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HIM Sample Policies and Forms
ICD-10 preparation checklist
The following ICD-10 preparation checklist was published in the Clinical Documentation Improvement Specialist's Guide to ICD-10.
OCR HIPAA audit protocol key activities
The Office for Civil Rights recently published its audit protocol for its current privacy and security audits. These protocols give healthcare organizations an inside look at the inspection process. Our sister publication, Briefings on HIPAA, recently published this breakdown of the audit protocols key activities.
ICD-10 education director job description
Christine Lewis, MHA, RHIA, CCS, CCS-P, health information services coding and record processing manager at the Medical University of South Carolina in Charleston, shared this job description, originally printed in Medical Records Briefing, in use at her hospital with those who might be wondering how to structure the position at their own facility.
ICD-10 Implementation Program Plan from The HIM Director's Guide to ICD-10
In this book excerpt, Gloryanne Bryant, BS, RHIA, RHIT, CCS, CCDS, Jean S. Clark, RHIA, CSHA, and Caroline Piselli, RN, MBA, FACHE, provide a snapshot of 11 milestones within an integrated, interdis¬ciplinary program plan that should span well beyond one’s own enterprise and to all trading partners. Physicians, hospitals, payers, billing clearinghouses, and others must collaborate in order to ensure intimate integration of plans.
Bonus Plan for Transcriptionist and Coder Positions
Kristen Bliss, RHIA, RHIT, director of medical record management at Sarah Bush Lincoln Health Center in Mattoon, IL, shares this sample form that outlines the policy her facility uses to establish a production bonus plan for transcriptionist and coder positions for individual productivity in excess of established production standards.
Monthly Coding Production Spreadsheet
Kristen Bliss, RHIA, RHIT, director of medical record management at Sarah Bush Lincoln Health Center in Mattoon, IL, shares this monthly coding production worksheet that her organization uses to facilitate its production bonus plan for transcriptionist and coder positions for individual productivity in excess of established production standards.
The RAC Survival Guide: Sample Tracking Tool
In this sample form, Kimberly Anderwood Hoy, JD, CPC, director for Medicare and compliance at HCPro, Inc., lists items providers should consider including when using an internally developed system for tracking recovery audit contractor requests, denials, and appeals. Click here to learn more about The RAC Survival Guide.
Audit Checklist: Shared/Split Visit
Elin Baklid-Kunz, MBA, CPC, CCS, the director of physician services for Halifax Health in Daytona Beach, FL, provided this sample audit checklist for shared/split visits, which you can use to help ensure compliant and accurate coding.
Confidentiality Agreement
Anissa Fabrizio, RHIA, CCS, administrative director of patient financial and information services at St. Anthony Central Hospital in Denver, shares this sample confidentiality agreement that employees should sign acknowledging their responsibility for all actions performed under their login information.
Audit Checklist: Incident-To Services
Elin Baklid-Kunz, MBA, CPC, CCS, the director of physician services for Halifax Health in Daytona Beach, FL, provided this sample audit checklist for incident-to services, which you can use to help ensure compliant and accurate coding.
Audit Checklist: Critical Care Services
Elin Baklid-Kunz, MBA, CPC, CCS, the director of physician services for Halifax Health in Daytona Beach, FL, provided this sample audit checklist for critical care services, which you can use to help ensure compliant and accurate coding.
Medical Records Documentation Audit Tool--Physician Office
Jean S. Clark, RHIA, CSHA, shares this audit tool, which you can use as a guide to documentation in physician practices to help prepare for survey readiness. It is difficult for practices to understand and apply standards to their unique situation, and this audit tool is helpful in ensuring compliance. This tool is an excerpt from HCPro’s Information Management and Record of Care, Treatment, and Services: The Compliance Guide to the Joint Commission’s Standards, Seventh Edition.
2009 Medical Records Documentation Guide, Fourth Edition
HIM professionals and hospital accreditation coordinators can use this tool to identify areas in which the documentation in a facility’s medical records may not provide clear evidence of Joint Commission compliance. Although this activity is fairly labor-intensive, hundreds of hospitals that have used past versions of the documentation guide have found it to be one of the best ways to identify documentation problems that need further attention.
Medical Records Forms Approval Process
Laura J. Rizzo, MHA, RHIA, director of health information management at Lancaster General in Lancaster, PA, shares these tools for approving new or revised medical records forms at your facility. The Medical Records Forms Approval Process includes a policy for approving forms to ensure standardization of design and to help reduce redundancy of medical records forms. Use this checklist to ensure that all form design requirements have been met. Finally, you can use the New/Revised Medical Record Approval Form to show that the appropriate parties have reviewed the new form according to the hospital’s policy.
Sample Template for Initial Preventive Physical Examination
Lori-Lynne Webb, CPC, CCS-P, CCP, an independent coding consultant in Melba, ID, shares this sample template for an initial preventive physical examination (IPPE). This can be a handy tool to ensure that physicians don’t overlook IPPE requirements.
Authorization for release of protected health information from mental health records
This form is an example of an authorization release of protected health information from mental health records. The form is excerpted from HCPro’s book, The Practical Guide to Release of Information by Rose T. Dunn, RHIA, CPA, CHPS, and Scott A. Edelstein, Esq. For more information, please visit HCMarketplace.com
Request to amend or correct protected health information
Use this tool when patients request to amend or correct their protected health information. The tool is excerpted from HCPro’s book, The Practical Guide to Release of Information by Rose T. Dunn, RHIA, CPA, CHPS, and Scott A. Edelstein, Esq. For more information, please visit HCMarket place.com.
Platinum form: POA indicator query form
Use this form to conduct present on admission queries.
Benefit investigation form
Beth Beers, coding and reimbursement specialist for the oncology/hematology clinic at Mercy Hospital in Portland, ME, developed this tool to help make providers aware of insurance coverage information prior to treatment. Use this form to determine whether the patient has coverage for the treatment, whether there is a high deductible for the treatment, whether the patient can pay for the treatment, and whether there are any assistance programs that will help the patient pay for services and medications.
Patient tracer worksheet
Patient tracer worksheet
Admission, history, and physical examination tracking form
Use this form to track documentation for admission, history, and physical examination. This form was excerpted from HCPro's book, Ongoing Records Review: A Guide to JCAHO Compliance and Best Practice. For more information, visit http://www.hcmarketplace.com/prod-5043.html.
H&P critical elements pre-surgery tracking form
Use this form to help track critical elements in the history and physical. This form was excerpted from HCPro's book, Ongoing Records Review: A Guide to JCAHO Compliance and Best Practice. For more information, visit http://www.hcmarketplace.com/prod-5043.html.
Source: Ongoing Records Review, Fifth Edition: A Guide to The Joint Comission Compliance and Best Practices, reprinted with permission.
For more information visit: http://www.hcmarketplace.com/prod-5043.html.
Ongoing records review process assessment
Use this form to help assess your ongoing records review process.
Source: Ongoing Records Review, Fifth Edition: A Guide to The Joint Comission Compliance and Best Practices, reprinted with permission.
For more information visit: http://www.hcmarketplace.com/prod-5043.html.
Protocol for a medical records committee with ongoing records review
Use this form to help develop a protocol for a medical records committee with ongoing records review oversight.
Source: Ongoing Records Review, Fifth Edition: A Guide to The Joint Comission Compliance and Best Practices, reprinted with permission.
For more information visit: http://www.hcmarketplace.com/prod-5043.html.
Clinical Documentation Improvement Program Case Manager's Training Session
Use this exam to test case managers after your clinical documentation improvement program training session.
Source: Guide to Inpatient Clinical Documentation Improvement Strategies to Ensure Compliance and Correct Reimbursement, reprinted with permission.
For more information visit http://www.hcmarketplace.com/prod-1047.html
Disclosure form
Use this sample form to track disclosures.
Source: Marshalltown (IS) Medical and surgical Center. Reprinted with permission.
Explanation of benefit audit tool
Track denials with this explanation of benefit audit tool in Excel.
Source: Denial Management: Key Tools and Strategies for Prevention and Improvement
For more information visit http://www.hcmarketplace.com/prod-3659.html
HIM department customer-satisfaction form
Use this sample form to quantify customer satisfaction pertaining to the HIM department.
Source: McAlester (OK) Regional Health Center. Reprinted with permission.
Request for accounting of disclosures
Use this sample form to requent accounting of disclosures.
Request for restrictions on protected health information
Use this form to request restrictions on protected health information.
Source: Medical College of Ohio Hospitals. Reprinted with permission.
Sample confidentiality of patient and hospital information form
Use this sample form to ensure confidentiality of all patient and hospital information.
Source: Adapted from Memorial Hospital of Union County, Marysvill, OH. Reprinted with permission.
Checklist of criteria for auditing firms
Use this checklist of criteria when selecting an auditing firm.
Source: Adapted from: Seven steps to HIM Compliance, copyright1998, HCPro, Inc.
Inpatient-coding audit tool
Use this tool when conducting an inpatient-coding audit.
Source: Adapted from: Coding Compliance: A Pratical Guide to the Audit Process, Copyright 2000, HCPro, Inc.
Physician delinquency assessment
Use this form to create a delinquency profile for your physicians.
Source: More With Less, Second Edition: Best Practices for HIM Directors, reprinted with permission.
For more information visit: http://www.hcmarketplace.com/prod-5170.html
Transcription productivity report
Use this form to measure transcription productivity.
Source: Southeastern Ohio Medical Center, Cambridge. Reprinted with permission.
Unapproved abbreviations review tool
Disseminate this list to your coding staff so that they may track physician usage of unapproved abbreviations.
Source: Ongoing Records Review, Fifth Edition: A Guide to The Joint Comission Compliance and Best Practices, reprinted with permission.
For more information visit: http://www.hcmarketplace.com/prod-5043.html.
Workday assessment form
Use this form to assess coders' workdays and improve employee satisfaction and retention.
McAlester (OK) Regional Health Center. Reprinted with permission
72-hour/account transfers
Use this form for 72/-hour/account transfers for different dates of service. If the transfer is during the same day, use one of the other duplicate forms.
Source: Marshaltown (IA) Medical & Surgical Center. Reprinted with permission
Hospital concurrent documentation improvement plan sample policy
Thinking about starting a concurrent documentation program? Use this sample policy as a foundation.
Source: Guide to Inpatient Clinical Documentation Improvement Strategies to Ensure Compliance and Correct Reimbursement, reprinted with permission.
For more information visit http://www.hcmarketplace.com/prod-1047.html
HIPAA complaint form
Use this form to report a privacy disclosure complaint.
Source: Granville (NC) Medical Center. Reprinted with permission
Sample claims tracking report for third-party payers
Use this sample claims tracking report to stay abreast of payments made by third-party payers.
Source: Revenue Cycle Management: A Best Practices Toolkit, reprinted with permission
For more information visit: http://www.hcmarketplace.com/prod-4003.html
Coding quality review for outpatient records
Use this form to review the coding quality of your facility's outpatient records.
Source: Adapted from: Coding Compliance: A Practical Guide to the Audit Process, copyright 2000, HCPro, Inc.
Data collection tool
Use this data collection tool to determine a monthly tally of denials.
Source: Denial Management: Key Tools and Strategies for Prevention and Improvement, reprinted with pernmission.
For more information visit http://www.hcmarketplace.com/prod-3659.html
Case manager self-evaluation form
Use this form to perform a case manager self-evaluation to assess coding and documentation improvement knowledge before implementing a clinical documentation improvement program.
Source: Guide to Inpatient Clinical Documentation Improvement Strategies to Ensure Compliance and Correct Reimbursement, reprinted with permission.
For more information visit http://www.hcmarketplace.com/prod-1047.html