Medical Record: Compliance with CMS Hospital CoPs and Proposed Changes

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 that went into effect on November 29, 2019? Did you know that all the medical records standards (health information management) apply to all departments including lab and x-ray?

Did you know that CMS made changes to the hospital CoPs on November 29, 2019, that were from two separate sets of federal regulations? This includes changes to the history and physicals for healthy outpatients. It also included some changes in the discharge planning on access to medical records. It also included changes in the final Hospital Improvement rule. CMS also changed the website to get copies of all the manuals and the email address to ask questions so this information will be provided.

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, access to medical records, standing orders, discharge summary, medication orders, and more.

CMS publishes a list of deficiencies received by hospitals and this will be discussed. The number of deficiencies in the 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 versus when authorization is needed. Did you know that OCR is now fining hospitals if patients are not given access to medical records timely? The last two fines were $85,000 each.

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 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 past 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 that 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 versus authorization which is final and which is also discussed in the CMS final 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 for all observation patients. The IM notice and detailed notice forms have also been updated in 2020 also. The federal law on substance use disorder records has also been amended.

Don’t be unprepared if the state department of health, a 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.

• Recall that CMS has specific informed consent requirements
• Describe when 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

• Introduction to the CMS hospital CoPs
• How to obtain a copy
• CMS Survey memos
• Interpretive guidelines issued 
  • Changes to verbal orders and H&P update
• How to keep posted of new changes 
• Confidentiality and privacy memo
• MOON form
• IM and detailed notice forms
• Transfer form requirements and proposed changes
• OCR information on HIPAA on patient access versus authorization
• TJC changes to comply with CoPs
• Autopsies requirement changed
• AHIMA practice guidelines
• HITECH and Breach Notification law
• Final changes to privacy, security, HITECH 
• Verbal orders and changes
• History and physicals and November 29, 2019 changes
• Grievances
• Incident reports
• Medical record service requirements
• Medical record education and personnel
• Author identification
• Content of records
• Standing orders and protocols
• Legibility and authentication requirements
• Informed consent
• List of procedures for consent requirements
• Discharge summaries
• Completed medical records
• Other sections of CoPs that are important for documentation in the medical record
  • Restraint and seclusion
  • Medication documentation
  • Pre-anesthesia assessment
  • Post-anesthesia assessment
  • Visitation with changes to advance directives, consent, and plan of care
  • Notification of OPO in deaths
  • Organ donation documentation
  • Anesthesia standards 

• Director of Health Information Management
• Health Information Management staff
• Chief Nursing Officer (CNO)
• Compliance Officer
• Director of Radiology
• Lab Director
• Hospital Legal Counsel
• Chief Executive Officer (CEO)
• Chief Operating Officer (COO)
• Chief Medical Officer (CMO)
• Joint Commission Coordinator
• Quality Improvement Coordinator
• Risk Managers
• Nurse Educator
• Patient Safety Officer
• Emergency Department Manager
• Nurse Managers/Supervisors
• Staff Nurses
• Clinic Managers
• Medical Department Nurse Manager
• Surgery Department Nurse Manager
• OR Nurse Director
• ICU Nurse Director
• CCU Nurse Director
• Outpatient Director
• IS Director
• Policy and procedure committee
• Anyone involved in the implementation of the CMS or Joint Commission medical record and documentation standards