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Interoperability is seen as the first step to using data for health improvement. I expect that 2019 will be the “Year of Interoperability”.  The Centers for Medicare & Medicaid Services (CMS), through its hospital and physician incentive programs, is asking providers to have their electronic health records (EHRs) capable of…
Rapidly shifting societal demographics impact SDoH. 2018 saw the Social Determinants of Health (SDoH) rise to be among the most popular hot topics for the healthcare industry. In 2018 alone: $1.7 trillion in care was attributed to 5 percent of the population. ICD-10 coding reimbursement for the SDoH took place…
Clinical validation denials continue to climb. When payers issue clinical validation denials, they challenge diagnoses documented in the chart by the providers caring for the patient. Sometimes, it’s not simply the validity of diagnoses in question, but whether coding rules were violated.  This being the case, assessment and subsequent potential…
Coders can expect to confront new challenges, including new payment models and HIPAA changes. The new year brings new challenges for the healthcare industry. From new payment models to updates to the Health Insurance Portability and Accountability Act (HIPAA) to 21st Century Cures, hold on to your hats, because it…
Coders are encouraged to query if not sure.The ratio of observed-to-expected deaths is considered a measure of hospital quality. Recording accurate metrics depends on capturing all relevant diagnoses to optimize the expected mortality denominator. The explanatory variables groupings of mortality modeling for institutions include both definitive diagnoses and signs/symptoms. A…
Integrity means moving from a retroactive, transactional approach to one that documentations patient care. There is much discussion and movement in the clinical documentation improvement (CDI) industry regarding using the word “integrity” in describing the discipline. In perusing the Internet for a solid definition of “integrity,” a Huffington Post article…
Coders must ensure documentation supports the service, either moderate sedation or MAC. Coding moderate sedation (or conscious sedation) and monitored anesthesia care (MAC) is not difficult; however, distinguishing what the services provided are and deciphering conflicted information about which physicians can report what codes can be confusing for some coders…
Address documentation and coding issues up front, rather than correct them later. Coders have had many challenges throughout the years.  When I started in the industry, we did not submit claims electronically; they were submitted on paper and we used an IBM Selectric Typewriter to complete what was then the…
New directives from the Administration focused to eliminate unnecessary regulatory burden The Centers for Medicare & Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC) have jointly released a draft titled “Strategy on Reducing Regulatory and Administrative Burden Relating to the Use of Health…
When considering to use the T code, simply tell the truth. Is your institution reluctant to code a T code? Are your quality professionals concerned about being penalized for any complication that crops up during the patient stay? Are they asking the clinical documentation integrity (CDI) team to contrive by…
New initiative is detailed in the OIG work plan. As many of you are aware, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently released a key addition to its work plan announcing an initiative to investigate and validate their concern of hospitals gaming…
Facilities are urged to re-double coder training and education. Coders and auditors are taught to be diligent for the high frequency, high cost, and problem-prone cases as these topics are the focus on third-party reviewers. What does that mean for the new coder? The new coder may not be aware…
To link, or not to link: that is the question for physician documentation Since the adoption of the ICD-10 code set, clinical documentation integrity specialists (CDISs) have experienced an ongoing dilemma of capturing complication codes with regard to adverse drug events versus ‘known’ or ‘inherent’ side effects. At our organization,…
New criteria could be incorporated in ICD-11. Malnutrition is a terrible problem worldwide, even more so in third-world countries than here in the U.S. Historically, it was due to starvation and famine, born of poverty, war, and nature, but malnutrition due to disease and inflammation is a major factor now,…
Ten things to consider before outsourcing your healthcare needs.  I have spent a good part of the past 10 years in the healthcare industry, immersing myself in the workings of foreign countries as it relates to coding, billing, compliance, HIPAA, Protected Health Information (PHI), etc., and have found that there…
No separate codes for podiatric E&M visits in final rule. The final rule for the 2019 Physician Fee Schedule was released on Nov. 1. Some of what was in the proposed rule was finalized, while other elements were either modified or completely eliminated. The proposal to reduce payment when evaluation and…
Are there “Zs” in your spinal fusion coding? The fiscal year (FY) 2019 ICD-10-PCS updated an area that has not received much attention: Spinal fusion codes. During the Centers for Medicare & Medicaid Services (CMS) Coordination and Maintenance Committee meeting in September 2017, the topic of invalid spinal fusion codes…
Numerous changes to the codes as well as to the MCC/CC lists, plus changes to the Official Guidelines for Coding and Reporting make it extremely difficult to identify clinical indictors necessary to validate an MCC or CC. This webcast will help you avoid compliance issues and reimbursement losses.
This webcast will help coders and clinical documentation integrity specialists understand the two definitions of sepsis: Sepsis-1, used by the Centers for Medicare & Medicaid Services as criteria for its hospital inpatient quality reporting (IQR), and Sepsis-3 used by providers and payers.
How healthcare providers can best prepare for the worst. Editor’s Note: The following is a transcript of a recent segment on Talk Ten Tuesdays by Julie Dooling, speaking on challenges and tips for healthcare organizations in the face of a natural disaster. Collectively, we continue to learn from experiences where…
Diabetes is the leading cause of blindness among workers in the United States. November is National Diabetes Month, as well as Diabetic Eye Disease Awareness Month. Are you aware that diabetes is the leading cause of blindness among the working people of the United States? The 2019 ICD-10-CM Official Coding…
The 2019 CMS risk adjustment model is version 23. The Centers for Medicare & Medicaid Services (CMS) released, in April, the latest update to the CMS-hierarchical condition category (HCC) Risk Adjustment Model (V23).  It applies to payment year 2019.  As Medicare Advantage is a prospective payment system, that means care…
CMS issued the final rule on Nov. 1. The Centers for Medicare & Medicaid Services (CMS) final rule includes updates to payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (MPFS) on or after Jan. 1, 2019. CMS has finalized a number of…
CDI is the critical link to quality outcomes.   Any healthcare system’s overall performance relies heavily on a strong clinical documentation integrity (CDI) program, and therefore on the professionals at the heart of this discipline. From patient outcomes and mortality rates to financial reimbursements and quality score profiles, CDI programs…
The aim of documentation is to tell the true story. Last year, I wrote a two-part series on clinical documentation integrity, specifically focusing on the emergency department (CDI in ED Part I; CDI in ED Part II). Today I will focus on how ED documentation supports medical necessity of investigative…
CMS released the MPFS on Nov. 1, ending months of turmoil. The Centers for Medicaid & Medicare Services (CMS) released the final rule on the Medicare Physician Fee Schedule (MPFS) and the Quality Payment Program (QPP) on Nov. 1. The 2,378-page document is available in the Federal Register. This marks…
Lack of a SOFA score change does not rule out sepsis. A couple weeks ago, I spoke about how the current definition of sepsis, known as "sepsis-3," was the best definition for the medical community to use at this time. This week, I'm going to discuss the clinical diagnosis of…
CMS updated Medicare regulations for 2019 EDITOR’S NOTE: Veteran Washington, D.C. observer Stanley Nachimson reported on the final rules from the Centers for Medicare & Medicaid Services (CMS) during Talk-Ten-Tuesdays today. The following is a transcription of his remarks. The Centers for Medicare & Medicaid Services (CMS) has been quite…
THIS STORY HAS CORRECTED TO REFLECT THE NOV. 2 RELEASE OF THE FINAL FOR 2019 EDITOR’S NOTE: CMS on Thursday released the 2019 Medicare Physician Fee Schedule. For 2019 and 2020, we will see no changes to our outpatient, office-based evaluation and management (E&M) services, but things will change come…
Release by CMS caps months of debate by stakeholders Long awaited and hotly debated, the 2019 Medicare Physician Fee Schedule (MPFS) and Quality Payment Program (QPP) late July, when the Centers for Medicare & Medicaid Services (CMS) released proposed rules for both. Tucked into the MPFS were the controversial revisions to…
CMS announced on Friday a proposed rule to expand telehealth access for patients. Hospitals, doctors, and other providers seeking an edge in today’s highly competitive healthcare environment would do well to consider a smart telehealth strategy. It’s not an option anymore to think that telemedicine doesn’t fit into your practice.…
Diabetes could be a contributing factor without being the direct cause. In the first article in this series, I compared pressure ulcers and diabetic foot ulcers (the latter are considered non-pressure chronic ulcers in ICD-10-CM). My conclusion was that there is significant overlap, but heel ulcers are prime candidates to…
The five “Ws” about the flu. It is that time of year again – flu season, which occurs in the fall and winter in the United States, stretching from early October until May. For me, it was a new experience this year, as I got my flu shot! I had…
New classification system noted for granularity. Several of my colleagues recently attended an ICD-11 presentation by Kathy Giannangelo[i] at the American Health Information Management Association (AHIMA) Convention & Exhibit. Kathy has been in the trenches with ICD-11’s development for some time. The attendees described the complexity of this new classification…
Even a podiatrist may not know for sure. When is a diabetic’s foot ulcer a pressure ulcer? When is a pressure ulcer a diabetic foot ulcer? These are the questions we are going to explore in this two-part series of articles elicited by my disgruntlement with the advice in the…
New coding clinic edition offers much to review and follow.Everyone in health information management (HIM), coding, and CDI (clinical documentation improvement) is abuzz about the fourth-quarter AHA (American Hospital Association) Coding Clinic on ICD-10-CM/PCS. We just received the third-quarter issue at the end of September, which everyone is still digesting.…
There is no specific code for this condition at the present time. Acute flaccid myelitis (AFM) is a rare and serious condition that affects the areas of the spinal cord called the gray matter and has been in the news recently. According to the Center of Disease Control and Prevention…
The biggest holdout to Sepsis-3 is still CMS. UnitedHealthcare has announced that it will be adopting the Third International Consensus Definition for sepsis and septic shock for all of its lines of business, effective Jan. 1, 2019. This definition is better known as "Sepsis-3." The announcement is significant because it…
The query process is no substitute for education and training.The hallmark of any true clinical documentation integrity (CDI) program consists of medical record chart review by clinical documentation integrity specialists (CDISs) with a goal of identifying gaps in diagnosis specificity as well as addressing other deficiencies requiring clinical clarification. Some…
New coding clinic brings valuable guidance Those of us in the health information management (HIM) coding profession were excited to see the third-quarter issue of the American Hospital Association (AHA) Coding Clinic on ICD-10-CM/PCS come out. Contained within the 31 pages for this issue is guidance and advice on several…
New program for live CDI education is gaining traction. Last week, I shared details about a new activity I have been doing with a client that I think is extremely beneficial, and suggested that perhaps others could implement a similar program in their own practices. I was asked to lay…
Local radio station personality goes public with his cancer fight. In August 2018, Marty Griffin, KDKA radio personality, announced to his listening audience that he had cancer. His cancer is related to human papilloma virus (HPV), which infects 80 million people, according to the Centers for Disease Control and Prevention…
Two recent studies report on the alarming rate of physician burnout. EDITOR’S NOTE: Physician burnout, a topic of great interest across the healthcare industry during recent years, continues to make headlines.Talk Ten Tuesday host and ICD10monitor Publisher Chuck Buck and renowned psychiatrist H. Steven Moffic, MD discuss the topic. What follows is…
A lesson in coding and policy.Medical marijuana, or cannabis, as it is commonly referred to in the healthcare field, is allowing chronically ill patients to relieve painful, often debilitating symptoms legally instead of taking pills many claim do little to ease severe pain. The widespread acceptance of marijuana as a useful…
CDI can drive down adversarial determinations of medical necessity and costly denials.  In my article published last week, titled Moving in the Right Direction in Getting to the Root Cause of Clinical Documentation Improvement (CDI), I outlined that CDI plays a major role indeed in the context of overall healthcare…
Congress passed an appropriations bill to fund the U.S. Department of Health and Human Services (HHS) through the 2019 fiscal year. We may be rapidly approaching the midterm elections, but there is no shortage of activity here in Washington, D.C. these days already. Before the House of Representatives wrapped up…
The lesbian, gay, bisexual, transgender, and queer (or questioning) (LGBTQ) population faces barriers to appropriate healthcare access. EDITOR’S NOTE: The American Health Information Management Association (AHIMA) has developed a practice brief on this issue, and ICD10monitor will continue to report on how recognition of this vulnerable population is being demonstrated…
Ongoing ethical issues persist requiring leadership guidance daily We live and work in times that are very challenging, and ever-changing to say the least. We also live and work in times in which our ethics seem to be challenged on a regular basis.  One just has to open any newspaper,…
CMS proposes to ease burdens on providers. When it comes to the ever-changing Centers for Medicare & Medicaid Services (CMS) agency rules and regulations, one can’t help but be reminded of the classic tune by The Byrds: “to everything (turn, turn, turn), there is a season (turn, turn, turn).” The…
Sharing insights on assumptive coding  When I was a physician advisor, I used to offer a diabetic Charcot joint as an example of why we must be explicit with linkage. Years ago, if a provider listed diabetes mellitus and a Charcot joint (neuropathic osteoarthropathy) as concomitant diagnoses without documenting clear…
New ICD-10 codes that address human trafficking become effective Oct. 1. This year has seen the launch of the ICD-10 Z codes, and now we will also have T codes to address human trafficking. Catholic Health Initiatives (CHI) has collaborated with several healthcare organizations , including the American Hospital Association's…
The new definition includes clinical concepts that were not an option before when choosing an MI diagnosis. Since 2012, changes and updates have continued to clarify the acute myocardial infarction (AMI) diagnosis. There are now five types of MI diagnoses that have been expanded and updated through the years, and…
The clinical query process is a small yet important part of any CDI initiative.By now I am confident that most in the clinical documentation improvement (CDI) industry are familiar with the lawsuit brought by data analytics firm Integra against Providence Health to recover $188 million for alleged upcoding perpetuated by…
With good collaboration and the right team members, continual improvements are attainable.Recently I have been engaged in a project of continual improvement in our clinics, and as chief compliance officer, I am continually looking for ways we can stay compliant, deliver excellent healthcare, and fix revenue leaks.We audit our physicians…
New code proposals from the ICD-10 Coordination and Maintenance Committee Meeting are discussed. The Coordination and Maintenance Committee met on September 11-12, 2018 to discuss new code proposals, as well as proposals that were previously presented. The presentations began with ICD-10-PCS proposals, with completion by mid-afternoon on the second day.…
The aftermath of Florence prompts a review of emergency preparedness We know the 2018 hurricane season is upon us, but we are always unsure of where the individual storms will appear, what their track will be, and how they will behave. Hurricane Florence—since downgraded to a tropic depression— has been…
Skin biopsy codes are changing. EDITOR’S NOTE: This is an updated version of the second installment in a two-part series on the 2019 CPT® codes released recently by the American Medical Association.For many years we have used two codes to report skin biopsies. CPT® 11100 for the first lesion and…
A review of Major Disease Category 18, Infectious and Parasitic Diseases, Systemic or Unspecified Sites. Systemic inflammatory response syndrome, or SIRS, due to a noninfectious cause can be confusing. SIRS caused by noninfectious conditions occurs in medical and surgical cases alike. Coding guidelines prohibit the use of codes R65.10, noninfectious…
September 14, 2018

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Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.
The authors discusses the lawsuit against Providence St. Joseph Health Services for alleged upcoding. Performance with a purpose must be the driving force for business operations, personal goals, work and life accomplishments, and personal choices. The concept of performance with purpose must be a fundamental foundation governing all aspects of…
Recent FCA activity focuses on coding compliance issues Recently in healthcare news were articles about two legal actions that cause one to reflect on the need for a strong (or stronger) coding and clinical documentation improvement (CDI) compliance programs.  The first legal action cited the False Claims Act (FCA) and…
ICD-10-CM supports this new classification system. Four major cardiology associations have once again collaborated to update the universal standard definition of myocardial infarction (MI), and this effort was more ambitious than any prior effort. In a document published simultaneously by the American College of Cardiology (ACC), the American Heart Association…
New code changes number 335. The new current procedural terminology (CPT®) codes have been released with 335 code changes in 2019.  There were many code revisions with guideline, description and instructional note changes.   Let’s look at the highlights of many new CPT codes for 2019. There six new codes in the…
The proposal is on the table as part of proposed E&M changes. EDITOR’S NOTE: The following story was published by RACmonitor on Aug. 16, 2018. By now I am sure that everyone is well aware that the Centers for Medicare & Medicaid Services (CMS) has proposed modifications to the reimbursement…
Proposed rule will cut by 50% claims submitted with modifier 25. In what is being reported as the biggest change of its kind in more than two decades, the Centers for Medicare & Medicaid Services (CMS) plans to redefine the documentation requirements for evaluation and management (E&M) coding in 2019,…
Coordination and Maintenance committee takes place Sept. 11 and 12 at CMS. The Coordination and Maintenance Committee meeting takes place twice per year, in March and September. These meetings develop the spirit of coding. In other words, the meetings center on the philosophy or the intent of the codes. One…
Proposed E&M code changes would impact specialty physicians. Some physicians are probably not very happy with recently proposed changes to the Medicare Physician Fee Schedule. The Centers for Medicare & Medicaid Services (CMS) designed the changes to reduce paperwork and enable physicians to spend more time with patients. Those seem…
HATA survey reveals membership dissatisfaction with prior authorization transactions. In a recent report to the U.S. Senate Committee on Finance, the Government Accountability Office (GAO) was asked to examine the Centers for Medicare & Medicaid Services’ (CMS’s) prior authorization programs, including its benefits and challenges. The GAO spoke with many…
The OIG continues to review cases of malnutrition. The diagnosis of severe protein calorie malnutrition is under high scrutiny from the Centers for Medicare & Medicaid Services (CMS) and the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG). Today, I’d like to explore the reasons…
In addition to CTE, head trauma could also lead to Parkinson’s and ALS. The National Football League (NFL) signed an agreement in January 2017 covering 17,200 registered league retirees to compensate them for treatment of diagnosed neurological disorders, up to $5 million per person. The proposed fund totaled $675 million…
It’s not the credentials, but knowledge of the clinical validator that counts. Clinical documentation integrity (CDI) professionals come from a variety of backgrounds and skill sets. Frequently, we see health information management (HIM) coding professionals and nurses stepping into the role of CDI. Their respective education and experiences help provide…
Trends in Clinical Documentation, Past, Present, and Future – Part II EDITOR’S NOTE: This topic has solicited many comments, creating as contentious debate, since Part I was published in the ICD-10monitor e-News on July 17 and discussed the same day on Talk-Ten-Tuesdays. I want to highlight some of the comments,…
Overview of CMS final rules is provided by the author So this is the season for 2019 Medicare facility payment rules. These rules are required each year to update payment rates and processes, as well as additional policies for the next fiscal year, which begins on Oct. 1. These are…
The author comments on proposed E&M changes. Has my entire career been based on a lie? For 33 years, I have been espousing the party line that good documentation positively impacts patient care. I have taught documentation to providers who have gotten in trouble with their medical boards for six…
Proposed rule on 2019 Physician Fee Schedule offers greater incentives Revisions in the Quality Payment Program (QPP) proposed rule, tucked into the 2019 Physician Fee Schedule, will make for heightened competition and expectations among physicians participating in the Merit-based Incentive Payment System (MIPS) as the Centers for Medicare & Medicaid…
CMS proposes significant changes to E&M services. There has been much confusion over the years regarding documenting for evaluation and management (E&M) services since the 1997 Official Guidelines were released. The Centers for Medicare & Medicaid Services (CMS) kept promising revised guidelines for years without delivering results.  During that time,…
Changes coming with 2019 Official Guidelines for Coding and Reporting of ICD-10-CM The 2019 Official Guidelines for Coding and Reporting of ICD-10-CM have been released, and they certainly encompass some notable changes, as always. Changes occur in the “Conventions,” the “General Guidelines,” and several chapter-specific guidelines as well. Narrative changes…
New codes to be presented at the September Coordination and Maintenance Committee meeting There is a lot of buzz in the industry about the possibility of ICD-11. We are so many years from that becoming a possibility, though, with our clinical modifications and political culture. And we still have a…
Major E&M changes on the horizon. Probably the biggest change in healthcare in two decades is the Centers for Medicare & Medicaid Services (CMS) proposal to redefine the documentation requirements for evaluation and management (E&M) coding in 2019. The agency is proposing to forego the 1995 and 1997 guidelines for…
The author responds to a Talk Ten Tuesday listener's comments regarding the coding of bronchoalveolar lavage. During the Talk Ten Tuesday broadcast on July 24, 2018, Stacey Elliott, an inpatient compliance specialist and a guest panelist on program, and I had a discussion regarding bronchoalveolar lavage (BAL). Stacey had a…
Patients in New York may be certified to use medical marijuana as a substitute for opioids. EDITOR’S NOTE: The following is a transcript of a recent Talk Ten Tuesday broadcast featuring the author. An interesting development in the use of medical marijuana was reported recently by a number of major…
CMS proposed major changes to E&M coding but still solicits feedback from stakeholders. The Centers for Medicare & Medicaid Services (CMS) wants to simplify outpatient E&M coding by letting providers choose an office visit code level based on the most important component, medical decision making (MDM), or face time spent…
More than physician payment rules in the CMS IPPS proposal The physician fee schedule rule is one of many payment system rules that the Centers for Medicare & Medicaid Services (CMS) issues each year. There are also rules for the Inpatient Prospective Payment System (IPPS), Outpatient PPS, Skilled Nursing Facilities…
Sexual harassment covers a wide range of behaviors. We are hearing more and more about sexual harassment in workplaces of all types, from business to the media and the arts. Unfortunately, this is also an issue in medicine. While some may think that physicians should “know better” and not engage…
FY 2019 Official Guidelines for Coding & Reporting were released on Thursday and contain notable changes.The National Center for Health Statistics (NCHS) has released and posted the fiscal year (FY) 2019 official guidelines for coding and reporting ICD-10-CM. Oct 1, 2018 will bring some notable changes that will help with…
Preparing for the 2019 IPPS final rule marks a busy time for healthcare professionals. While the Centers for Medicare & Medicaid Services (CMS) posted the 2019 Inpatient Prospective Payment System (IPPS) proposed rule back in April, the move continues to generate controversy and confusion. Of particular note is the agency’s…
Reporting bronchoalveolar lavage is all about location, location, location Reporting bronchoalveolar lavage (BAL) has historically been a documentation nightmare for physicians and a quandary among coders. Physicians often use the right and left lung lobe sections to geographically indicate where the bronchoscope was advanced in the bronchial tree during BAL…
Integrated approach targets both the physical and mental health needs of patients. Up to one in four primary care patients suffer from depression. And some recent studies have shown surprising ties between cardiac health and mental health. Yet for many people, it is difficult to find quality mental health resources…
The author reports on the recently released American Hospital Association’s Coding Clinic. I was just able to free up the time to review the most recently published Coding Clinic (CC), and I will share my thoughts on the updates with you in this article. It took some energy to sort…
Trends in Clinical Documentation, Past, Present, and Future – Part I For nearly a century, since Grace W. Myers of Massachusetts General Hospital became the first medical records librarian in the early 1900s and the American College of Surgeons (ACOS) sought to improve the standards of medical records being created…
CMS proposes to change physician evaluation and management (E&M) coding with a drastic overhaul. EDITOR’S NOTE: The following report first appeared on RACmonitor on July 13, 2018 After soliciting comments from many stakeholders in the last year, the Centers for Medicare & Medicaid Services (CMS) has just proposed sweeping changes…
Document it right on the front end; avoid fighting a denial on the back end I was recently asked about a post from Hospital Performance regarding acute respiratory failure and airway protection (https://soundphysicians.com/blog/2018/06/20/from-the-appeals-desk-acute-respiratory-failure-part-1-2/), and I wanted to expand on what the author, Dr. Hesham Hassaballa, wrote. A key point is…
The “right documentation” is the central pivot point to the revenue cycle   Physician clinical documentation plays a critical role in any overall healthcare delivery model, including the life of the revenue cycle, which drives reimbursement for quality medical care provided to patients. The revenue cycle is defined by the…
The WHO’s definitions of gender-related issues continue to cause controversy. The recent news coming out of Geneva, Switzerland and reported here by ICD10monitor that the World Health Organization (WHO) had released its 11th edition of the International Classification of Diseases (ICD) was greeted by most healthcare professionals as good news.…