News: New York limits documentation, coding requirements in light of COVID-19 spread

CDI Strategies - Volume 14, Issue 14

The state of New York issued an executive order directly effecting the work of health information management (HIM) professionals in light of the COVID-19 pandemic. Currently, the state of New York has over 83,000 confirmed COVID-19 cases and has reported more than 1,900 deaths, making it the epicenter of the pandemic in the United States.

The order states that

Notwithstanding any law or regulation to the contrary, health care providers are relieved of recordkeeping requirements to the extend necessary for health care providers to perform tasks as may be necessary to respond to the COVID-19 outbreak, including, but not limited to, requirements to maintain medical records that accurately reflect the evaluation and treatment of patients, or requirements to assign diagnostic codes or to create or maintain other records for billing purposes.

It says that anyone acting reasonably and in good faith under the order will be given absolute immunity from liability for any failure to comply with recordkeeping requirement.

This order comes in an attempt to relieve providers and faculty of documentation time in hopes it can be redistributed to treating those who are sick. However, it raises concern about the ability to collect accurate data about the COVID-19 outbreak if the state’s healthcare facilities are not keeping records.

“It doesn’t mean that records are not being kept,” says Laurie L. Prescott, RN, MSN, CCDS, CDIP, CRC, CCDS-O, CDI education director at HCPro. “It means that the documentation is not going to be assessed for specific components to support billing.”

The important information will likely still be captured, Prescott says, and much of the documentation we do today is not purely for patient safety; it is oriented towards capturing and supporting billing and regulatory demands. That this is what the order is speaking to.

Editor’s note: More COVID-19 related articles from ACDIS can be found here, here, here and here.

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Clinical & Coding, News