Journal of AHIMA - May 2012

gap analyses and exploring modified “superbills,” among other approaches. Talking through ICD-10’s advantages and potential means of implementation with physicians can help shoot down many of the myths that exist about the coding system and begin a conversation about how practices can benefit from using the codes internally.

HIM state associations can also work with state hospitals, long term care facilities, and physician offices to facilitate the approach to and scheduling of testing between the providers of codes and the health plans and government agencies that use them. While the delay is frustrating to many, it does give us the opportunity for extra time to implement, test, and train for a successful transition.

Talking through ICD-10’s advantages and potential means of implementation with physicians can help... begin a conversation about how practices can benefit from using the codes internally.

HITECH Privacy and Security

As we await the final ICD-10-CM/PCS compliance date, we also are on alert for the long-awaited final rules on the HITECH changes to the HIPAA privacy and security rules. These rules could appear at any time (even while this issue of the Journal is in the mail). The Office for Civil Rights (OCR) sent final rules to the Office of Management and Budget (OMB) for review on March 24.

Rules have languished in OMB for months in the past and, in the case of the breach notification final rule, have been withdrawn without being released. So while AHIMA staff is preparing for the release any day, we have no idea of when the rule will appear, what it will contain, or when its requirements will be effective.

It is also not clear whether the final rule will be an omnibus rule—with all the interim and proposed rules related to HITECH privacy and security legislation included—or just a portion. There has been no discussion on the accounting for disclosures in recent months and AHIMA has indicated the difficulty behind such a tracking to the OCR, as have others.

Meaningful Use

Responses to the meaningful use stage 2 proposed rules are due early this month, and I hope that your organization will join with AHIMA and request that ICD-10-CM/PCS capabilities be required of all electronic health record systems that become certified for stage 2. We are pleased to see the Office of the National Coordinator for HIT include ICD-10-CM/PCS and the

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SNOMED-CT terminologies in their proposals as well. While ICD-10-CM/PCS may be delayed, we are seeing an increasing understanding of the impact the terminologies and classification will have on the US health systems.

Data Integrity

AHIMA staff gave a presentation on data integrity at a forum hosted by the Institute for e-Health Policy in March. Data integrity is fast becoming a subject of interest across the government and the healthcare industry. AHIMA chose to provide a description of the processes, functions, and infrastructure that support integrity, beginning with the collection of information in the treatment or diagnosis encounter. The potential impact of incomplete and mismatched data is an area of particular focus because we have reached a stage where data no longer exists in one record solely for the benefit of one provider. Rather, information will now be shared across institutions, with other secondary uses in addition to the traditional needs of the patient.

The increased role of health information technology has magnified the impact of documentation, and the problems and gaps that currently exist will continue to become more apparent. It is important to start addressing the issues from the vantage point of today’s environment. Soon, data and metadata will provide a clear path to situations and environments were documentation is failing. In order for organizations to reduce problems, HIM professionals need to be proactive about working with providers, vendors, and innovators alike.

Moving Forward

All of these developments illustrate clearly that HIM is not a static profession. With the implementation of electronic health record systems, ICD-10-CM/PCS, HITECH privacy and security, with meaningful use reporting and the demands of “usual business,” HIM has never been more important.

One of our discussions with Congress was the recognition of the HIM profession as an educated and trained workforce with the experience and knowledge to help and lead in implementing these changes and identifying what to do next.

This is a message that has to be delivered across the industry if we are to see good HIM principles and practices engaged in our response to all of the requirements currently before us as well as those still coming down the road. Staff and many HIM volunteers serving on AHIMA practice councils, committees, and task forces will be working hard to provide the profession and the industry with the information and guidance needed to chart a way successfully through each of these changes. ¢