Neurosurgery Coding Alert
Look Beyond Patient’s Medical Record for PHI
Question: Is there more to protected health information (PHI) than just a patient’s medical record? Is this information actually protected by HIPAA? Maine Subscriber Answer: Yes, there is more to PHI than just what’s in a patient’s chart. PHI by definition is protected health information. If a record is completely de-identified in a such a manner that it cannot possibly be connected to an individual, then no, that would not be protected. Technically, it is no longer PHI. So, PHI is demographic information as well as information about a patient’s health, and when health information can be linked to a specific individual via one of 18 different identifiers, it is regarded as protected. Those identifiers include such things as a person’s name, Social Security number, physical and electronic mail addresses, telephone numbers, license plate numbers, and account numbers. Remember: If there are unlisted identifiers, PHI still needs to be protected. So, for example, if the information identifies a man who just returned to a small town from being overseas in the Marines, though that itself is not PHI, townspeople would easily be able to identify this person and thus, the information needs to be protected. Resource: Find the full list of identifiers at www.hhs.gov/sites/ default/files/ocr/privacy/hipaa/understanding/coveredentities/ De-identification/hhs_deid_guidance.pdf.
Neurosurgery Coding Alert
- CPT®:
Establish Exact Number of Treatment Days, Understand Term “Racz Catheter” to Accurately Report Adhesiolysis
Hint: Never report codes 62263 and 62264 together. If your neurosurgeon performs percutaneous epidural adhesiolysis [...] - Quiz:
6 Questions Guaranteed to Improve Your Bell’s Palsy Coding Skills
Hint: Facial palsy is the same as Bell’s palsy. Since you only have one ICD-10-CM [...] - E/M 2021:
Expect Definition of Time to Change When Preparing for E/M 2021
Hint: Only guidelines for codes 99202-99215 will change. In past issues of Neurosurgery Coding Alert, [...] - You Be the Coder:
Surgeon Repaired Depressed Skull Fracture? Do This
Question: To fix a depressed skull fracture, my neurosurgeon made an incision in the scalp, [...] - Reader Questions:
Decipher This Injection Situation
Question: The neurosurgeon injected a diagnostic agent into the patient’s facet joint at two levels [...] - Reader Questions:
Grasp What Vertebroplasty Procedure Entails
Question: I came across the term “vertebroplasty” in a medical record. Can you explain what [...] - Reader Questions:
Choose Correct Dx for Cerebral Palsy
Question: My physician performed a level-three office evaluation and management (E/M) service for an established [...] - Reader Questions:
Make Sure to Most Recent ABN Form
Question: How do I know whether I’m using the correct advanced beneficiary notice (ABN) form [...] - Reader Questions:
Look Beyond Patient’s Medical Record for PHI
Question: Is there more to protected health information (PHI) than just a patient’s medical record? [...] - Reader Questions:
Know Options When Physicians Signature Illegible
Question: Do we have any options if our physician’s signature is illegible? Texas Subscriber Answer: [...]
