The top finding in Joint Commission surveys for the first half of 2013 should be no surprise for HIM professionals. For the last three years, RC.01.01.01 has been No. 1 on the top 10 list of most frequently cited standards in Joint Commission surveys. The good news is that RC.01.01.01 is the only standard from the Record of Care, Treatment and Services (RC) chapter to make the list. The bad news is that this standard and some of its EPs will most likely continue to be a challenge.
For many people, the new year brings the promise of a fresh start, which is one of the reasons why we often make New Year's resolutions. These resolutions date back to ancient Babylonian times, when people would make resolutions to gods during the vernal equinox. But for HIM professionals, a New Year's resolution often means establishing and abiding by organizational timelines, training your workforce, and updating technology.
The release of CMS' 2014 inpatient prospective payment system (IPPS) final rule was a major game changer for hospitals. While you may be caught up in understanding and applying the 2-midnight rule for inpatient admissions, it's important to remember that the final rule also brings about significant changes to quality of care. We discussed these issues and their impact on the hospital landscape during HCPro's September 10 audio conference "2014 IPPS Final Rule Explained."
It's no secret that ICD-10-CM allows for more specific coding of many diseases and conditions. However, your physician's current clinical documentation may not have enough detail to allow coders to take advantage of this increased specificity.
Healthcare providers are used to regularly changing guidelines and regulations that drastically alter their processes for coding and billing. Despite few guideline changes since 2008, drug administration still frequently causes confusion because of all the necessary factors to properly document, code, and bill the services.
Every healthcare organization should develop and implement a policy and a well-defined process that provides guidance for managing incident and breach response.
