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Reap Benefits of EMR But Don’t Let it Dictate What to Document & Which Code to Use

26. June 2014

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The E/M code suggestions offered by your EMR can be helpful; but that does not mean you can use that to justify all high-level codes. Using electronic medical records (EMRs) in your practice comes with umpteen benefits – Be it saving time, creating legible documentation or sharing history with fellow providers. However, relying too heavily on EMRs could come with its own pitfalls. Heed these three tips to know where your EMR system could be leading you astray: Exam Documentation Does Not Carry Over You may be relying on your EMR too much if it constantly shows E/M documentation that’s robust in one section and not so in another (such as exam). To cite an example, an auditor down-coded many of a practice’s E/M claims due to empty ‘physical exam’ sections in the documentation. The practice explained that the EMR vendor had told them that patients being seen for established problems…

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Do We Have To Report All Employee Contact With Patients’ PHI?

14. April 2010

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Question: A patient requested that we account for all disclosures of her protected health information (PHI). Does the privacy rule require us to provide her with the names of each employee who accessed her medical information? Answer: No, says Kelley Meeusen, privacy officer for Harrison Hospital in Bremerton, WA. “HIPAA created a clear distinction between ‘uses’ and ‘disclosures,’” and internal employee access is most likely a ‘use,’ he explains.

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Got Removable Media? These 5 Tips Safeguard Your PHI

7. April 2010

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Don’t let lost pen-drives and other removable media cause deep regrets. You have your protected health information (PHI),but can you take it with you? Yes, you can, but unfortunately, so can many others who shouldn’t. HIPAA requires you to have controls on so-called, “removable media.” Here are some simple tips you can use to keep pendrives, CD-ROMs, external hard disks, and other media properly accounted for. HIPAA’s security rule requires you to take certain precautions when it comes to media devices that contain PHI [164.310(d)(1)]. That means you have to implement policies and procedures that address the receipt and removal of hardware and electronic media that contain electronic PHI into and out of your facility, as well as the movement of such media within your facility. 1. Identify your problem areas. How many pen-drives contain PHI in your facility? Do you know where they are at all times? There are…

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Will You De-Identify Your Patients’ PHI?

7. April 2010

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De-identification safe harbors in the new HIPAA Privacy rule may be tempting: The new penalty provisions of the rule do not apply – nor does HIPAA in general – to the loss or disclosure of protected health information that has been “de-identified,” or, so to speak, “cleaned.” If your practice or organization is interested in learning how to de-identify health information so that you don’t have to worry quite so much about the new penalties – which can now reach $1.5 million – read on for a primer, along with the possible downsides.

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HIPAA Compliance: Outsource PHI Security Safely With These 5 Steps

22. March 2010

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Learn these facts before you nail down your HIPAA plan with a consultant. You may be relieved to find a consultant who is willing to take over the overwhelming task of helping you protect the privacy in your medical records — but keep in mind that not all outsourced privacy protection companies are the same. Last week, the Federal Trade Commission (FTC) settled with LifeLock, Inc., a company that offered identity protection services. “According to the lawsuit, LifeLock claimed its service would protect consumers against all forms of identity theft, when, in fact, LifeLock offered only limited protection against only some forms of ID theft,” the FTC’s statement noted regarding its $11 million settlement with LifeLock. If you’d like help staying current with HIPAA privacy regulations, consider these tips before you outsource any of your privacy needs. 1. The Government Does Allow HIPAA Consultants. Practices that are gun-shy about asking for…

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Reader Question: Are Photographs PHI Identifiers?

18. March 2010

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Question: For demonstration purposes in a sales context, if a picture or video of a patient were used with no identifying information, would this violate Health Insurance Portability and Accountability Act (HIPAA)? Answer: A photo is an identifier, explains Kristen Rosati, a partner at Coppersmith Gordon Schermer Owens & Nelson. Why? Read on …

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EMR 101 for Newbies

17. March 2010

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Feel like you’re babe in the woods when it comes to EMR? Here’s a quick-start guide for small providers. Thinking about scrapping your paper documentation and plugging into electronic patient records? You’ve got a lot of things to consider. Our Rehab Report editor talked to the experts about EMR questions that PTs, OTs and SLPs should ask before they buy EMR systems, and a lot of the advice we got applies to other small providers as well. Integrating new electronic medical record (EMR) or documentation software is a critical step into the future, experts contend — yet it’s not a walk in the park. Whether you’re starting from scratch or looking to upgrade your current system, get the straight-up facts of what to expect and how to survive the process. Get Started on the Right Foot The minute you decide to move forward with an EMR system, take time to…

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Red Flags Rule Applies to Health Care Providers (for Now!)

10. February 2010

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While medical groups are gearing up to challenge the application of the FTC’s Red Flags Rule to health care providers, the viability of such a challenge is not assured. So aside from being required to do so by the Federal Trade Commission, your practice or facility should implement a Red Flag compliance program that helps to detect and prevent medical identity theft because it’s a best practice. The good news is, it’s not that hard, according to Duane Abbey, who recently gave an audio conference, “Achieve Red Flag Compliance.” “I don’t think we’re going to see any exemptions,” Abbey predicted. The original Red Flags regulations in the Federal Register back in 2007 mentioned health care creditors specifically, he pointed out. Enforcement of the Red Flags regs has been delayed until June 1, 2010. “The incremental procedures through which you have…

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HHAs That Use HIT Can Reduce Hospital Admissions

9. February 2010

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One-quarter of agencies now have telehealth systems, study says. Home health agencies that want to improve their patients’ care may want to take a page from these providers’ technology playbooks. Saddleback Memorial Medical Center in Laguna Hills, Calif. reduced readmissions of congestive heart failure patients by 50 percent under a new program using home care telehealth devices combined with patient education and other components, it says. “The results from the CHF program are truly impressive when you consider that a significant percentage of our patients are elderly, have a range of comorbidities and are often uncomfortable with technology,” says Saddleback’s heart failure outreach care coordinator Laurie Carson. The hospital is extending its telehealth program to chronic obstructive pulmonary disease patients next, it says.

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Shore Up Your HIPAA Compliance Before Enforcement Storm Hits This Year

3. February 2010

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Tip: You’re not off the hook if the breach is your vendor’s fault. Using electronic health records may cut costs and reduce errors, but they also can increase your compliance risks — and scrutiny from the feds. Wake-up call: You are accountable for compliance even if a third party installs and maintains your records system. Providers will still be responsible for ensuring the same privacy protections as if they did have their own IT department, points out Jim Sheldon-Dean with Lewis Creek Systems in Charlotte, Vt.

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