Health information and the importance of clinical coding

From Hippocrates to HIPAA: Privacy and confidentiality in Emergency Medicine—Part I: Conceptual, moral, and legal foundations

Machine learning (ML)-driven diagnosis systems are particularly relevant in pediatrics given the well-documented impact of early-life health conditions on later-life outcomes. Yet, early identification of diseases and their subsequent impact on length of hospital stay for this age group has so far remained uncharacterized, likely because access to relevant health data is severely limited. Thanks to a confidential data use agreement with the California Department of Health Care Access and Information, we introduce Ped-BERT: a state-of-the-art deep learning model that accurately predicts the likelihood of 100+ conditions and the length of stay in a pediatric patient’s next medical visit. We link mother-specific pre- and postnatal period health information to pediatric patient hospital discharge and emergency room visits. Our data set comprises 513.9K mother–baby pairs and contains medical diagnosis codes, length of stay, as well as temporal and spatial pediatric patient characteristics, such as age and residency zip code at the time of visit. Following the popular bidirectional encoder representations from the transformers (BERT) approach, we pre-train Ped-BERT via the masked language modeling objective to learn embedding features for the diagnosis codes contained in our data. We then continue to fine-tune our model to accurately predict primary diagnosis outcomes and length of stay for a pediatric patient’s next visit, given the history of previous visits and, optionally, the mother’s pre- and postnatal health information. We find that Ped-BERT generally outperforms contemporary and state-of-the-art classifiers when trained with minimum features. We also find that incorporating mother health attributes leads to significant improvements in model performance overall and across all patient subgroups in our data. Our most successful Ped-BERT model configuration achieves an area under the receiver operator curve (ROC AUC) of 0.927 and an average precision score (APS) of 0.408 for the diagnosis prediction task, and a ROC AUC of 0.855 and APS of 0.815 for the length of hospital stay task. Further, we examine Ped-BERT’s fairness by determining whether prediction errors are evenly distributed across various subgroups of mother–baby demographics and health characteristics, or if certain subgroups exhibit a higher susceptibility to prediction errors.

Public health information needs in districts

The Australian Health Information Workforce is a critical discipline in the health sector as the investment in digital technologies increases. Yet historically there was no standardized reporting about the workforce and its six professional areas: clinical coding, costing analysts, data analysts, health informaticians, health information managers and health librarians. This paper presents the findings from the inaugural Australian Health Information Workforce Census. Analysis of 1,596 responses indicates this is an aging (56.1% ≥45 years) workforce with a large (78.1%) female population. Working in permanent (82%), public hospital (72%) roles, in professional or managerial roles (84%). The majority (93.2%) of respondents hold a tertiary qualification in health information, one-quarter of these at masters or doctoral level. Fewer than 30% of respondents hold a health information credential from a professional or industry association. The data from the ongoing national census will inform workforce planning and enable forecasting of the future workforce needs.

Philip Hoyle presents a compelling argument for the significant and highly valued role that the management of health information plays in the Australian healthcare system and the delivery of health services in this country. However, he also brings to our attention the ill-defined nature of the ethical oversight of this very information. Hoyle uses words such as "honesty," "commitment to beneficence," "commitment to equity" and "respect for variation" when describing the characteristics of ethical leadership. He singles out health information management professionals - Health Information Managers (HIMs) and Clinical Coders (CCs) - as the key professional group who need to step up and seize the initiative, get conversations going, form partnerships, do research and publish findings, so the knowledge and insights that the health information management profession has the potential to offer are not only more widely known and understood but also more useful to others working in the healthcare arena. Hoyle calls on health information management professionals to step out from behind the scenes and take responsibility for the ethical use of the information they help produce. Hoyle's words resonated powerfully with me, particularly with respect to the clinical coding workforce in Australia, which is made up of trained CCs and qualified HIMs. In a truly ethical environment, HIMs and CCs would not be asked to meet performance indicators for increased funding metrics or to change codes to avoid triggering certain indicators; they would simply be asked to ensure complete, accurate coding for every episode of care. This is what ethical leadership would look like. I am concerned about our clinical coding workforce. I am now asking, are our CCs and HIMs up to the task of taking back absolute and unchallenged ownership of their particular skill set, which makes them the keepers of the clinical coding standards and the experts in accurate and complete code assignment?

Improving Medication Management of Depression in Health Plans

Utility of administrative and clinical data for cardiac surgery research: A case-based approach to guide choice

Background: Health Information Technology (HIT) has become a foundational component of modern healthcare systems, integrating hardware, software, and standardized data processes to support clinical, administrative, and research functions. It plays a critical role for health information management professionals, including medical records specialists, medical coders, health administrators, and medical secretaries, whose responsibilities depend on accurate, secure, and accessible health data. Aim: This article aims to examine the role of HIT in supporting healthcare accountability, improving patient and population health outcomes, enhancing healthcare delivery efficiency, and reducing overall healthcare costs, with particular emphasis on its impact on health information management professionals. Methods: A narrative-based analytical approach was used, synthesizing evidence from established literature, policy discussions, and real-world case examples. The article reviews key HIT components such as electronic health records (EHRs), computerized physician order entry (CPOE), health information exchanges (HIEs), and interoperability standards, and evaluates their influence on clinical decision-making, operational workflows, and population health monitoring. Results: HIT was shown to improve patient safety through error reduction, support population health surveillance, streamline administrative workflows, and enable data-driven decision-making. However, challenges including high implementation costs, interoperability limitations, data security risks, and user-related inefficiencies persist. Conclusion: HIT remains essential for effective healthcare delivery, provided its challenges are addressed through strategic investment, training, and system optimization.

On August 21, 1996, the Health Insurance Portability and Accountability Act of 1996 (HIPAA) was signed into law. One part of the law requires the adoption of uniform national standards for health information, establishing how information should be formatted, shared, and protected. This will affect every aspect of pediatric practice, and you should begin now to understand HIPAA. Over the next 2 years, the American Academy of Pediatrics (AAP) will develop summaries and sample materials to help you incorporate these requirements into your practice.Standardization of electronic transactions in health care will greatly facilitate the sharing of data, raising concerns about how the data will be protected. HIPAA required the first-ever national standards for privacy protections of health information. The privacy rule establishes significant restrictions on the use and release of medical records, describes privacy safeguard standards that must be met, gives patients several important rights, and provides for significant penalties for misuse of health information. In addition to concerns about privacy of health information, increased exchange and compilation of electronic health information raises concerns about physical and technical security. HIPAA requires the adoption of a national standard for security of electronic health information. The 1998 proposed rule describes minimum security requirements and requires each health care organization covered by the rule to designate a security official.The core element of administrative simplification is to require the use of a single standardized format for 10 common health care transactions including health care claims, eligibility inquiries, referral certification and authorization, and payment. In these transactions the use of specific clinical code sets, including Current Procedural Terminology and International Classification of Diseases, Ninth Revision, Clinical Modification is required. The use of national standard identifiers for providers, health plans, and employers will also be required.The requirement for a national identifier for individuals has been extremely controversial, and in the fall of 1998, Congress prohibited the promulgation of a national patient identifier.The AAP expects that most pediatricians will be covered by HIPAA because they submit electronic claims themselves and/or use a billing service or clearinghouse to convert paper claims to electronic format. The HIPAA administrative simplification provisions apply to the following covered entities:Final rules have been published on standards for electronic transactions and privacy of health information. Covered providers must comply with the transactions rule by October 16, 2002, and with the privacy rule by April 14, 2003. Proposed rules on security, national provider identifiers, and national employer identifiers were published in 1998. No other proposed or final rules have been published yet, and the US Department of Health and Human Services has no expected date for publication.The AAP will continue its efforts to educate pediatricians about HIPAA and to advocate for HIPAA implementation that works for children’s health care. More information on HIPAA is available on the AAP Members Only Channel (http://www.aap.org/moc). In the future, this Web site will contain pediatric-specific compliance guidance and model policies and procedures. In addition, future issues of this newsletter will contain articles focusing on specific aspects of HIPAA implementation.For more information about HIPAA and its effect on pediatricians, e-mail HIPAA@aap.org, or call the AAP Division of Health Care Finance and Practice at 800/433-9016, ext 4089.

ABSTRACT
 The coding of diagnoses for inpatients at the Diagram Heart Hospital is carried out by the Coder, based on the diagnoses written in the Discharge Summary. The purpose of this study is to determine the diagnostic coding procedure, the completeness of the diagnosis writing, the accuracy of the diagnosis coding and the factors that cause the inaccuracy of the diagnostic coding. Quantitative descriptive research method. The sample used was 63 inpatient discharge summaries in May 2020 which were collected randomly. The results obtained, the completeness of the diagnosis writing on the discharge summary was 100% complete, the accuracy of coding diagnosis was 70% correct, and 30% incorrect, the results of the identification of the diagnostic coding procedure. available refer to coding of diagnoses and coding of medical procedures. The cause of the inaccurate diagnosis coding is known from the Coder's power factor because he is not careful and is unable to read the diagnosis by hand. The understanding of the rules that apply in coding diagnoses by the coder is not optimal, supported by educational background that has not reached a minimum of diploma 3 medical records and health information, thus the accuracy of the diagnosis code is supported by coders who have formal education diploma 3 medical records and health information, understanding of diagnostic coding rules, completeness of diagnosis writing, and clarity of diagnosis writing
 Keywords: Diagnostic Coding Accuracy, discharge summary, inpatients

1. Elizabeth Kenimer Leibach, Ed.D., MLSCM, SBBCM[⇑][1] 1. Principal Officer, Healthcare Management and Education Services, Augusta, GA <!-- --> 1. Address for Correspondence: Elizabeth Kenimer Leibach, Ed.D., M.S., MLS(ASCP)CMSBBCM, 706 Summergate Court, Augusta, Georgia 30909, 706-925-0810, eleibach{at}comcast.net, Consumer demand for increased value in clinical laboratory services delivery has intensified. On the heels of the Health Insurance Portability and Accountability Act (HIPAA) of 1996,1 Protection of Human Subjects, “Common Rule,”2 and Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009,3 the U.S. Department of Health and Human Services, effective April 7, 2014, amended Clinical Laboratory Improvement Amendments of 1988 (CLIA) and HIPAA Privacy regulations to allow patients/consumers direct access to their laboratory reports.4 The nexus of these regulatory forces, along with unprecedented health information access and exchange characterizing our society, suggests a prominent consultative role in services delivery for clinical laboratory practitioners. However, the interpretation of duty to patients, society, and other healthcare professionals, as codified in the clinical laboratory science Code of Ethics,5 becomes critical to ethical practice as issues of societal duty and “good” are viewed through the lens of patient/consumer autonomy. Our responsibility broadens and deepens if we accept the challenge to transform laboratory information into actionable knowledge for patients/consumers and providers alike. With these recent environmental changes, principles of access to meaningfully interpreted best evidence for providers' clinical decision support and patients/consumers' shared decision making compete with confidentiality concerns in everyday services delivery. We must internalize not only the laws and regulations governing protected health information, but we must also operationalize decision-making grounded in fundamental ethical principles guiding thorough informed consent. Patients/consumers expect to gain knowledge from us that will equip them to share in decisions regarding their medical care; they… [1]: #corresp-1

This research was conducted with the aim of determining the influence of PMIK (Medical Recorder and Health Information) professional competence on the performance of medical record officers at the Dr. Air Force Hospital. Esnawan Antariksa. The research method used is quantitative with inferential analysis. The data collection techniques used were observation, interviews and questionnaires. The sampling technique used a total saturated sampling technique of 14 people. Obtained from 7 PMIK competency standard indicators (Noble Professionalism, Ethics and Legal, Introspection and Personal Development, Effective Communication, Health Data and Information Management, Clinical classification skills, Disease coding and other Health Problems as well as Clinical Procedures, Health Statistics Applications, Basic Epidemiology, and Biomedicine, Management of Medical Records Services and Health Information, there are still 2 indicators in the percentage that are not good, and in the 5 performance indicators of medical record officers (Quality of Work, Quantity of Work, Supervision, Attendance, Conservation) there are still 2 indicators in the percentage not good. It was found that 3 officers had a D-III RMIK education and 11 officers still had a high school education. Based on the results of the T test, it was found that the Sig. value was 275. It could be concluded that there was no influence of PMIK competency on the performance of medical records officers.

Health information and the importance of clinical coding

You have accessThe ASHA LeaderFeature1 Sep 2006Clinical Documentation in Speech-Language PathologyEssential Information for Successful Practice Becky Sutherland Cornett Becky Sutherland Cornett Google Scholar https://doi.org/10.1044/leader.FTR3.11122006.8 SectionsAbout ToolsAdd to favorites ShareFacebookTwitterLinked In Clinical documentation is one of our most important tasks, yet many practitioners view documenting services as a "chore"-or something they have to do to "get paid." It may be helpful to think of documentation as the story of what we do to help individuals communicate or accomplish other crucial functions (such as swallowing) and to carry out the requirements of ethical clinical practice. The ASHA Code of Ethics, Principle I, Rule K states: "individuals shall adequately maintain and appropriately secure records of professional services rendered, research and scholarly activities conducted, and products dispensed and shall allow access to these records only when authorized or when required by law" (ASHA, 2003). The Joint Commission on Accreditation of Healthcare Facilities (JCAHO) provides detailed guidance regarding expectations for "Management of Information" (IM) in the Comprehensive Accreditation Manual for Hospitals (CAMH) (see www.jcaho.org). According to the JCAHO's overview of the CAMH IM section, the goal of the information management function is to "support decision making to improve patient outcomes, improve health care documentation, improve patient safety, and improve performance in patient care, treatment and services; governance; management; and support processes….a hospital's provision of care is a complex endeavor that is highly dependent on information" (p. IM-1). JCAHO emphasizes that accurate, complete, and secure information is essential to the provision of safe and effective patient care. Hospitals and other health care organizations purchase access to online and paper versions of the CAMH; therefore, readers are encouraged to review this resource on organization intranet sites or in accreditation services department offices, as available. Professionals now also consult Internet resources. A recent Google inquiry about the definition of documentation yields: "information recorded permanently," "substantiation of actions or decisions," "providing evidence," and "descriptive text." These phrases, together with our more formal documents, provide a foundation to a discussion of essential information for clinical documentation. As SLPs, our definition of documentation is comprehensive, and includes the components of the service itself (e.g., the use of information for clinical decision-making), charge capture, diagnosis coding, and procedure coding as well as the actual recording of clinical service activities. Why Document? It is helpful to think of the clinical record primarily as a communication tool shared among the team (however large or small) serving the patient/client. The team also includes the patient/client and family members and/or caregivers and practitioners as full participants, with access to health information. The clinical record is an overall indicator of clinical and service quality, and serves as a basis for planning care and for service continuity. According to Paul & Hasselkus (2004), the purposes of documentation are to: Justify initiation and continuation of treatment Support diagnosis and treatment (including medical necessity and need for skilled services) Describe client progress Describe client response to interventions Justify discharge from care Support reimbursement Communicate with other practitioners Facilitate quality improvement Justify clinical decisions Document communication among involved parties (practitioners, client, caregivers, or legally responsible parties) Protect legal interests of client, service provider, and facility Serve as evidence in a court of law Provide data for continuing education Provide data for research (i.e., efficacy) Documentation Requirements and Formats When practitioners discuss documentation requirements for reimbursement, they usually refer to the guidelines published by the Centers for Medicare and Medicaid Services (CMS), although commercial payers and managed care organizations also have certain rules. Requirements related to the nature and type of services provided and the contents of the clinical records of Medicare beneficiaries are discussed in detail in Chapter 15, sections 220 and 230 of the Medicare Benefit Policy Manual (an Internet-only manual found at www.cms.hhs.gov under "Regulations and Guidance"). Medicare fiscal intermediaries (FI) also may have their own requirements stated in Local Coverage Determinations (found under "Medical Policy" at the FI Web site). According to the Medicare Benefit Policy Manual, "therapy services shall be payable when the medical record and the information on the claim form consistently and accurately report covered therapy services…Medicare requires that the services billed be supported by documentation that justifies payment. Documentation must comply with all legal/regulatory requirements applicable to Medicare claims." The documentation required by CMS for Medicare payment includes: Evaluation and certified plan of care Certification by the treating physician or non-physician practitioner (NPP), who may be a nurse practitioner or physician assistant, for example, that the treatment services are medically necessary and meet coverage rules (required 30 treatment days after initial treatment) Progress reports (when treatment exceeds 10 treatment days or 30 calendar treatment days/one month, whichever is less) Treatment encounter notes (may also serve as progress reports when required information is included in the notes) Records justifying services over the cap for therapy cap exceptions Treatment Encounter Notes The current revision of Chapter 15 of the Medicare Benefit Manual includes, for the first time, the important distinction between progress notes and treatment encounter notes, which document every treatment day, and every treatment service. The purpose of the encounter note is to create a record of all encounters and skilled interventions by qualified professionals to justify the use of the billing codes on the claim (patient bill to Medicare). The progress note documents medical necessity or appropriateness of ongoing services. The following elements must be included when documenting each treatment encounter: Date of treatment Treatment minutes and total treatment time for timed codes. (The amount of time for each specific intervention provided to the patient is not required because it is indicated in the billing of the codes.) However, billing and total timed code treatment minutes must be consistent. Identification of each specific intervention/type of treatment provided and billed for both timed and untimed codes CMS also details the assumptions underlying the required documentation. Payable services, for example, are those offered by qualified professionals who treat eligible beneficiaries. It must be demonstrated that the patient needs services that can be provided only by a professional with the expertise, knowledge, clinical judgment, and decision-making ability of the qualified clinician (e.g., the SLP) and that other staff or caretakers could not provide similar services independently. The clinician's services may also be required for patient safety reasons. Moreover, the patient must be under the care of a physician/NPP. That clinician must demonstrate evidence of involvement in the patient's care. The physician/NPP must have an expectation that: The patient's condition has the potential to improve or is improving in response to treatment. Maximum improvement is yet to be attained. The anticipated improvement is attainable in a reasonable and generally predictable period of time. CMS requirements for each step in the documentation process are too detailed for the scope of this article. Therefore, a sample "Outpatient Speech-Language Pathology Services Audit Template" that can be used to review and monitor Medicare requirements is posted on The ASHA Leader Online with this article (see note at end of article). Although Medicare documentation requirements often serve as a model, professional associations, health care provider organizations, and commercial payers have established their own policies and templates to guide practitioners. ASHA lists the following components of clinical record-keeping (Paul & Hasselkus, 2004): Identifying information Client history Assessment of current client status Treatment plan Documentation of treatment Discharge summary Record of consultation (with other professionals; with client/caregivers) Electronic Health Records There is no single format used by all professionals or organizations; whatever format is used for clinical record-keeping should conform to federal, state, and local laws and adhere to specific facility standards. Clinical records should be consistent in format and style and use appropriate terminology, approved abbreviations, and correct diagnosis and procedure codes. The advent of electronic health records (EHR) has both streamlined and complicated clinical documentation. Electronic records can use free text, structured text ("macros" or "boilerplate"), and interactive text that includes clinical decision-support functions. Electronic records may be supplemented by bar coding (for tracking supplies used, medications administered, etc.) and use of identity recognition programs to authenticate users. Swigert points out that electronic documentation can pose specific challenges: "Clinicians who have the opportunity to participate in the development of templates for a computerized documentation system should plan carefully to assure that each template is thorough enough to capture integral information and that a template is available for each type of disorder presented by patients treated. The templates must allow for personalization so that the document is accurate and complete" (Swigert, 103). Readers are encouraged to thoroughly review Swigert's article for comprehensive information and detailed samples of documentation formats, coding, and billing requirements. Coding Basics Codes in health care are numeric (or alphanumeric) representations or identifiers of a diagnosis of illness, injury, condition, or disorder (the patient's reason for seeking care) or a health care procedure or service performed by the provider or professional. Coding is integral to billing compliance. The essence of billing compliance is found in the following four points. All diagnostic and treatment services are necessary, appropriate, and meet established standards of care. All care is documented accurately and completely. ICD-9-CM codes accurately represent documented problems/disorders/conditions/diseases. CPT codes accurately represent documented care. Clinicians should code to the highest level of specificity possible. Code sequencing is also important for payment purposes. For example, for rehabilitation services, code first the reason the patient/client is receiving SLP treatment; then code the underlying medical diagnosis. Also code all documented conditions that coexist at the time of the encounter. Swigert states it most succinctly: "Coding and billing are intertwined with clinical documentation. Correct diagnosis and procedure codes must be selected to describe the presenting disorder or condition and the services provided in order to bill and receive payment" (Swigert, 108). Original-source Web sites should be used to obtain complete information. ASHA's Web site is also an excellent source of detailed information about codes applicable to speech-language pathology and audiology services and information about documentation, billing, and reimbursement issues (see Web resources, page 29). The International Classification of Diseases (ICD) is the international resource used to classify mortality and morbidity. Although most of the world uses the ICD-10, the United States uses the International Classification ofDiseases, Ninth Revision, Clinical Modification, (ICD-9-CM). The ICD-9-CM includes: A tabular list containing a numerical list of the disease code numbers in tabular form An alphabetical index to the disease entries A classification system for surgical, diagnostic, and therapeutic procedures (alphabetic index and tabular list) Readers are advised to seek specific training in using the ICD-9-CM because there are pitfalls involved in trying to code without instruction. For example, errors likely will result for those who do not first seek correct code assignment in the Alphabetic Index followed by review of the tabular list. CMS offers a 60-minute on-line instruction module titled "Using the ICD-9-CM" at: www.cms.hhs.gov/MLNEdWebGuide/. Practitioners who work for hospitals or other facilities should seek help from coding specialists employed by the health information department. Clinical documentation is among the most basic of our professional responsibilities-and is both an obligation and a privilege. An era of accountability is advancing upon the health care community. We must demonstrate our added value to our organizations, but more importantly, to our patients' lives. Attention to the foundations of our practice will help us continue to thrive. Outpatient Speech-Language Pathology Services Audit Template This audit template is a tool for managers and clinicians to assess compliance with Medicare requirements for outpatient speech-language pathology services. It is meant to be an internal mechanism for SLP practices and programs to determine whether documentation, coding, and billing practices will withstand scrutiny, and to provide an educational resource to improve the organization's clinical and business processes. Individual Record Worksheet Patient Name: ____________________ MRN:____________________ Acct.__________ Referring Physician: _______________DOS:____________ Today's Date: ___________ Qualified Therapy Staff: Speech-language pathology services are offered only by qualified providers. Yes_____ No_____ The services provided are of such a level of complexity and sophistication that such services can be provided safely and effectively only by or under the supervision of a speech-language pathologist. Yes_____ No_____ Physician/Non-Physician Practitioner (i.e., nurse practitioner, physician assistant or clinical nurse specialist) Certification/Approval of Therapy Services: Individuals receiving outpatient therapy services must be under the care of a physician/NPP. The physician/NPP must certify approval of the plan of care/treatment. Certification for services should be obtained as soon as possible after the plan of care is established (before the end of the first 30-day interval of treatment). Certification may be documented by signature or verbal order, and dated before the end of the first care interval. If the order to certify is verbal, it must be followed within 14 days by a signature to be a timely certification. All records for Medicare beneficiaries contain the required certification of the plan of care. Yes_____ No_____ If applicable, the physician/NPP who is responsible for the patient's care at that time recertifies the plan of treatment every 30 days. Yes_____ No_____ Evaluation: The initial evaluation or plan of care including an evaluation, documents the necessity for a course of therapy through objective findings and subjective patient self-reporting. The evaluation includes: a diagnosis and description of the specific problem to be evaluated and/or treated. All conditions and complexities that may impact treatment are described. Description may include premorbid function, date of onset, current function. Yes_____ No_____ Objective measurements (preferably standardized patient assessment instruments and/or outcomes measurement tools related to current functional status), when available and appropriate, are documented. Yes_____ No_____ The clinician's clinical judgments or subjective impressions describe the patient's current functional status of the condition being evaluated, when these statements provide further information to supplement measurement tools. Yes_____ No_____ Prognosis is given for return to premorbid function or maximum expected condition with expected time frame and a plan of care. Yes_____ No_____ Plan of Care The plan of care must relate directly and specifically to a written treatment plan. The plan must be established before treatment is begun. The plan is established when it is developed (written or dictated). The plan may be established by a physician/NPP and/or the SLP who will provide the services. The evaluation and treatment may occur (and are both billable) on the same day or at subsequent visits. It is appropriate that treatment begins when the plan is established. Therapy may begin based on a dictated plan after it has been committed to writing and before it is signed (provided it is signed by close-of-business on the day following dictation by the person who established the plan). Treatment may begin before the plan is committed to writing only if the treatment is performed by the same qualified professional who established the plan and the plan is established and signed by close-of-business on the next day by the same qualified professional. The plan of care was established, written, and signed in accordance with Medicare requirements. Yes_____ No_____ The plan of care, at a minimum, contains the following information: therapy diagnoses and underlying medical diagnoses; long-term treatment goals; and type, amount, and frequency of therapy services. Yes_____ No_____ Changes to the plan of care are made in writing in the patient's record and signed by one of the professionals responsible for the patient's care (physician/NPP, SLP, or the RN or physician/NPP on the staff of the facility pursuant to verbal orders of the physician/NPP or therapist). Yes_____ No_____ Progress reports: The progress report provides justification for the medical necessity of treatment. Information required in progress reports should be provided at least once every 10 treatment days or once during the 30-day/one-month interval, whichever is less. The evaluation and plan of care are incorporated into the progress report and it is not necessary to repeat information about those documents in the progress report. Progress reports are documented at the required 30-day intervals, including date of the beginning of the interval and date the report was written (which must occur during the interval), and signature (or electronic identification) of professional completing the report. Yes_____ No_____ The report includes objective measurements (preferred) or description of changes in status relative to each goal currently being addressed in treatment. Descriptions make identifiable reference to the goals in the current plan of care. The 30-day interval report adds, changes, or deletes short-term goals, or deletes completed long-term goals. Yes_____ No_____ Documentation includes an assessment of improvement and progress made (or lack thereof) for this reporting period; techniques used to achieve goals; the patient's continued potential to make "significant, practical improvement," and changes in the plan of treatment. Yes_____ No_____ Plans for continuing treatment, reference to additional evaluation results, and treatment plan revisions, as applicable, are documented. Yes_____ No_____ The Discharge Note is a interval note covering the period from the last interval note to the date of discharge. This note may summarize the entire episode of treatment, or justify services that have extended beyond those usually expected for the patient's condition. The discharge note is the last opportunity to justify medical necessity for the entire treatment episode. The discharge note provides suitable information for review and justification of services. Yes_____ No_____ Treatment Encounter Note: The treatment encounter note documents every treatment day and every therapy service. The note must record the elements listed below. In addition, the encounter note may include the following optional elements: patient self-report; adverse reaction to intervention; communication/consultation with other providers; significant or unusual changes in clinical status; equipment provided; and/or any additional relevant information the qualified professional wishes to provide. Date of treatment is documented : Yes_____ No_____ Total timed code treatment minutes and total treatment time (timed and untimed codes) is provided. Yes_____ No_____ Each specific intervention provided and billed, for both timed and untimed codes. Yes_____ No_____ Signature and professional identification of the qualified professional who provided the service and list of each person who contributed to treatment during the encounter (e.g., assistants or students). Yes_____ No_____ Group Therapy: Speech-language group therapy sessions are covered by Medicare if they are rendered under an individualized plan of care; have no more than four (4) group members; and group therapy does not represent the entire plan of treatment. Group sessions must be conducted by a qualified SLP. Group therapy services meet Medicare requirements. Yes_____ No_____ Note: In a hospital setting, group therapy codes may be billed more than once per day, but sufficient documentation must be provided to determine medical necessity and clinical appropriateness. Source Documents: Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services, Sections 220 and 230. Accessed at: www.cms.hhs.gov Medicare Claims Processing Manual, Chapter 5, Section 20.2, Reporting of Service Units – Form CMS-1500 and Form CMS-1450. Accessed at www.cms.hhs.gov Paul, D. & Hasselkus, A. (2004). Clinical record-keeping in speech-language pathology for healthcare and third-party payers. Rockville, MD: ASHA. Author Notes Becky Sutherland Cornett, is associate compliance director, the Ohio State University Medical Center, Columbus, OH. Contact her at [email protected]. Advertising Disclaimer | Advertise With Us Advertising Disclaimer | Advertise With Us Additional Resources FiguresSourcesRelatedDetails Volume 11Issue 12September 2006 Get Permissions Add to your Mendeley library History Published in print: Sep 1, 2006 Metrics Current downloads: 15,888 Topicsasha-topicsleader_do_tagasha-article-typesleader-topicsCopyright & Permissions© 2006 American Speech-Language-Hearing AssociationLoading ...

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