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For The Record Magazine - eNewsletter
January 2010
In this issue...

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A Snapshot of Healthcare 2009
The people, places, and legislation that made headlines—and some that didn’t—are recapped by an elite panel of experts. Read more

HIPAA Targets
New HITECH rules bring greater scrutiny to dictation and transcription practices, as well as business associates. Read more

The Impact of New Communication Tools
The industry is opening its eyes to the value of text messaging, e-mail, and observations of daily living. Read more

Never Say Good-Bye?
Opponents argue that a proposed 10-year nationwide record retention policy would not serve the best interests of healthcare organizations or consumers. Read more

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Other News

Canadian Students Design iPhone App for Docs
Read about how students at Canada's University of Saskatchewan  have developed a physician diagnosis reference tool for the iPhone.

Georgia Health-e Connect Launches
According to The McDuffie Mirror, Georgia HIT leaders have launched an initiative to create a statewide EHR.

Editor’s E-Note

Health information technology is supposed to make everyone’s life easier, right? Hold on a sec, says G. Michael Bellenghi.

In this month’s E-News Exclusive, the executive vice president of the Association of Health Information Outsourcing Services contends that technology is making it that much harder to handle release-of-information requests.

— Lee DeOrio, editor

E-News Exclusive

Where EHRs Hit a Wall in the HIM World
By G. Michael Bellenghi

As healthcare begins adjusting to all the changes created by ongoing healthcare reform, new sets of HIM-related issues arise. One of these issues involves the release-of-information (ROI) process. The perception may be that fulfilling an ROI request is made significantly easier by the existence and usage of both EHRs and legal health records (LHRs). The reality is that the addition of technology and related regulations complicates the ROI process.

One reason healthcare organizations maintain an LHR—also known as the business health record or postdischarge health record—is to adhere to ROI requests made by authorized requestors. However, there are very complex processes that must be followed to legally provide any portion of an LHR, which requires significant human oversight. Few outside the HIM arena know the full levels of intricacy and risk involved in providing medical records. There are critical, time-sensitive, and strictly regulated steps by which well-trained HIM specialists must abide to ensure that both patient information is protected and healthcare organization liability is minimized.


Industry Insight

Public Hospitals Nationwide Join Patient Safety Initiative

Kaiser Permanente, together with the National Patient Safety Foundation (NPSF) and the National Association of Public Hospitals (NAPH) and Health Systems, has announced the Patient Safety Initiative at America’s Public Hospitals. This two-year program is designed to enhance patient safety programs at public hospitals to ensure safe, high-quality care for vulnerable and low-income populations that depend on publicly supported healthcare institutions for medical care.

Kaiser Permanente contributed $718,010 to fund 85 hospitals for the two-year program. Forty-two hospitals were selected for phase 1 in 2009, with the remaining 43 to be selected for phase 2 in 2010. There is potential to expand this program to all 140 NAPH member hospitals.


Ask the Expert

Have a coding or transcription question?
Get an expert answer by sending an e-mail to

How would the facility for which I work bill services for this scenario: The family of a patient with Alzheimer’s disease requests to see the physician to discuss the patient’s care.

Some literature leads us to believe that this should be billed with 90846. Other literature seems to state that this could be billed as a regular evaluation and management service based on time spent with the family members.

What guidance do you have for us to accurately code for this situation? We run into this situation regularly with our geriatric clinic and sometimes a similar situation occurs with the pediatric clinics (only these patients do not have Alzheimer’s but other disorders).

Sally Roland, MS, RHIA, CPC
Compliance Coordinator
Methodist Physicians Clinic
Omaha, Neb.

CPT codes 90846 and 90847: Family psychotherapy is covered when the primary purpose of such counseling is the treatment of a patient’s condition. For example, two situations where family counseling services would be appropriate are as follows:

When there is a need to observe the patient’s interaction with family members and/or when there is a need to assess the capability of and assist the family members in aiding in the management of the patient.

See CMS Publication 100-3, the National Coverage Determinations Manual, Chapter 1, Section 70.1.

— Rebecca Woodward is a member of the American Academy of Professional Coders’ Medical Coding & Billing Forum.

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