Total Rules
1,847
+32 updated
Active Standards
12
6 primary sources
Automated Checks
1,203
65% of total
Critical Rules
284
Monitored 24/7
Centers for Medicare & Medicaid Services (CMS)
The Joint Commission
American Medical Association (AMA)
Office of Inspector General (OIG)
American Health Information Management Association (AHIMA)
American Academy of Professional Coders (AAPC)
Complete History and Physical within 24 hours
H&P must be completed and documented within 24 hours of inpatient admission per Medicare conditions of participation
Medication Reconciliation
Medication reconciliation must be performed and documented at all transitions of care
Patient Identification Protocol
Use at least two patient identifiers when providing care, treatment, or services
Improve Safety of High-Alert Medications
Label all medications and medication containers in perioperative and procedural settings
Documentation Completeness
Clinical documentation must be complete, accurate, and timely with all required elements present
Authentication and Signatures
All entries must be dated, timed, and authenticated by the author
Fraud Prevention Standards
Implement effective compliance and ethics program to detect and prevent fraud
Code to Highest Specificity
Assign codes to the highest level of specificity supported by documentation