News & Information

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How to Craft an Effective Record Retention Policy

As healthcare organizations create and manage vast quantities of electronic data from various sources, record retention has become an increasingly vital and challenging aspect of information governance. Providers are pressed to make tough decisions—what to keep, what to destroy, and how to retain or archive information in a cost-effective manner.

Many uphold the idea that storage is cheap—why not keep records forever? However, a “keep everything” approach is not a practical long-term plan.
| Read More.

ICD-10-CM Mental Health Code Changes

One of the hardest jobs for coders is to translate physician terminology into ICD-10 coding terminology. This has been especially challenging with codes related to mental and behavioral health. In some cases during the year following ICD-10 implementation , there was no way to convert DSM-5 terminology used by psychiatrists and psychologists to ICD-10-CM. Lack of understanding of the differences between the code sets led to misinterpretation and frustration among coders and mental health professionals. | Read More.

Part B News

Question: When two surgeons are working a patient, when is modifier 62 (Two surgeons) appropriate and when is modifier 80 (Assistant surgeon) appropriate?
Answer: If you’re going to bill 62, the procedure must “really need the individual skills of two surgeons to even perform — a complex nature, like certain spine or heart transplant procedures,” says Corina Marquardt, CPC, CPMA, senior consultant with the Haugen Consulting Group in Denver.

CMS helps you figure out whether these modifiers are appropriate by listing co-surgery and assistant-at-surgery status indicators in the relative value file of the Medicare physician fee schedule. | Read More.

Uniting HIM and IT

Uniting HIM and IT: LESSONS LEARNED OFFER TANGIBLE TAKEAWAYS TO BRIDGE THE DISCONNECT AND BRING DEPARTMENTS TOGETHER. Date: January 2017 AS HEALTHCARE ORGANIZATIONS move toward value-based models, health information management (HIM) and information technology (IT)...

Spinal Fusion Procedures

Of all the challenges associated with the transition to ICD-10-PCS, coding spinal fusion procedures is by far the most difficult to tackle, in this author’s opinion. Even after training, many coders still struggle with the complexities of coding these procedures. This article focuses on the importance of thoroughly reviewing operative reports and offers valuable insights and practical strategies for ensuring accuracy, improving efficiency, and avoiding costly errors. | Read More.

Investments in Patient Access Staff Education Pay Strong Dividends

Patient registration is the gateway to quality care and data integrity for hospitals and health systems. Patient access staff are the catalyst for the financial health of every account, essentially “teeing up” the future success of each claim. Because of the influence these personnel have on positive patient experiences and strong revenue cycles, many hospital leaders are working to manage the following patient access department challenges. | Read More.

HIM Briefings

Hospital offers incentives for identifying incorrect patient status/

It’s no secret that hospitals struggle with assigning the most appropriate status for patients, and this challenge is compounded by CMS’ frequent changes to its regulations and guidance. To combat incorrect patient status assignments, one hospital has developed a system that rewards employees for speaking up when they suspect a patient’s status is incorrect. | Read More.

Bridging HIM’s Disconnect with IT

Consider the following fictional, and perhaps all-too-familiar, conversation between health information management (HIM) department staff and health information technology (IT) staff:

Chief Information Officer (CIO) to HIM Director: “Were you aware that last month we implemented a documentation system for the cardiologists?”

IT Analyst to HIM Director: “This clinical application was not designed to print documents.”HIM Director to CIO: “The requirements for electronic signature are stated in the CMS regulations, the medical bylaws, and hospital policies and procedures.” | Read More.

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