The Centers for Disease Control and Prevention (CDC), one of the Cooperating Parties responsible for the ICD-10-CM codes and guidelines, recently released a 2018 ICD-10-CM Official Guidelines for Coding and Reporting errata. Slight changes were made to the guidelines for diabetes, hypertension, and principal diagnosis selection.
Five senators recently asked the Government Accountability Office (GAO) to examine the costs and risks associated with mismatched patient records during the agency’s review of patient matching. The GAO is required by the 21st Century Cures Act to conduct an assessment on patient matching to protect patient privacy and security.
My experience in ICD-10-CM documentation and coding integrity is that many physicians know in their heads what is wrong with their patients; however, they have not been taught to “think with ink” in describing their patients' illness in the EHR using ICD-10-CM’s language to ensure proper coding.
RC.01.01.01 is one standard that just won’t go away. The first half of 2017 (January–June) standards compliance data was published in the September issue of The Joint Commission’s Perspectives, and RC.01.01.01 made the list again. This means that the standard has been on the top 10 list for at least the last five years, along with other frequent flyers such as Environment of Care, Life Safety, and Infection Prevention.
Having just witnessed nature wreak havoc with back-to-back hurricanes, I feel it’s important to take a few minutes to remind everyone of the importance of Plan B—the backup plan. Let’s look at some real examples of how HIM professionals can be proactive to prevent chaos when unexpected events occur.
Patient care continues to move from the inpatient setting to outpatient. With this change, the challenge of securing comprehensive documentation that articulates the services rendered and the patient care provided now needs to extend across the care continuum.
Cognitive computing will transform the future of clinical care as we know it in three direct ways: making data accessible, making it approachable, and making it actionable.
