RMC’s Blog

Education and Training . . . for HIM and CDI

For those of us within the Health Information Management (HIM) profession and even Clinical Documentation Integrity (CDI) profession one of the main aspects to our jobs, our careers, is in fact obtaining “Education and Training”.  Although related to each other,...

FY2022 ICD-10-CM Codes Released . . . Time for Education!

Don’t you love summertime? School is out, we are taking vacations and trips, barbeques, sunny days, AND the new ICD-10-CM codes get released! Yes, it has occurred already (earlier than expected), the FY2022 ICD-10-CM codes have been released by the Centers for...

Clinical Coding Errors to Watch for . . .

Recently I was talking with a colleague about the most common coding errors or variances we’ve been seeing lately when conducting inpatient coding audits. The selection of the “Principal Diagnosis” and a “Missed or Unsupported Secondary Diagnosis” certainly were at...

CMS MACs Begin to Audit Again – DOS After 3/2020

According to a recent Centers for Medicare and Medicaid Services (CMS) MLN Connections, Medicare Administrative Contractors (MAC) are beginning to conduct post-payment medical reviews for dates of services (DOS) after March 2020.  After a pause in audits due to...

ICD-10-PCS FY2022 Final Rule Released!

Lots of excitement over the release of the FY2022 ICD-10-PCS (Procedure Coding System) changes which came out on June 4, 2021. In addition, there are a few changes to the PCS “Official Guidelines” (i.e., 3.7B Control), that every inpatient coding professional needs to...

Project Management for Risk Adjustment Coding Reviews – Part 2

Project Implementation Phase:  Starting the reviews, ensuring quality, and staying on target. Starting the Reviews:  We have lined up the Team, delineated the scope of the review, lined out the review approach and guidelines (as well as other necessary items). ...

Working from Home

When working from home it is important to keep the HIPAA Privacy and Security standards at the forefront as we set up remote working environments in the home office setting. It is equally important to keep a healthy work-life balance in order to manage our time and...

Tiresome But Oh-So-Necessary Audit Log Monitoring

Audit log monitoring is probably one of the most unsexy, uninteresting activities a healthcare organization or business associate has to do.  But neglect it at the risk of your solid bottom line and reputation. Last time we talked about how you can get into legal...

Infusions, Injections and Hydration

Certain elements of documentation must be present to code infusions, injections, and hydrations     properly. An order by the physician, which must be dated, timed, and signed with the name of the drug, the dose and the route of administration...