The Centers for Medicare and Medicaid Services issued a final rule for implementation of ICD-10-CM and -PCS this morning, with an implementation date of October 1, 2013.

The new code set will replace the 30-year-old ICD-9-CM set. CMS had originally set a 2011 deadline in its notice of proposed rule making last year. The final rule summarizes the varied industry response that proposal received.

A second rule sets implementation dates for HIPAA transaction standards necessary to support ICD-10. Upgrade to the X12 version 5010 standard has a deadline of January 2012. Implementation of NCPDP version D.0 is required in January 2013.

HHS offers a fact sheet summarizing both rules.

(This story was updated 1/16/2009 with links to the published rules.)

Anita Majerowicz, MS, RHIA, is director of clinical coding and reimbursement at AHIMA. She offers this look at the 2009 CPT updates in the upcoming February print issue of the Journal.

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Changes to CPT codes for 2009 include 293 additions, 133 revisions, and 92 deletions. This article highlights some of the more notable changes; a comprehensive list can be found in appendix B of the 2009 CPT code manual. The changes took effect January 1.

E/M Codes

Numerous changes were made to the pediatric E/M codes, including newborn care services, delivery and birthing room attendance and resuscitation services, pediatric critical care patient transport, and inpatient neonatal and pediatric critical care services. Coding professionals should read the extensive revisions to the instructional notes, as many codes were renumbered for 2009.

A new section titled “Newborn Care Services” was added to report the physician services provided to newborns in a variety of settings from birth through the first 28 days of life. These services are reported using codes 99460–99463, replacing deleted codes 99431–99435. They include the maternal and fetal history, newborn history and physical examination, ordering of diagnostic tests and treatments, discussions with the family, and documentation in the patient’s health record.

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Physicians seeking to transform their primary-care practices are seeing increasing support for the patient-centered medical home model. Growing recognition from payers and new help with the transition are advancing the model as a viable future for primary care.

In December consulting company TransforMED began offering products and services publicly for the first time, following a two-year national demonstration project aimed at showing the healthcare model’s efficiency and benefits to both patients and physicians.

TransforMED, a wholly owned subsidiary of the American Academy of Family Physicians, offers services ranging from practice assessments and consultations on partial implementation to assistance with full medical-home operations. The company’s services are offered in tiers, allowing a practice to transition in incremental steps. (more…)

For organizations that allow clinicians to carry forward clinical documentation in electronic records, auditing its proper use is key to ensuring document integrity. Copying clinical documentation poses both clinical and compliance risk. The feature “Auditing Copy and Paste” offers guidance in creating a solid audit plan.

The story is adapted from the broader AHIMA resource “Copy Functionality Tool Kit.” It offers sample policies, testing activities, case scenarios, and questions organizations can ask when considering the use of copy and paste.

You’ll find a lot of other good practice resources on that page.

What’s the difference between a taxonomy and a terminology? A terminology and a vocabulary? The January “e-HIM Fundamentals” column offers help in differentiating the terms that describe data management in electronic clinical records. The online version (available to AHIMA members) offers an expanded list of definitions.

The January practice brief recommends resources for regulations and standards that apply to HIM practice in a range of settings. See the online version for links directly to the sources.

The January Journal examines the HIM issues in healthcare reform and the issues the incoming Obama administration needs to take on in order to move the industry forward. Other features outline best practices on auditing copy and paste, the need for standardized clinical terminologies for health information exchange, and how HIM professionals can lend a hand to medical practices facing changes in information management and technology. (more…)