Recommended Regulations and Standards for Specific Healthcare Settings (Updated)


Editor’s note: This update supplants the December 2002 practice brief “Recommended Regulations and Standards for Specific Healthcare Settings (Updated).”


HIM skills are applied to a multitude of healthcare settings. This practice brief lists recommended resources for each setting.

Whether honing existing skills or making the transition to a new healthcare setting, acquisition of and thorough familiarization with the regulations and standards listed below is recommended.

Practice Setting: Acute Care/Hospitals

Recommended Resource Source
Certified inpatient EHRs Certification Commission for Healthcare Information Technology, www.cchit.org/choose/index.asp
CMS Conditions of Participation for Hospitals (42 CFR 482)

CMS, www.access.gpo.gov/nara/cfr/waisidx_04/42cfr482_04.html

Comprehensive Accreditation Manual for Hospitals

The Joint Commission, www.jointcommission.org/AccreditationPrograms/Hospitals

Comprehensive Accreditation Manual for Critical Access Hospitals

The Joint Commission, www.jointcommission.org/AccreditationPrograms/CriticalAccessHospitals

Conditions of Participation for Patient Rights

CMS, www.cms.hhs.gov/CFCsAndCoPs/downloads/finalpatientrightsrule.pdf

Critical Access Hospitals Center

CMS, www.cms.hhs.gov/center/cah.asp

Healthcare Facilities Accreditation Program

American Osteopathic Association, www.aoa-net.org/Accreditation/HFAP/HFAP.htm

Hospital Outpatient Prospective Payment System

CMS, www.cms.hhs.gov/HospitalOutpatientPPS/HORD/list.asp

Interpretive guidelines for hospitals

CMS, www.cms.hhs.gov/manuals/Downloads/som107ap_a_hospitals.pdf

Interpretive guidelines for swing bed hospitals

CMS, www.cms.hhs.gov/manuals/downloads/som107ap_t_swing_beds.pdf

Long-Term Care Hospitals Prospective Payment System

CMS, www.cms.hhs.gov/LongTermCareHospitalPPS/01_overview.asp

Medicare Benefit Policy Manual

CMS, www.cms.hhs.gov/manuals/Downloads/bp102c01.pdf

Medicare Hospital Inpatient Prospective Payment System

CMS, www.cms.hhs.gov/AcuteInpatientPPS

Medicare Hospital Prospective Payment System

CMS, www.cms.hhs.gov/AcuteInpatientPPS/01_overview.asp

Medicare Program Manuals

CMS, www.cms.hhs.gov/Manuals/IOM/list.asp

Physician Certification and Recertification of Services

CMS, www.cms.hhs.gov/manuals/downloads/ge101c04.pdf

Office of Inspector General Compliance Program Guidance

Department of Health and Human Services Office of Inspector General, http://oig.hhs.gov/authorities/docs/cpghosp.pdf


Practice Setting: Ambulatory and Physician Practice

Recommended Resource

Source

Accreditation Handbook for Ambulatory Health Care

Accreditation Association for Ambulatory Health Care, www.aaahc.org/eweb/StartPage.aspx

Ambulatory surgery center certification and compliance

CMS, www.cms.hhs.gov/CertificationandComplianc/02_ASCs.asp

Ambulatory Surgical Centers Conditions of Coverage

CMS, www.cms.hhs.gov/CFCsAndCoPs/downloads/ambsurgreg.pdf

Certified inpatient EHRs

Certification Commission for Healthcare Information Technology, www.cchit.org/choose/index.asp

CMS Physician Center

CMS, www.cms.hhs.gov/center/physician.asp

CMS Ambulatory Surgical Centers (ASC) Center

CMS, www.cms.hhs.gov/center/asc.asp

Comprehensive Accreditation Manual for Ambulatory Care

The Joint Commission, www.jointcommission.org/AccreditationPrograms/AmbulatoryCare

Documentation Guidelines for E&M Services

CMS, www.cms.hhs.gov/MLNEdWebGuide/25_EMDOC.asp

Medicare Benefit Policy Manual for Comprehensive Outpatient Rehab

CMS, www.cms.hhs.gov/manuals/Downloads/bp102c12.pdf

Medicare Benefit Policy Manual for Rural Health Centers

CMS, www.cms.hhs.gov/manuals/Downloads/bp102c13.pdf

Rural Health Center

CMS, www.cms.hhs.gov/center/rural.asp


Practice Setting: Behavioral Health

Recommended Resource

Source

Behavioral Health Standards Manual

Commission on Accreditation of Rehabilitation Facilities, www.carf.org/providers.aspx?Content=Content/Accreditation/Opportunities/BH/toc.htm

Certification for community mental health

CMS, www.cms.hhs.gov/CertificationandComplianc/03_CommunityHealthCenters.asp

Comprehensive Accreditation Manual for Behavioral Health Care

The Joint Commission, www.jointcommission.org/AccreditationPrograms/BehavioralHealthCare

Conditions of Participation for Drug, Alcohol, and Substance Abuse (42 CFR 2)

National Archives and Record Administration, Code of Federal Regulations, www.access.gpo.gov/nara/cfr/waisidx_01/42cfr2_01.html

Managed Behavioral Healthcare Organization Accreditation Program

National Committee for Quality Assurance, www.ncqa.org/tabid/94/Default.aspx

Medicare Benefit Policy Manual for Inpatient Psychiatric Hospital Services

CMS, www.cms.hhs.gov/manuals/Downloads/bp102c02.pdf

Psychiatric residential treatment provider certification

CMS, www.cms.hhs.gov/CertificationandComplianc/13_PRTFs.asp#TopOfPage

State Operations Manual for Psychiatric Hospitals

CMS, www.cms.hhs.gov/CFCsAndCoPs/downloads/som107ap_aa_psyc_hospitals.pdf


Practice Setting: Clinical Research

Recommended Resource

Source

Animal welfare

National Archives and Record Administration, Code of Federal Regulations, www.access.gpo.gov/nara/cfr/waisidx_02/9cfrv1_02.html

Office for Human Research Protections

HHS, www.hhs.gov/ohrp

Privacy rule and information for researchers

National Institutes of Health, privacyruleandresearch.nih.gov

Protection of Human Subjects (45 CFR 46)

National Archives and Record Administration, Code of Federal Regulations, www.access.gpo.gov/nara/cfr/waisidx_01/45cfr46_01.html


Practice Setting: Corrections

Recommended Resource

Source

Standards for Correctional Health Care

American Correctional Association, www.aca.org/standards/healthcare

Standards for Health Services in Jails

National Commission on Correctional Health Care, www.ncchc.org/pubs/catalog.html#standards

Standards for Health Services in Juvenile Detention and Confinement Facilities

National Commission on Correctional Health Care, www.ncchc.org/pubs/catalog.html#standards

Standards for Health Services in Prisons

National Commission on Correctional Health Care, www.ncchc.org/pubs/catalog.html#standards


Practice Setting: Critical Access Hospitals

Recommended Resource

Source

Certification and compliance

CMS, www.cms.hhs.gov/CertificationandComplianc/04_CAHs.asp#TopOfPage

Guidance for laws and regulations for critical access hospitals

CMS, www.cms.hhs.gov/GuidanceForLawsAndRegulations/04_CAHs.asp

Standards for critical access hospitals

The Joint Commission, www.jointcommission.org/AccreditationPrograms/CriticalAccessHospitals

State Operations Manual

CMS, www.cms.hhs.gov/manuals/downloads/som107c01.pdf


Practice Setting: End Stage Renal Disease/Renal Dialysis

Recommended Resource

Source

Conditions of Participation (42 CFR Part 405.2100, Subpart U)

National Archives and Records Administration, Code of Federal Regulations, http://frwebgate.access.gpo.gov/cgi-bin/get-cfr.cgi?TITLE=42&PART=405 &SECTION=2100&YEAR=2001&TYPE=PDF

Dialysis

CMS, www.cms.hhs.gov/GuidanceForLawsAndRegulations/05_Dialysis.asp

End Stage Renal Disease Quality Initiative

CMS, www.cms.hhs.gov/ESRDQualityImproveInit

ESRD General Information

CMS, www.cms.hhs.gov/ESRDGeneralInformation

Medicare Benefit Policy Manual

CMS, www.cms.hhs.gov/manuals/Downloads/bp102c11.pdf

Medicare Coverage of Kidney Dialysis and Kidney Transplant Services

HHS, www.medicare.gov/Library/PDFNavigation/PDFInterim.asp?Language=English &Type=Pub&PubID=10128

Medicare ESRD Center

CMS, www.cms.hhs.gov/center/esrd.asp

National Voluntary Consensus Standards for End Stage Renal Disease Care

National Quality Forum, www.qualityforum.org/projects/ongoing/esrd/index.asp


Practice Setting: Government Healthcare Facilities

Recommended Resource

Source

Federal Privacy Act of 1974 (Pub. L. 93-579, Dec. 31, 1974, 88)

US Department of Justice, www.usdoj.gov/04foia/privstat.htm

Freedom of Information Act

US Department of Justice, www.usdoj.gov/oip/04_3.html


Practice Setting: Home Health

Recommended Resource

Source

Comprehensive Accreditation Manual for Home Care

The Joint Commission, www.jointcommission.org/AccreditationPrograms/HomeCare

Conditions of Participation for Home Health (42 CFR 484)

National Archives and Records Administration, Code of Federal Regulations, www.access.gpo.gov/nara/cfr/waisidx_99/42cfr484_99.html

Interpretive guidelines for Conditions of Participation

CMS, www.cms.hhs.gov/GuidanceforLawsAndRegulations/06_HHAs.asp

Medicare Benefit Policy Manual

CMS, www.cms.hhs.gov/manuals/IOM

Medicare Home Health Prospective Payment System

CMS, www.cms.hhs.gov/manuals/Downloads/bp102c07.pdf

OASIS

CMS, www.cms.hhs.gov/OASIS

Office of Inspector General Compliance Program Guidance

Department of Health and Human Services Office of Inspector General, http://oig.hhs.gov/authorities/docs/cpghome.pdf

Standards of practice for community health

Community Health Accreditation Program, www.chapinc.org


Practice Setting: Hospice

Recommended Resource

Source

Comprehensive Accreditation Manual for Home Care

The Joint Commission, www.jointcommission.org/AccreditationPrograms/HomeCare

Conditions of Participation for Hospices (42 CFR 418)

National Archives and Records Administration, Code of Federal Regulations, www.access.gpo.gov/nara/cfr/waisidx_01/42cfr418_01.html

Medicare Benefit Policy Manual Coverage of Hospice Services Under Hospital Insurance

CMS, www.cms.hhs.gov/manuals/Downloads/bp102c09.pdf

Medicare Claims Processing Manual

CMS, www.cms.hhs.gov/manuals/downloads/clm104c11.pdf

Office of Inspector General Compliance Program Guidance

Department of Health and Human Services Office of Inspector General, http://oig.hhs.gov/authorities/docs/hospicx.pdf

Quality Partners Self-Assessments

National Hospice and Palliative Care Organization, www.nhpco.org/i4a/pages/index.cfm?pageid=4990

Standards of practice for community health

Community Health Accreditation Program, www.chapinc.org


Practice Setting: Long Term Care

Recommended Resource

Source

Long Term Care Accreditation Program

The Joint Commission, www.jointcommission.org/AccreditationPrograms/LongTermCare

Minimum Data Set 3.0

CMS, www.cms.hhs.gov/NursingHomeQualityInits/25_NHQIMDS30.asp

Nursing Home Quality Initiatives

CMS, www.cms.hhs.gov/NursingHomeQualityInits/01_overview.asp

Office of Inspector General Compliance Plan for Nursing Facilities

Department of Health and Human Services Office of Inspector General, http://oig.hhs.gov/authorities/docs/cpgnf.pdf

Skilled Nursing Facility Center

CMS, www.cms.hhs.gov/center/snf.asp

Skilled Nursing Facility Prospective Payment System

CMS, www.cms.hhs.gov/SNFPPS/01_overview.asp

State Operations Manual

CMS, www.cms.hhs.gov/manuals/downloads/som107c07.pdf


Practice Setting: Managed Care

Recommended Resource

Source

Health Network Accreditation

URAC, www.urac.org/programs/prog_accred_HN_po.aspx?navid=accreditation&pagename =prog_accred_HN

Health Plan Employer Data and Information Set (HEDIS) products

National Committee for Quality Assurance, www.ncqa.org/tabid/59/Default.aspx

Managed Behavioral Healthcare Organization Accreditation Program

National Committee for Quality Assurance, www.ncqa.org/tabid/94/Default.aspx

MCO Accreditation Program

National Committee for Quality Assurance, www.ncqa.org/tabid/67/Default.aspx

Medicare Managed Care Manual

CMS, www.cms.hhs.gov/Manuals/Downloads/mc86c05.pdf

Physician Organization Certification Program

National Committee for Quality Assurance, www.ncqa.org/tabid/128/Default.aspx

Preferred Provider Organization Accreditation Program

National Committee for Quality Assurance, www.ncqa.org/tabid/99/Default.aspx

Workers’ Compensation Accreditation Program

URAC, www.urac.org/programs/prog_accred_WCUM_po.aspx?navid=accreditation&pagename =prog_accred_WCUM


Practice Setting: Physical Medicine and Rehabilitation

Recommended Resource

Source

Certification and compliance for outpatient rehabilitation providers

CMS, www.cms.hhs.gov/CertificationandComplianc/15_OutpatientRehab.asp

CMS guidance to laws and regulations for outpatient rehabilitation

CMS, www.cms.hhs.gov/GuidanceForLawsAndRegulations/15_OutpatientRehab.asp

Commission on Accreditation of Rehabilitation Facilities

www.carf.org

Conditions of Participation: Specialized Providers (42 CFR 485)

National Archives and Records Administration, Code of Federal Regulations, www.access.gpo.gov/nara/cfr/waisidx_01/42cfr485_01.html

Inpatient Rehabilitation Facilities

CMS, www.cms.hhs.gov/CertificationandComplianc/16_InpatientRehab.asp


Practice Setting: Substance Abuse

Recommended Resource

Source

National Outcome Measures

Substance Abuse and Mental Health Services Administration, http://nationaloutcomemeasures.samhsa.gov/outcome/index_2007.asp

Standards for behavioral health

Commission on Accreditation of Rehabilitation Facilities, www.carf.org/providers.aspx?Content=Content/Accreditation/Opportunities/BH/toc.htm

Substance Abuse Program Administrators Certification

The Substance Abuse Program Administrators’ Certification Commission, www.sapacc.org

Substance abuse resources

Center for Substance Abuse Treatment, http://csat.samhsa.gov/resources.aspx

Substance abuse treatment practices

Center for Substance Abuse Treatment, http://csat.samhsa.gov/treatment.aspx

Revised by

Jill Burrington-Brown, MS, RHIA, FAHIMA


The information contained in this practice brief reflects the consensus opinion of the the professionals who developed it. It has not been validated through scientific research.


Article citation:
AHIMA. "Recommended Regulations and Standards for Specific Healthcare Settings (Updated)" Journal of AHIMA 80, no.1 (January 2009): 61-67.