What Are Conditions of Participation
The Medicare Conditions of Participation, established by the Centers for Medicare and Medicaid Services, are the minimum health and safety standards that healthcare organizations must meet to participate in the Medicare and Medicaid programs. RHIA candidates should understand that these requirements touch nearly every aspect of hospital operations, including medical record services.
Medical Record Requirements Under CoPs
- Records must be maintained for every patient evaluated or treated
- Records must be accurately written, promptly completed, properly filed and retained, and accessible
- A qualified medical record practitioner must supervise the health information function
- Records must be completed within a facility-defined timeframe after discharge
These requirements form the basis for many hospital health information policies, including record completion timelines and delinquency management.
Survey and Certification Process
Compliance with the CoPs is assessed through surveys, which may be conducted by state survey agencies acting on behalf of CMS, or through accreditation by a CMS-approved accrediting organization such as The Joint Commission, which grants deemed status. HIM departments are frequently surveyed for record completeness, documentation of informed consent, and accurate reflection of patient care.
Consequences of Noncompliance
Failure to meet the CoPs can result in a plan of correction requirement, and in serious or repeated cases, termination from the Medicare program, which would eliminate the facility's ability to bill Medicare for services. This makes CoP compliance a top organizational priority.
HIM's Role in CoP Compliance
HIM professionals monitor record completion rates, ensure timely dictation and signature of reports, and maintain policies for record content and retention that align with CoP standards. They also often coordinate directly with survey teams during onsite inspections, providing requested documentation and demonstrating compliance processes.
Interaction With Other Standards
Candidates should understand how CoPs interact with accreditation standards, since accredited facilities must still meet CoP requirements even though survey responsibility may shift to the accrediting body.
Exam Focus
Expect scenario questions on record completion timeframes, the consequences of noncompliance, and identifying which department bears primary responsibility for specific CoP requirements related to health information services.