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CMS Hospital CoPs Medical Records – Webinar

August 22 @ 9:00 am - 11:00 am

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If a CMS surveyor showed up at your door tomorrow would you know what to do? Are you up to date on all the recent CMS hospital CoP changes? Did you know that all the medical records standards (health information management) apply to all departments including lab and x-ray?

This program will cover in detail the CMS regulations and interpretive guidelines for medical records. This is an extremely important section and includes hot issues like verbal orders, history and physicals, organization of the department, standing orders, discharge summary, medication orders, and more.

It will include the proposed changes in 2019 under the Hospital Improvement Rule. This includes changes to outpatient medical records, the rights of patients, and documentation changes. One proposed change would require that the diagnosis and records be completed within 7 days for outpatients. The proposed changes to the CMS discharge planning standards and the proposed changes to transparency, including H&P changes, will also be covered.

CMS publishes a list of deficiencies received by hospitals and this will be discussed. The number of deficiencies in medical records section has gone up significantly. Come learn how to be compliant with these CMS requirements.

This program will cover some information on HIPAA from the Office of Civil Rights including the difference between patient access verses when an authorization is needed. It will discuss the changes to the federal law on alcohol and drug records which are now called substance abuse disorder records under 42 CFR Part 2.

It is important to ensure that the required CMS documentation elements are contained in the electronic medical record (EMR) as hospitals move toward a completely integrated EMR. These should also be reflected in the hospital P&Ps. The number of deficiencies in each of the CMS medical records sections will be discussed.

Most every hospital in the America accepts Medicare and Medicaid reimbursement and as such must be in compliance with the CMS Conditions of Participation (CoPs) for hospitals. There have been many changes to these over the recent past. This includes changes to Tag 454 (verbal orders), 457 (standing orders) and 458 (H&P update). Hospitals ask many questions regarding the regulations for standing orders, order sets, protocols, and preprinted orders.

There are several important CMS memos that have been published including an 11 page memo which addresses confidentiality and privacy. These are important in light of the recent large fines related to HIPAA being assessed by the Office of Civil Rights. This webinar will also discuss the OIG document on access verses authorization which is final and which is also discussed in the CMS proposed rules.

 The medical records section has many important standards such as informed consent, history and physicals, verbal orders, discharge summaries and more. The CMS worksheet section about getting discharge summaries into the hands of the primary care doctor to prevent unnecessary readmissions will be discussed.

 A discussion of the NOTICE law will be covered which requires a form to all observation patients. The IM notice and detailed notice forms have also been updated. The federal law on substance use disorder records also been amended.

Don’t be unprepared if the state department of health, state agency, or CMS shows up for a complaint or validation survey. Joint Commission has also recently changed many of their standards to comply with the CMS CoP requirements so not doing this right could also result in being out of compliance with standards from the Joint Commission. CMS states that all of their medical record regulations also apply to documents maintained by radiology and the lab.

Objectives:

  • Recall that CMS has specific informed consent requirements
  • Describe when a history and physical must be done and what is required by CMS and the Joint Commission
  • Discuss that both CMS and TJS have standards on verbal orders
  • Recall that CMS has standards for preprinted orders, standing orders, and protocols

 

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