changes.

Probably the biggest change in the guidelines is the requirement for a causative link between a complication and a procedure, Nicholson says. If the provider documents a cause-and-effect relationship, coders may assign a complication of care, but if the provider doesn't, coders can't. "Coding Clinics have given us guidance on that for a long time … but the ICD-10 guidelines really come out and talk about it."

This requirement will probably lead to additional queries, she notes. As Coding Clinic indicated for ICD-9-CM, if the physician doesn't document a cause-and-effect relationship (e.g., for postop bleeding), coders will need to query the physician regarding whether a complication is directly related to the procedure. That said, not all coders may do so in ICD-9. That changes with ICD-10. "The ICD-10 guidelines make it very clear that we have an obligation to query. We can't just use the ICD-9 version of the 900 codes. We can't just make that assumption anymore just because the physician says it is postop," Nicholson says.

Similarly, if a patient returns from the procedure room and spikes a fever or has high blood pressure while in recovery, coders can't assume these conditions are complications of the procedure, says Shelley C. Safian, PhD, MAOM/HSM, CCS-P, CPC-H, CPC-I, CHA, AHIMA-approved ICD-10-CM/PCS trainer of Safian Communications Services in Orlando, FL.

"You would have to have the physician document the underlying cause of the fever. If it is expected that their blood pressure is going to spike or they'll have a fever, then that's not a complication," she says.

Glaucoma

Another significant change for 2012 includes an entirely new set of guidelines for glaucoma. They're very specific, Nicholson points out, and current levels of documentation may not be adequate. "We need to be aware of that and start discussing whether we want to query," she says. "I personally have not ever seen a patient admitted for glaucoma; it's just not heard of much. But potentially it's going to be important down the road that we have that stage and type."

Note the following guidelines:

When a patient has bilateral glaucoma and the physician documents both eyes as being the same type and stage, and a code for bilateral glaucoma exists, report only the code for the type of glaucoma, bilateral, with the seventh character for the stage. If there is no code for the bilateral glaucoma under these circumstances (i.e., with subcategories H40.10, H40.11, and H40.20), report only one code for the type of glaucoma with the appropriate seventh character for the stage.
When a patient has bilateral glaucoma but each eye has a different type or stage, and the classification distinguishes laterality, assign the appropriate code for each eye rather than the code for bilateral glaucoma. For patients with a different type of bilateral glaucoma in each eye but without classification for laterality, coders should assign one code for each type of glaucoma with the appropriate seventh character for the stage.
Finally, when a patient has bilateral glaucoma of the same type in each eye but in different stages, and the classification does not distinguish laterality, coders should assign a code for the type of glaucoma for each eye with the seventh character for the stage documented for each eye.

The guidelines also address the use of the seventh character "4" (indeterminate stage):

The seventh character "4" is used for glaucomas whose stage cannot be clinically determined. This seventh character should not be confused with the seventh character "0", unspecified, which should be assigned when there is no documentation regarding the stage of the glaucoma.

The coding guidelines also note that if a patient's glaucoma progresses during admission, coders should report the highest stage documented.

Neoplasms

There are a few important changes to the guidelines for neoplasm coding as well.

ICD-10-CM guidelines instruct coders to classify a primary malignant neoplasm that overlaps two or more contiguous sites to the subcategory/code .8 (i.e., "overlapping lesion"), unless the combination is specifically indexed elsewhere. Look at code C85.28 (mediastinal [thymic] large B-cell lymphoma, lymph nodes of multiple sites) as an example, Safian says.

In addition, the guidelines state that coders should assign a code for each site when multiple neoplasms of the same site aren't contiguous, such as tumors in different quadrants of the same breast.

The new guidelines also address malignant neoplasms of ectopic tissue, saying, "Malignant neoplasms of ectopic tissue are to be coded to the site mentioned, e.g., ectopic pancreatic malignant neoplasms are coded to pancreas, unspecified (C25.9)."

Ectopic tissue is tissue located somewhere it shouldn't be, just as an ectopic pregnancy is one where the embryo implants in a place outside of the uterus, Nicholson explains.

Anemia associated with chemotherapy

When a patient is admitted or sees a provider for management of anemia associated with a malignancy, and receives treatment only for anemia, report the code for the malignancy as the principal or first-listed diagnosis followed by the appropriate code for the anemia, according to the 2012 guidelines. Further, when a patient has anemia associated with an adverse effect of chemotherapy or immunotherapy and receives treatment only for the anemia, coders should sequence the anemia code first followed by the appropriate codes for the neoplasm and the adverse effect.

"There are some changes made to how we sequence anemia with neoplasm," Nicholson explains. "With ICD-10, we will be assigning the malignancy as the principal diagnosis. If it's just an anemia associated with a malignancy, the malignancy is sequenced as principal; the anemia is secondary."

However, situations where anemia is associated with chemotherapy haven't really changed. "So that's a good thing, and that is familiar to us," Nicholson says. "We do sequence the anemia code first, but it's now considered an adverse effect and we would code the adverse effect secondary."

Other changes

The official guidelines included several other changes for 2012, including:

Pain disorders related to psychological factors. There is a new note that instructs coders not to use code G89 (pain not elsewhere classified) when documentation supports a psychological component for the pain. In that case, coders should go back to code S45.41, Nicholson explains, noting that such a distinction hadn't previously existed.
Syndromes. If no code exists for a particular syndrome, ICD-10 guidelines now state that coders should report the manifestations (e.g., those conditions identified as a result of the patient having that syndrome) instead, Safian says. "But the connection has to be documented by the physician to qualify," she points out.
Conditions affecting organ transplant. Per the guidelines, coders should assign a code from category T86.xx (complications of transplanted organ) as well as an additional code identifying the specific complication. "This specifically now says that the complications of the transplanted organ code should be reported first," Safian explains. "Previously there was no guideline regarding order, so this addition makes sense."
Late effects (i.e., sequela). Coders won't be using the term "late effects" any longer, but instead will look for the word "sequela." "It makes perfect sense and really correlates with the use of sequela in the seventh digit characters in the musculoskeletal system," Nicholson says.

Coders need to pay attention to these new guidelines, Nicholson says. "I would highly recommend that all coders have a copy of the ICD-10 guidelines and review them periodically. Because even though we aren't held to these guidelines right now, we need to be ready to apply them as soon as we start assigning ICD-10 codes, which we will all be doing for practice so when the drop-dead date arrives, we'll be ready."

Coders should familiarize themselves with new terminology, such as "sequela," and highlight changes that will be of particular importance for their organization and their own coding, she advises. "Like the time period for the acute myocardial infarction-that's changing to four weeks and we're used to eight weeks. We're going to have to be aware of that," Nicholson says. "So keep looking for those changes."

Hire an ICD-10 educator: Sample job description

Tue, 01 May 2012 04:00:00 GMT

Hire an ICD-10 educator: Sample job description

Here's one wheel that HIM directors and managers may not need to reinvent: an ICD-10 educator job description.

Many organizations may want to consider hiring a staff member to manage the educational component of the transition to ICD-10.

Thankfully, Christine Lewis, MHA, RHIA, CCS, CCS-P, health information services coding and record processing manager at the Medical University of South Carolina in Charleston, was willing to share the job description in use at her hospital with those who might be wondering how to structure the position at their own facility.

Refer to the sample job description for an ICD-10 educator on p. 12 for a look at how her facility has handled the position.

Medical Records Briefing, May 2012

Tue, 01 May 2012 04:00:00 GMT

Feeling the heat: Providers share their experience with Recovery Audit Program and other auditors

Survey respondents held the following positions within their facilities:

21%: Recovery audit coordinators
19%: Compliance officers and professionals
13%: HIM directors, managers, and staff
8%: Case managers and case management professionals
6%: Coding professionals

Automated, semi-automated, and complex audits

In addition, more than 80% of providers have received records requests for semi-automated or complex reviews over the course of 2011, as seen in the sidebar on p. 3.

Challenges with the Recovery Auditor Program

CMS also made changes to the discussion period in the new September 2011 scope of work for the Recovery Auditors, which is available on the CMS website.

Additional government auditors

Providers also saw substantial audit activity by other contractors in addition to Recovery Auditors. Thirty-five percent of respondents have seen audits from the CERT program.

In addition to the Medicare arena, we are also seeing audit activity from Medicaid, with 16% of respondents having received Medicaid Integrity Contractor audits.

Additional education
Internal audits
Strengthening existing processes

Dealing with auditing activity

Physician involvement

Handling the appeals process

HIPAA Q&A: Facility directories, opt-outs, and discussing personal health information

Test staff knowledge of HIPAA with these questions.

QIf a patient says he or she doesn't want to be in the facility directory, what does this mean?

QWhat is the difference between "opt out" and "opt in" strategies?

QOne of my colleagues has been quite open about her health issues in the office. She is also a patient here. Is it a HIPAA violation if we discuss her health issues in the office?

Prepare now for ICD-10 coding productivity challenges

Many HIM directors and coding managers are aware of the decrease in productivity that is anticipated with the implementation of ICD-10.

This might not sound like a significant problem, Dunn explained, but consider the advantage of the 5010 transaction set.

"We're now able to enter 25 diagnoses and 25 procedures, whereas before we were limited to nine and six," she said. "So that split second adds up to seconds and minutes."

Predicted declines

That said, given the longer time needed to enter codes and the potential increase in queries, Dunn doesn't believe coders will ever achieve today's level of productivity under ICD-10.

Inpatient records could decrease from 3-3.5 records per hour to 2.5-3.
Ambulatory surgery records could drop from 6-7 records per hour to 5.5-6 records, assuming coders only code the surgeries in CPT® and not in ICD-10-PCS. However, if coders will be dual coding in both ICD-10-PCS and CPT, Dunn anticipates the rate will fall to 5 or fewer records per hour.
Noninterventional radiology tests (i.e., lab tests and outpatient diagnostic tests) may fall from 30 or more cases per hour down to 23-26 per hour because they are diagnosis based. Considering that many hospitals handle a high volume of these tests, it may be necessary to increase staffing to deal with the productivity decrease, Dunn noted.

Tips for minimizing the decreased productivity

Dunn provided the following tips for mitigating the expected decreases in productivity that will come with ICD-10 implementation:

Consider using coding assistants. These include clerical staff members who can help follow up on queries to reduce the double handling that coders currently do. This way coders only need to attend to an encounter when medical staff responds to a query, she explained.
Eliminate non-coding duties. "We no longer have that luxury," Dunn explained. It may also be necessary to consider having other staff members enter the codes into the billing system or perform abstracting, she said.
Reduce distractions for coders-both in the office and off-site. Consider conducting spot visits for remote coders to ensure they are free from distractions while working off-site.
Take a look at technology needs. Optimize connectivity for off-site staff and consider dual or triple screens for coders. Don't overlook the advantages that computer-aided coding applications may provide.
Consider dual coding as soon as ICD-10 education is complete, and be sure to provide feedback to coders based on their dual coding performance.
Emphasize that coders must take responsibility for their own professional development. "The point should be that the organization will provide some support, but that each team member is expected to do some preparation on their own," Dunn said. Encourage team members to work together with their colleagues and share what they learn with each other.
Use skills assessments to identify weaknesses. This includes assessing coders prior to educational refresher courses, such as on anatomy and physiology, and assessing them again after the courses are complete. Conduct assessments yet again after detailed ICD-10 education occurs.
If your coders have strong stomachs and could use some education on different procedures and surgeries, consider taking advantage of the free videos available on YouTube.
Consider supplemental staffing options, including cross-training coders, or backfilling with contracted staff so coders can participate in educational activities. Implementing an apprentice system may also be an option for "growing your own." Consider nurses or therapists who, due to a physical injury, may no longer be able to perform their job but have all the bioscience skills necessary to learn how to code, Dunn said.

And remember, if there are problems that exist today, they need to be fixed before getting to ICD-10, Dunn said.

Editor's note: For more information about this and other presentations from the JustCoding Virtual Summit, please visit www.hcmarketplace.com/JCSummit.

The 10 P's of ICD-10 coder productivity preparation

According to Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, chief operating officer of St. Louis-based First Class Solutions, Inc., the 10 P's of ICD-10 productivity preparation are:

?1.Capture a Point of reference

?2.Predict labor requirements

?3.Plan for sources of labor

?4.Product and tool considerations

?5.Take the Pulse on skill sets

?6.Polish the skill sets

?7.Prep coders, physicians, and others for ICD-10

?8.Practice ICD-10

?9.Adjust labor Predictions based on training and practice results

10.Be Poised for 10/1/2013?

Get to know the 2012 ICD-10-CM guideline changes

The additions and revisions to the ICD-10-CM Official Guidelines for Coding and Reporting in 2012 include some new information that coders should be aware of in preparation for ICD-10 implementation.

Glaucoma

Note the following guidelines:

When a patient has bilateral glaucoma and the physician documents both eyes as being the same type and stage, and a code for bilateral glaucoma exists, report only the code for the type of glaucoma, bilateral, with the seventh character for the stage. If there is no code for the bilateral glaucoma under these circumstances (i.e., with subcategories H40.10, H40.11, and H40.20), report only one code for the type of glaucoma with the appropriate seventh character for the stage.
When a patient has bilateral glaucoma but each eye has a different type or stage, and the classification distinguishes laterality, assign the appropriate code for each eye rather than the code for bilateral glaucoma. For patients with a different type of bilateral glaucoma in each eye but without classification for laterality, coders should assign one code for each type of glaucoma with the appropriate seventh character for the stage.
Finally, when a patient has bilateral glaucoma of the same type in each eye but in different stages, and the classification does not distinguish laterality, coders should assign a code for the type of glaucoma for each eye with the seventh character for the stage documented for each eye.

The guidelines also address the use of the seventh character "4" (indeterminate stage):

The coding guidelines also note that if a patient's glaucoma progresses during admission, coders should report the highest stage documented.

Neoplasms

There are a few important changes to the guidelines for neoplasm coding as well.

In addition, the guidelines state that coders should assign a code for each site when multiple neoplasms of the same site aren't contiguous, such as tumors in different quadrants of the same breast.

Ectopic tissue is tissue located somewhere it shouldn't be, just as an ectopic pregnancy is one where the embryo implants in a place outside of the uterus, Nicholson explains.

Anemia associated with chemotherapy

Other changes

The official guidelines included several other changes for 2012, including:

Pain disorders related to psychological factors. There is a new note that instructs coders not to use code G89 (pain not elsewhere classified) when documentation supports a psychological component for the pain. In that case, coders should go back to code S45.41, Nicholson explains, noting that such a distinction hadn't previously existed.
Syndromes. If no code exists for a particular syndrome, ICD-10 guidelines now state that coders should report the manifestations (e.g., those conditions identified as a result of the patient having that syndrome) instead, Safian says. "But the connection has to be documented by the physician to qualify," she points out.
Conditions affecting organ transplant. Per the guidelines, coders should assign a code from category T86.xx (complications of transplanted organ) as well as an additional code identifying the specific complication. "This specifically now says that the complications of the transplanted organ code should be reported first," Safian explains. "Previously there was no guideline regarding order, so this addition makes sense."
Late effects (i.e., sequela). Coders won't be using the term "late effects" any longer, but instead will look for the word "sequela." "It makes perfect sense and really correlates with the use of sequela in the seventh digit characters in the musculoskeletal system," Nicholson says.

Scanning productivity: How do you match up?

Sun, 01 Apr 2012 04:00:00 GMT

Scanning productivity: How do you match up?

When it comes to the scanning function, how does your facility compare to those of your peers? To help you answer that question, MRB focused its latest quarterly benchmarking survey on scanning productivity. We hope you'll find the results helpful. More than 200 survey respondents completed the 2012 survey, including:

42% HIM directors
32% HIM managers
7% other HIM staff members

Most respondents work in hospitals, including a full 61% who work in acute care and 13% who work in critical access hospitals. Other respondents reported working in locations such as skilled nursing facilities (4%), long-term acute care hospitals (3%), and healthcare system corporate offices (3%).

Respondents from hospitals also provided information on the number of beds at their facility:

15% work in hospitals with 25 or fewer beds
19% work in hospitals with 26-99 beds
22% work in hospitals with 100-199 beds
14% work in hospitals with 200-299 beds
15% work in hospitals with 300-499 beds
14% work in hospitals with 500 or more beds

Productivity expectations

In 2012, productivity expectations for those performing the prepping function were as follows:

0-150 images per hour: 16%
151-300 images per hour: 23%
301-450 images per hour: 14%
451-600 images per hour: 9%
More than 600 images per hour: 4%

An additional 34% of the respondents were uncertain, didn't measure productivity for the prepping function, or measured it differently (e.g., inches of records).

These productivity expectations have changed somewhat since 2009, when expectations tended to be higher:

0-150 images per hour: 12%
151-300 images per hour: 20%
301-450 images per hour: 16%
451-600 images per hour: 9%
More than 600 images per hour: 10%

The productivity expectations for those who perform the actual scanning process have also changed since 2009. The 2012 expectations were as follows:

0-500 images per hour: 45%
501-1,000 images per hour: 24%
1,001-2,000 images per hour: 18%
2,001-3,000 images per hour: 8%
3,001-4,000 images per hour: 4%
More than 4,000 images per hour: 1%

In the 2009 survey, 47% of facilities reported expectations of 1,000 images per hour or less. In 2012, that number rose to 69%. Meanwhile, 11% of facilities expected more than 3,000 images per hour in 2009, but by 2012, only 5% did. Thus, the number of images facilities expect to be scanned per hour has decreased in the prior years.

Consider the following changes in expectations:

0-200 images per hour: 24% in 2009 vs. 38% in 2012
201-400 images per hour: 27% in 2009 vs. 25% in 2012
401-600 images per hour: 16% in 2009 vs. 21% in 2012
601-800 images per hour: 18% in 2009 vs. 8% in 2012
801-1,000 images per hour: 6% in 2009 vs. 3% in 2012
More than 1,000 images per hour: 8% in 2009 vs. 5% in 2012

The trend seems to be a decrease in productivity expectations. When it comes to expectations for those performing quality control, the numbers once again decreased since 2009. The expectations for 2012 were:

300 or fewer images per hour: 40%
301-500 images per hour: 31%
501-1,000 images per hour: 16%
1,001-1,500 images per hour: 8%
1,501-2,000 images per hour: 3%
More than 2,000 images per hour: 1%

In 2009, 41% of facilities expected those in quality control to process 1,000 or fewer images per hour. That number jumped to 71% by 2012. Meanwhile, the number of facilities expecting more than 1,500 records processed per hour fell from 10% in 2009 to 4% in 2012.

Process, technology, and staffing changes

While productivity expectations generally seem to be on the decline, other aspects of the scanning function seem to have remained fairly steady in the past few years. For example, most facilities are still using in-house staff to perform the scanning function: 92% used in-house staff in 2009, and 94% do so in 2012. Of the remaining facilities, both years showed a fairly even split between those who use an off-site vendor and those who use a third-party vendor that performs the scanning function on-site.

Similarly, in both 2009 and 2012, the majority indicated that they scan their records post-discharge, but not necessarily until after the record is complete, as seen below. Other changes to the scanning function, including the use of technology such as color or backup scanners, and other information, such as how facilities approach back-scanning, can be found in the sidebars on pp. 4-5.

New measures for 2012

We began surveying respondents on several new aspects of scanning in 2012. For example, survey data showed that 75% of facilities use bar codes on at least some forms to assist with indexing, but only 21% do so on all forms. The survey also asked those who perform their scanning in-house whether those doing the work also perform outside tasks. Survey respondents indicated:

78% perform other HIM functions as well as scanning
20% only perform scanning functions
2% perform other duties mostly for departments outside of HIM

For those who perform their scanning in-house, we also asked which departments beyond HIM perform the scanning function. Survey data showed that nearly half of the facilities have only the HIM department scanning into the medical record (48%), while another 48% indicated that certain select clinical departments also scan documentation into the record. Only 4% of facilities have all clinical departments scanning into the record.

Finally, the survey asked how many FTEs facilities have allocated to the scanning function:

37% indicated 1-2 FTEs
20% indicated 3-4 FTEs
15% indicated 5-6 FTEs
7% indicated 7-8 FTEs
6% indicated 9-10 FTEs
15% indicated more than 10 FTEs

Along with other productivity expectations, survey data regarding the number of FTEs allocated to scanning is available according to provider size. Download this additional information at www.hcpro.com/downloads/140.

Quiz: ICD-10-CM codes for symptoms, signs, and abnormal clinical and laboratory findings

Sun, 01 Apr 2012 04:00:00 GMT

Quiz: ICD-10-CM codes for symptoms, signs, and abnormal clinical and laboratory findings

Use this quiz to test coding staff members.

1.What is the ICD-10-CM code for right upper quadrant abdominal pain?

a.R10.10

b.R10.11

c.R10.31

d.R10.811

2.What is the ICD-10-CM code for functional quadriplegia?

a.R53.0

b.R53.1

c.R53.2

d.R54

3.What is the ICD-10-CM code for an elevated carcinoembryonic antigen?

a.R97.0

b.R97.1

c.R97.2

d.R97.8

4.What is the ICD-10-CM code for anorexia?

a.R62.51

b.R63.0

c.R63.4

d.R64

5.What is the ICD-10-CM code for straining to void?

a.R39.0

b.R39.14

c.R39.15

d.R39.16

6.What is the ICD-10-CM code for intercostal pain?

a.R07.1

b.R07.2

c.R07.82

d.R07.89

7.What is the ICD-10-CM code for unspecified ataxia?

a.R26.0

b.R26.2

c.R26.9

d.R27.0

8.What is the ICD-10-CM code for localized edema?

a. R60.0

b. R60.1

c. R60.9

d. R61

9.What is the ICD-10-CM code for spontaneous ecchymoses?

a. R23.0

b. R23.3

c. R23.8

d. R23.9

10.What is the ICD-10-CM code for an inconclusive mammogram?

a. R92.0

b. R92.1

c. R92.2

d. R92.9

Answers: 1. b 2. c 3. a 4. b 5. d 6. c 7. d 8. a 9. b 10. c

Manage EHR access and audit controls

Sun, 01 Apr 2012 04:00:00 GMT

Manage EHR access and audit controls

HIPAA requires implementation of technical policies and procedures for electronic information systems that maintain electronic protected health information (ePHI) to allow access only to those persons or software programs that have been granted access rights [§164.312(a)] as specified in the administrative safeguards under access authorization, establishment, and modification [§164.308(a)(4)].

Implementation specifications include the requirement for unique user identification and an emergency access procedure. Automatic logoff and encryption/decryption of data retained in systems are addressable implementation specifications.

Access controls should be consistent with the requirements for minimum necessary use [§164.512(d)(2)(i)], in which the persons or classes of persons, as appropriate, in the workforce who need access to PHI to carry out their duties are identified, and for each such person or class of persons, the category or categories of PHI to which access is needed and any conditions appropriate to such access are identified.

HIPAA also requires audit controls that record and examine activity in information systems that contain or use ePHI [§164.312(b)].

Compliance concerns

Compliance with access controls is highly dependent upon the vendor's technical capabilities. As more facilities adopt health IT (HIT) and EHR system components, it is incumbent upon the healthcare organization to demand appropriate access controls.

Many healthcare organizations find access management cumbersome and frequently cannot even do what they would like to be able to do.

Many vendors do not support emergency access procedures within their technical capabilities, so facilities adopt manual procedures that are rarely effective.

A better solution, also known as "break-the-glass," is a technical emergency access procedure that should permit a person who is not otherwise authorized access to invoke the break-the-glass function (much like breaking the glass on a fire alarm pull) and have immediate access.

The break-the-glass function establishes a special audit log of the access, which some organizations direct not only to IT, but also to a supervisor, department chair, or attending physician.

It has been found that the break-the-glass function is a highly effective deterrent to inappropriate access yet is not cumbersome to use. Note that some organizations find such functionality cumbersome (i.e., it involves too many exceptions) when the access controls aren't specific enough to begin with or when there are problems with documentation concerning which clinicians are clinicians of record.

Some IT departments have questioned the need for strong access controls when audit controls exist. In fact, there are concerns about audit logs that make them less-than-ideal means to control access. Audit logs vary greatly in their level of sophistication as well. Some log access to the application only, others associate a login with an individual's ePHI, and others are capable of more granular logging, such as to a specific data element.

Of course, the more granular the auditing, the more sophisticated the aids to review the audit trails must be. There are many utilities on the market that can provide pattern and other analysis of these logs.

Some organizations deploy these to associate an access login with individuals sharing a last name, target VIPs, or flag other common targets. Just the same, the review of false positives and the sheer volume of logs, especially as hospitals adopt more HIT and EHR components, are often difficult to manage.

In addition to monitoring audit logs, many organizations are not sure how long they need to retain their audit logs.

HIPAA requires "an action, activity, or assessment required by the Security Rule to be documented and maintained for six years from the date of its creation or the date when it was last in effect, whichever is later" [§164.316(b)].

Some security experts suggest that it is only necessary to retain the actual audit logs for long enough to detect a potential problem, after which you can delete the logs if you retain the findings of the analyses.

Some organizations, however, simply move the logs to a separate storage area instead of deleting them.

Policy implications

Your electronic environment with respect to your security policies should:

Ensure that access controls, including the technical capability for an emergency access procedure should it become necessary, make it easy for members of the workforce to gain access to PHI when authorized or in an emergency or extenuating circumstance. One best practice is to ensure that access is established only when there is written authorization and upon physical presentation of positive identification (e.g., a government-issued photo ID).
Periodically evaluate the need for encryption of data residing in HIT and EHR systems.
Ensure that audit controls are robust enough to support proactive detection of potential unauthorized access. This includes evaluating the use of break-the-glass functionality that directs audit trail data to designated persons.

Editor's note: Amatayakul is president of Margret\A Consulting, LLC, in Schaumburg, IL, an independent consulting firm that focuses on EHR readiness preparation, selection, implementation, and adoption strategies, as well as HIPAA/HITECH assessment and compliance.

This article is excerpted from The No-Hassle Guide to EHR Policies, Second Edition, published by HCPro. For additional information, visit www.hcmarketplace.com/prod-8872.

Can I get a EHR reality check, please?

Sun, 01 Apr 2012 04:00:00 GMT

Can I get a reality check, please?

While I was on one of my first consulting engagements in the early 1980s-when the pundits were predicting that everyone would be fully on EMRs no later than 1990-I experienced a rude wake-up lesson: the automating dysfunction "reality check" factor.

I was contacted by a physician who wanted to "computerize" his office, starting with the implementation of electronic records. Of course, there wasn't really a whole lot of software available at that time because PCs hadn't been around for more than a year or two. My reality check occurred when I saw piles of toppled-over charts in his office, medical forms lying loose and scattered in all the examination rooms, and plenty of desktops and counters that you couldn't see the bottom of. Oh my.

I looked at the physician and explained to him that unless he had a clean work flow and a clear plan, putting computerization in place would only lead to automating dysfunction. Of course, he didn't move forward, and I'm sure he retired before he ever organized his desktop or installed a functional EMR system in his office.

Fast-forward 30 years

Now it's 2012. The pundits are still predicting everyone will be fully transitioned to EMRs in the next few years, and that's despite the February CMS data showing that less than 6% of physicians and 10% of hospitals have attested to meeting meaningful use criteria.

Why are we moving so slowly? There are more than enough software vendors now, and government funding has become available to facilitate the process. We have a tremendously large (and growing) group of high-level professionals who are knowledgeable in health information technology (HIT), even with the current labor shortage. Yet even today, I frequently walk into a facility only to be struck by another reality check and another potential case of automating dysfunction.

Create a new reality

Change is difficult. None of us really like it, and we are naturally averse to encouraging it unless we see a personal benefit (hence the ever-important question, "What's in it for me?"). But when attempting to move forward with automation, getting rid of the status quo is a necessary evil.

Below are some suggestions to help you prepare for change and avoid the trap of dysfunctional automation:

Know your strengths and weaknesses. If you know where your facility stands compared to best practices, you'll have a fighting chance of actually embracing and encouraging change. If you aren't sure what the best practices are, research them or hire an expert. Once you have identified where your variances and gaps are, you can begin to put an action plan in place to tweak your processes. Good processes create a solid foundation for EMRs.
Avoid remaining silent in lieu of discussion. It's sometimes easier to quietly accept decisions that you don't agree with rather than debate with another department or individual (or maybe even your boss). Unfortunately, silent acquiescence can lead to a suboptimized environment where work-arounds and bandages are routine, and there are more exceptions than standardizations. If this sounds like your environment, you are seriously in need of a revamped process-even if it means undoing a few layers before understanding the root causes of your environment's dysfunction.
Acknowledge that tried and true might just be the best course. KISS (Keep it Simple, Stupid) is one of my favorite acronyms because it's easy and true. When we eliminate complexity and replace it with common sense, we also build stability into a system. There is a reason HIM professionals were taught in school that analysis should occur before coding records. By staffing properly and completing deficiency analysis first, coders need only handle the record once it contains completed documentation and is ready for coding. With the coder shortage and the importance of clinical documentation, can we really afford to skip this analysis step and slow down coders by presenting them with anything other than properly analyzed and completed medical records?
Keep an open mind. As important as it is to follow core best practices, it is equally important to keep an open mind to new processes and the opportunity technology brings to the table. Work with vendors to understand and create new ways to get old tasks done. This takes a pioneering spirit, but it can be very fulfilling. Today's leading-edge practitioners create the best practices of tomorrow. Computer-assisted coding? Computer-assisted clinical documentation improvement? Charge description master auditing software? Jump on board with these types of automated processes, all of which can help build the path toward EHR adoption.

Make your own reality

HIM experts can help guide the way when implementing EMRs. Specifically, look to AHIMA knowledge resources, practice communities, and official practice briefs. Learn from your more experienced colleagues, and above all, ask for help when you can't do it alone. We have all experienced the phenomenon of a consultant telling an executive the same message you have been saying for years-only now it's become the executive's reality check!

Don't forget about ethical and professional practice principles. Use them when you are trying to make your voice heard because something doesn't feel right. Speak up as a patient confidentiality advocate next time there is a proposed policy that allows everyone access to a discharged patient's electronic records or protected health information, even if they haven't been involved with the care of that specific patient. Say something the next time you are asked to reverse a patient's observation status after discharge "just to get the bill paid by the insurance company" even though the documentation clearly indicates three days of hospitalized inpatient services. It may be time to remind everyone what the purpose of observation status really is.

If we want to ever have those pundits succeed in their predictions of getting us all on electronic records, we'd better stop allowing our physicians, our executives, our vendors, and ourselves to implement solutions and make decisions that simply automate our existing dysfunctional environments. Do a reality check within your own four walls to see what might really be getting in the way of an improved work flow-one where everyone is pulling in the same direction.

Editor's note: Grzybowski is the president of HIMentors, LLC, which specializes in HIM operations, education, best practices, EHR/EDMS implementation, legal health record management, and the provision of strategic marketing services for physician-owned practices, hospitals, and healthcare technology vendors. She is a nationally recognized author, speaker, and expert in automation in healthcare and data management. For more information, go to www.HIMentors.com or info@HIMentors.com.

Comply with CMS' CoP for order authentication

Sun, 01 Apr 2012 04:00:00 GMT

Comply with CMS’ CoP for order authentication

In November 2006, CMS published a final rule on the Conditions of Participation (CoP) for hospitals. Among the finalized provisions, there was a five-year window given during which CMS permitted orders (including verbal and telephone orders) to be signed by either the ordering physician or another physician responsible for the patient's care (e.g., a covering physician or practice partner). Those five years came to an end on January 27, 2012, meaning that, as of that date, hospitals needed to ensure that their orders were signed only by the ordering practitioner him- or herself. However, in October 2011, CMS released a proposed rule addressing the five-year sunset provision. Per the Federal Register:

The new provision would retain the requirement that all orders, including verbal orders, must be dated, timed, and authenticated promptly by the ordering practitioner, but would add the exception . . . allowing for authentication by either the ordering practitioner or "another practitioner who is responsible for the care of the patient . . ."

The proposed rule comment period ended at the end of 2011, and January 27 has now passed. So do hospitals need to restrict signatures only to ordering physicians? Technically, the five-year window allowing other physicians to sign the orders has expired, so until CMS publishes a final rule indicating otherwise, they do.

"It does appear that until the proposed rule changes are published, hospitals will be expected to abide by the requirement to have physicians authenticate their own orders," says Jean S. Clark, RHIA, CSHA, director for accreditation at Roper St. Francis Healthcare in Charleston, SC, and former president of AHIMA.

Clark believes CMS will revise the CoPs to allow other appropriate practitioners to sign for one another. She suggests that HIM professionals begin working with their licensing agencies to change state laws, if needed, to coincide with the proposed rule change when it happens. She also suggests that hospitals advise their medical staff of the change and begin to monitor compliance.

CMS also proposed removing the 48-hour time frame for order authentication, requiring instead that it occur based on hospital policy or existing state law. "This is an excellent change and a step in the right direction," Clark says. "All of the proposed rule changes are great news to hospitals. We just need them to happen quickly!"

CMS also used the proposed rule to reiterate the risk involved in the use of verbal orders and urged providers to discourage their use.

Tips, strategies, and hints for achieving physician engagement in ICD-10-CM/PCS

Sun, 01 Apr 2012 04:00:00 GMT

Tips, strategies, and hints for achieving physician engagement in ICD-10-CM/PCS

We hear about physician engagement across and throughout all healthcare settings almost daily.

This is not new, but when it comes to ICD-10-CM/PCS preparation, facilities and practices need engaged physicians.

Engagement has many meanings and applications, but for the purpose of ICD-10-CM/PCS, the definition that best fits is the act of sharing in the activities of a group.

You may struggle to obtain this type of engagement, but you need to build it into your readiness and implementation plan.

The fact is, ICD-10-CM/PCS is a very large change that impacts many, including physicians.

Importance of physician engagement

According to Gallup.com, organizations with high levels of physician engagement exhibit the following positive outcomes:

Higher revenue and earnings per admission and per patient day
Increased referrals from engaged physicians
Reduced physician recruiting costs
Sustained growth and profitability

"The physician needs to engage in the process," says Kelly Caverzagie, MD, an academic hospitalist in the division of hospital medicine at Henry Ford Hospital in Detroit. Caverzagie defines that engagement as "active enrollment and doing it for the right reason."

To achieve engagement, you must be able to articulate the benefits and reasons for the switch to ICD-10-which include patient care, quality, and safety-to physicians.

We know that some physicians are not convinced of the need for ICD-10 and called for the delay in implementation.

It's obvious from that we need better communication and increased understanding within the industry about the benefits of the new code sets across the healthcare continuum.

ICD-10 experts can assist with the messaging and communication efforts to engage physicians and their associations and societies.

Current and future documentation concerns

I recently attended a compliance conference during which one of the physician speakers discussed gaining physician buy-in.

He spoke about the need to understand the physician perspective and their challenges. He noted that the No. 1 issue physicians face today is documentation.

This isn't just an issue arriving with the advent of ICD-10-CM/PCS-it's something they're facing right now with the current coding systems.

Physicians already need to provide documentation for the following reasons:

Patient care
Quality
Safety
Reimbursement
Severity and acuity data

The list goes on and on. We can't leave physicians out of the loop when it comes to ICD-10-CM/PCS because documentation is vital to accurate coded data.

Engaging physicians around documentation issues will take a lot of effort since documentation is not seen as a priority in physicians' day-to-day patient care functions.

Tips for engaging physicians

Here are some tips that might provide some direction and insight into your engagement and readiness efforts:

Develop a set of Microsoft® PowerPoint® slides or material dealing with ICD-10-CM/PCS awareness. Keep the material short and simple, and request 10 minutes at a medical staff meeting to present the information. Invite the physician office staff to participate-this will increase the understanding of the scope and impact of ICD-10, and engagement of the physician office staff is critical to ensure collaboration and success.
Create some documentation and coding examples using ICD-10-CM/PCS terms and codes. Post these where they can be seen by your medical staff. Remind physicians that ICD-10-CM is simply an extension of ICD-9-CM with added specificity for laterality and several other relevant clinical details.
Communicate with your hospital medical staff office and ask to publish some regular ICD-10-CM/PCS articles in the medical staff newsletter or bulletin over the next two years.
Invite those physicians who code to attend your educational programs and other offerings.
Include physicians on your ICD-10-CM/PCS implementation committee. If possible, appoint a physician champion who can communicate to other physicians and lead physician-related activities surrounding ICD-10.
Provide tools to your physicians. Look at your EHR and see whether you can add any quick enhancements, electronic templates, and/or reminders to help with documentation specificity (this may be an extension of your current documentation improvement activities). If you are still using paper records, look at templates that might be useful. Providing tools will ease the anxiousness that exists regarding ICD-10.
Always present the facts and give data whenever possible. Run some reports on diagnoses that are not elsewhere classified and not otherwise specified; this might help you spot a pattern or trend.
Offer to conduct a documentation assessment and provide the findings to your physicians. Target clinical specialty areas (e.g., orthopedics) to focus on the areas of ICD-10-CM/PCS with the most changes from ICD-9.
Join forces with clinical documentation improvement and other HIM professionals in your physician engagement activities-ICD-10-CM/PCS expertise lies within HIM. Offer to help with physician awareness and their implementation plan as well.
Always be open to suggestions and responsive to questions. Try to be as available and accessible as possible. Being known as an ICD-10-CM/PCS resource will help with physician engagement.

ICD-10-CM/PCS increases specificity and granularity, thereby providing better diagnostics and targeted treatment of illnesses, which benefits all of healthcare in the long run. Being prepared takes organization and planning, which will be pivotal to success with ICD-10, so don't wait; physician engagement is your calling card as we move into 2012!

Editor's note: This article originally appeared in the January issue of the HCPro newsletter JustCoding. Visit www.justcoding.com for additional information.

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

Sun, 01 Apr 2012 04:00:00 GMT

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

It's 2:30 p.m. and you haven't stopped moving since you stepped into your office this morning.

As you run down your mental to-do list for the rest of the afternoon, you realize you're double-booked for multiple meetings, and you're having trouble prioritizing because your phone keeps buzzing with new e-mail notifications.

If you're an HIM director, this scenario likely repeats day in and day out.

From researching and implementing EHR systems to developing training and education plans for ICD-10 to overseeing your Recovery Audit Program review results, the daily tasks of an HIM director can quickly become overwhelming.

In the past year or two, Monica Pappas, RHIA, president of MPA Consulting in Long Beach, CA, and MRB advisory board member, has noticed a drastic increase in the amount of major projects overseen by the HIM department. And many of these projects have far-reaching effects that impact the entire organization, compared to times in the past when projects may have had a more limited effect.

Pappas points to HIPAA implementation as the most recent project spearheaded by HIM that mirrors the organizationwide effects of EHR implementation and ICD-10 conversion.

The difference between HIPAA and these new initiatives is that HIPAA came about during a relatively calm period for HIM, whereas multiple projects are currently due to launch around the same time.

That said, the projects must get done, which means HIM professionals need to be at their best.

So MRB asked Pappas and two other HIM professionals for their advice on how they handle their busy schedules and what they do when the pressure becomes too much.

Reach out to professional peers and resources

Pappas finds professional organizations such as AHIMA or state HIM organizations provide excellent tools and resources that HIM professionals may adapt for use in their own organization.

She recommends taking the time to research training modules, job descriptions, and policies and procedures that you may be able to use to fill gaps in your department.

Pappas also suggests reaching out to your fellow HIM professionals-they may have already formulated the policies you wish to develop.

"If I see someone else's policies and procedures, I can take 20 minutes to adapt them as my own," she says. "It gives [HIM professionals] a jumping-off point rather than starting from scratch."

It's when HIM directors don't have a plan that they can feel the most frustrated, she notes.

Pappas stresses the importance of talking to your manager if you are feeling overwhelmed. "It can't all be negative, but if you don't give some warning signals, you won't get help," she says.

Help may come in many forms, from contracting with a vendor to take over a project or hiring temporary support staff to alleviate some of the burden.

Asking for help is not a sign of weakness, says Pappas, and the consequences of not asking for help can be far worse than the perception of weakness.

It's also critically important to recognize what you have managed to get done versus focusing on what remains, says Pappas.

She suggests breaking down projects into smaller, manageable tasks and formally scheduling those tasks into your calendar. In doing so, HIM professionals will be able to manage the set due dates for each step of their projects.

Use Outlook for more than just e-mail

Patti Reisinger, RHIT, CCS, HIM director and privacy officer at County Medical Center in Missoula, MT, is currently overseeing the implementation of a new EHR system, monitoring the Recovery Audit Program audit process, and working on ICD-10 education and training-in addition to her day-to-day responsibilities of overseeing the HIM department.

Reisinger finds using her Microsoft® Outlook® calendar to schedule and track her meetings helps in managing her hectic schedule.

"I use Microsoft Outlook for everything to do with my professional life," she says.

Additionally, Reisinger uses Outlook's tasks feature to keep a virtual to-do list of all her deadlines and assignments.

As e-mails come in that need attention, she prioritizes them using Outlook's flags and follow-up features to keep order within her inbox. And with the large volume of e-mail she receives every day, having a system in place helps ensure important messages are not lost in the shuffle.

Reisinger even uses her Outlook calendar to make sure she builds in a bit of time for herself.

"Schedule your noon hour in Microsoft Outlook for your lunch," she recommends.

She says people looking to schedule meetings will take any available space in your calendar, so blocking out that time will ensure you have a much-needed break between meetings and deadlines.

Reisinger also recommends taking time away from your desk, even it is just for five minutes. "I stress to my staff to take breaks. Take time away from your desk and away from the office," she says.

For example, when Reisinger needs a quick break, she may take the long way back from the hospital cafeteria after lunch or, when the weather permits, goes for a brief walk outside.

Even five minutes away from your desk can provide enough of a mental break to alleviate stress and get refocused, she says. Delegate responsibilities to your staff

Tesa Topley, RHIA, director of HIM and privacy officer at Providence St. Patrick Hospital in Missoula and St. Joseph Medical Center in Polson, MT, is also in the process of implementing an EHR system and managing ICD-10 education and training.

She finds delegating certain responsibilities to her staff mutually beneficial.

Specifically, she says that the EHR rollout has led to 10-14 hours of conference calls per week, plus internal meetings.

"I've reached out to my staff and asked them who wants to work on each initiative and participate in these phone calls," she says. "It's helped them understand that these changes are coming, and they get to feel some ownership in the changes."

Topley has shifted much of the responsibility for ICD-10 training and education to her coders.

She has already sent four of her coders to an AHIMA Train-the-Trainer seminar and each of those four actively participate in ICD-10-related phone calls.

"I've really put the ownership on my coders and they love it," she says.

Topley finds the collaborative environment extends beyond just those whom she has chosen to participate in the new committees and initiatives.

Those employees not directly involved have stepped up to cover the day-to-day responsibilities of the department.

This has freed up time for those who spend some of their time on the special committees.

"Rely on your staff. They are experts in their domain, so let them be the experts," says Topley.

Relinquishing that bit of control will allow you to focus on other areas that need your attention.

If all else fails, what does Topley recommend? Buy a coloring book.

"When I get home, I have two little boys, so we are always doing something like playing Nintendo® Wii™ or coloring. You work to live, you don't live to work," she says.

Transitioning to an EHR: Three steps to consensus building

Sun, 01 Apr 2012 04:00:00 GMT

Transitioning to an EHR: Three steps to consensus building

2012 is upon us, and for many healthcare organization leaders, the ticking clock of healthcare reform just got a lot louder. In a mere two years, the incentives to implement EHRs will end, and penalties for those that have failed to comply will begin.

Yet, as time ticks away, the industry literature increasingly tells us that organizations are not ready to make the transition. The underlying reasons are plentiful. Organizations face a host of obstacles, among them a lack of financial resources. While I can't alleviate financial hardships, I can offer support to help organizations tackle another major challenge: lack of staff support.

No organization can hope to make the EHR transition without the support and buy-in of their staff. The key to securing that support is consensus building, and organizations that are not yet on the road to implementation need to start working now to build that consensus. For these organizations, I offer my three I's to consensus building-a three-step process to creating a climate of acceptance and enthusiasm among staff.

Step 1: Identify

You hear the rumblings, you feel the tension, and you have a general sense that the staff is not embracing healthcare reform. But do you know who the actual resisters are and what commonalities they may share in job function or background? Do you know why staff members are resisting? You need to identify the source of the tension before you can address it. Create a focus group of employees to discuss their concerns in a safe environment. Only with that insight can you move forward to build consensus.

Step 2: Include

All too often leaders make decisions by consulting other leaders, forgetting that those decisions will have ramifications for every employee all the way down the chain. You cannot build consensus in a dictatorial regime. I do not mean to suggest that leaders should abdicate decision-making to low-level employees. However, if you want to build a true consensus, which is necessary for a transition of this magnitude, you need to include your employees in the conversations.

A great way to foster inclusion is, again, through focus groups. Bring in a good cross section of employees from all levels and all departments. You might be surprised to hear legitimate concerns from someone in a department that you didn't imagine would be affected by the change.

Step 3: Inform

Resistance to change is often rooted in fear of the unknown. Educate your staff, both in terms of how to use the new systems and in terms of their value.

A 30-year veteran who has been doing things one way for three decades may be terrified of learning a new system. Moreover, he or she may not see a reason to change. Provide the necessary education so staff can feel confident that they will succeed with the new processes.

Recognize, too, that the level of education required for each staff member may vary considerably. Recent graduates, like those coming out of the University of Phoenix Health Administration program, are likely to be aware of new technologies and more amenable to the transition, while more seasoned employees may need more education and time to warm up to the idea. Be candid with them about the benefits of making the transition and the ramifications of not transitioning.

Change is always challenging. However, with the support and help of the staff, it can be a little easier.

Editor's note: Patton is associate dean of the University of Phoenix College of Natural Sciences and responsible for the university's Health Administration program.