Medical Record Updates & Reminders

Tuesday, April 19, 2011 at 3:26:54 PM

Be Ready! The team has started education with physicians on upcoming changes that will take place when we switch from ICD-9 coding to ICD-10 on October 1, 2013. Many changes will occur regarding documentation. There will be more specification required for coding which may lead coders to query the physician for more detailed documentation to assign the code. As this education moves forward we will be publishing some examples in Vital Signs, and also provide information on where we are with the education.

According to the New York State Department of Health, section 405.10, “All medical records are to be completed within 30 days following discharge.” Please make sure that all of your reports have been dictated in a timely manner to ensure that this 30 day regulation can be met. When completing your deficiencies on line please take note of the REASON field. There may be a message from the HIM staff with a question or explanation for the deficiency.

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