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If there is no organ dysfunction, it is not sepsis. EDITOR’S NOTE: Dr. Erica Remer reported this story live during the Sept. 10 edition of Talk Ten Tuesday. The following is an edited transcript of her reporting. Apparently, I am not done pondering and pontificating about sepsis, which is apropos, considering…
Confusion persists for the coding of vaping. The Centers for Disease Control and Prevention (CDC) is currently investigating vaping-related illnesses that have recently been reported. There are 450 confirmed or suspected cases in 33 states. The first death was reported on Aug. 23, 2019, in Illinois. The concern has escalated…
The CDI is more than diagnosis capture through the query process. The Association for Clinical Documentation Improvement Specialists (ACDIS) recently released a paper titled Proactive CDI: Tackling the Problem of Physician Engagement, which featured six CDI leaders outlining their thoughts and ideas on facilitating physician engagement in CDI initiatives within…
Under PDPM, reimbursement will be driven by coding and documentation. South Florida has historically been a hotbed of healthcare fraud, and there is a long list of those responsible other than Philip Esformes, who was sentenced to 20 years in prison on Thursday for fraud committed in connection with billings…
Artificial intelligence (AI) solutions are designed to support CDI teams in their quests for efficiency. The concept of “doing more with less” is far from uncommon. You hear it every day in nearly every aspect of life: at home, we strive to live simply; in the community, we build resiliency;…
Fall ICD-10-CM/PCS Coordination and Maintenance Committee Meeting kicks off today. Today and tomorrow mark the dates for the next ICD-10 Coordination and Maintenance Committee meeting. Health information management (HIM) and coding and clinical documentation integrity/improvement (CDI) professionals often wonder about what the Coordination and Maintenance Committee is and does, so…
Counseling and treatment are reimbursable.  Is your medical practice providing smoking cessation counseling and treatment? Did you know you can bill and get reimbursed for your services? There are rules, linked diagnosis codes, and frequency guidelines to be mindful of, but this is a reimbursable service that physician practices need…
Moving from the inpatient to the outpatient setting is gaining momentum. Outpatient clinical documentation improvement (CDI) programs are becoming more prevalent in the healthcare sector, as the value and benefit to the revenue cycle have become readily apparent. Consulting companies are developing service lines and software to grow their position…
Data for clinical and business intelligence can uncover significant opportunities within clinical documentation improvement. In my previous article, I discussed the process of how transformational change occurs, through transparency resulting from strategic connectivity across the healthcare system. To expand on this theory, let's examine the current state of clinical documentation…
Where CDI went awry: missing an opportunity for safety. In last week’s ICD10monitor news edition, I authored an article titled “How a Texas Health System Beat a $61.8 Million Billing Fraud Case.” The dismissal of the case was based upon a citation of previous language the Centers for Medicare &…
In search of good collaboration among stakeholders. For many years I’ve been surprised at the various levels of disagreement between staff involving both outpatient and inpatient coding in the physician and hospital settings. Having worked in a production environment, with the need to maintain a good quality score of at…
A look at the proposed Medicare Physician Fee Schedule. As you may be aware, the proposed Medicare Physician Fee Schedule (MPFS) rule for 2020 was officially published on Aug. 14, 2019.  There are many components to the rule, including a proposed change in the PFS conversion factor to $36.09, the…
The author reports on the recent court decision to dismiss a False Claims Act lawsuit against Dallas-based Baylor, Scott & White Health. EDITOR’S NOTE: Dr. Erica Remer reported this story live during the Aug. 27 edition of Talk Ten Tuesday. The following is an edited transcript of her reporting. My…
The allegations in the case focused on CCs and MCCs. A Texas federal judge recently dismissed a False Claims Act lawsuit alleging that Dallas-based Baylor Scott & White Health overbilled Medicare by improperly upcoding claims. The whistleblower lawsuit, filed in 2017, alleged that the health system submitted more than $61.8…
Changes are effective Oct. 1, 2019. It’s that time of year again! Time for the Inpatient Prospective Payment System (IPPS) for fiscal year (FY) 2020. And with that comes the updates to the Medicare-Severity Diagnostic Related Groups (MS-DRGs) and the complication/comorbidity and major complication comorbidity (CC/MCC) diagnosis lists. See the…
Transactional data promotes an informed and proactive environment, which leads to transformed processes.  Healthcare organizations have been on a journey to digitalization and higher efficiency for quite some time, continually investing in various technology solutions. All the while, the landscape of healthcare is only increasing in complexity, with organizations continuously…
There is an ICD-10 code for gender dysphoria. Recently, the Family Equality Council (FEC) published a comprehensive research study featuring some inspiring statistics, all of which point to the fact that the number of LGBTQ+ families in the United States is set to grow dramatically in the coming years. In…
Documentation becomes meaningful when using evidence-based medicine. I see a lot of conversations ongoing about clinical documentation integrity (CDI) efforts that in my opinion, seem to reflect a less-than-productive way of gaining progress. CDI should be about documenting for evidence-based medicine, and not coding guidelines. Coding guidelines have no place…
2019 AHIMA Clinical Documentation Improvement (CDI) Summit Summary At the American Health Information Management Association’s (AHIMA’s) recent Clinical Documentation Improvement (CDI) Summit, CDI industry experts shared insights on the most pressing issues affecting the CDI industry. Real-world examples and best practices on compliance, documentation across the healthcare continuum, clinical validation,…
Four areas where HIM professionals impact collections. I met with a coding manager recently who shared that her annual pay increase would be partially based on collections. Of course, we both looked at each other and said “why?!” But then I reflected on it and said, “why not?”  We know…
An effective query process aids the hospital’s compliance with billing/coding rules. According to the American Health Information Management Association (AHIMA), Centers for Medicare & Medicaid Services (CMS), AAPC, the American Medical Association (AMA), and many other authoritative sources, a query can be a powerful communication tool used to clarify documentation in…
Cliff notes for the FY20 ICD-10-CM Guidelines for Coding and Reporting. EDITOR’S NOTE: Senior healthcare consultant Laurie Johnson reported this story live during Aug. 13 edition of Talk Ten Tuesday. The following is an edited transcript of her reporting. Last week, I announced that the 2020 ICD-10-CM guidelines were finally released…
All sepsis now is the condition formerly known as severe sepsis. EDITOR’S NOTE: Dr. Erica Remer reported this story live during the Aug. 13 edition of Talk Ten Tuesday. The following is an edited transcript of her reporting. I’m the co-chair of the American College of Physician Advisors CDI Education Subcommittee.…
Some proposed IRF provisions were not finalized. On July 31, 2019, the Centers for Medicare & Medicaid Services (CMS) issued the final rule for the inpatient rehabilitation facility prospective payment system for the fiscal year 2020. The proposed rule is on display for review at this link:  IRF FY 2020…
Clinical documentation improvement (CDI) failed to achieve improvement. EDITOR’S NOTE: Hahnemann University Hospital is a 427-bed academic medical center affiliated with Drexel University located in Philadelphia that primarily serves the healthcare needs of Medicare and Medicaid patients. The hospital recently filed bankruptcy due to long-standing financial challenges that became unsustainable. Hahnemann…
Final rules will impact nearly every type of healthcare provider. The Centers for Medicare & Medicaid Services (CMS) presented us with quite a number of Medicare payment rules in the last week or so, referencing almost every type of provider in the program.  The final rules included the Fiscal Year…
CMS delays acting on CC/MCC revisions as had been expected. EDITOR’S NOTE: Dr. Erica Remer reported this story live during the Aug. 6 edition of Talk Ten Tuesday. The following is an edited transcript of her reporting. For those of you who were tuned in to Talk Ten Tuesday to hear…
Anticipated changes in the CC/MCC designations were delayed.  EDITOR’S NOTE: Senior healthcare consultant Laurie Johnson reported this story live during Aug. 6 edition of Talk Ten Tuesday. The following is an edited transcript of her reporting. The Centers for Medicare and Medicaid (CMS) Inpatient Prospective Payment System (IPPS) FY20 Final Rule…
Have we lost the art of telling the patient's story? Coming off of two weeks of health information management (HIM) conferences and listening to presentations on incorrectly reporting combination codes and the importance of coded data for quality and data analytics, in addition to speaking on the topic of ICD-10-CM…
Some payers will take back the fee-for-service payment if the wrong diagnosis code is selected. There have been many conversations had since the healthcare industry moved to ICD-10-CM, and many more guidelines developed regarding when to query a physician, which has sparked even more debate. Guideline 19 in ICD-10-CM states:…
Two-thirds of the 27 million annual ED visits by privately insured people in the U.S. are avoidable. Hospital emergency departments (EDs) have long been known as the front lines of healthcare. Especially for communities facing issues associated with the now-infamous social determinants of health (SDoH), EDs provide a site for a…
Don’t preoccupy yourself with DRGs, CCs and MCCs. I don’t think about my previous life as a practicing physician much, but I took a little trip down memory lane this morning. When I was on my pediatrics rotation in Buffalo, I had a supervising resident who had the most profound…
In performing my emergency department documentation audit, I ran across a curious practice regarding critical care time documentation. I had to do some investigating and thought I would share my findings with you. Background: Critical care time (CCT) can only be billed for critical patients. A critical patient according to…
Wrapping your brain around Cerebral Edema You may be noticing an uptick in clinical validation denials for cerebral edema. Here’s my take on this. There are two distinct cerebral edema codes. They both serve as major comorbidity conditions or complications (MCCs). Non-traumatic conditions, which are accompanied by cerebral edema, get…
Applied correctly and consistently, these can solve the problem of missing query opportunities. With each passing year, it seems that clinical documentation improvement (CDI) branches out into new territory. In addition to performing everyday CDI tasks, it is now becoming more important than ever for CDI specialists (CDISs) to understand…
Mid-revenue cycle is becoming increasingly important for driving financial stability. How do you define revenue cycle management (RCM)? Have you clearly delineated what is included in the front, middle, and back of RCM for your facility? You must do so before you can appropriately address the resource requirements for each…
For some coders, confusion exists when coding for critical care services. Code 99291 is used for critical care, evaluation, and management of a critically ill or critically injured patient, specifically for the first 30-74 minutes of treatment. It is to be reported only once per day, per physician or group member of…
With the reimbursement so complex and antiquated, should Congress investigate? Medicare reimbursement payments to hospitals for graduate medical education are based on calculations so complicated, it boggles the mind.  The computation for direct graduate medical education (GME) payments starts with an allowable cost per resident (ARPA) determined in the early…
Guidance and advice effective with discharges occurring on and after June 21, 2019. The American Hospital Association (AHA) Coding Clinic for ICD-10-CM/PCS for the second quarter of 2019 was released last month, and there are some interesting topics and guidance within this volume (Volume 6, Number 2). Due to copyright restrictions,…
“Let me count the ways.” EDITOR’S NOTE: Dr. Remer reported on this topic during the most recent edition of Talk Ten Tuesdays. I have been doing a project evaluating emergency department documentation, and many of the emergency providers utilize voice recognition. As such, illegibility has been replaced by unintelligibility. I…
All bad documentation is based on lies – the lies doctors (and all human beings) tell themselves. We always believe our lies, because they are how we construct a false reality that makes our bad behavior seem acceptable to ourselves. Theologians might call it original sin, humanists might call it…
The Gravity Project will be the editorial focus on tomorrow’s Talk Ten Tuesdays. The latest big development associated with the oft-discussed social determinants of health (SdoH) – a national collaborative funded by the Robert Wood Johnson Foundation – will be reported on during the next upcoming edition of the Talk…
The author shares highlights from the annual conference. I am going to continue my series on what you should know from the sessions I attended at ACDIS. There was just so much excellent material. Sam Antonios did a fantastic presentation on how CDI impacts quality. He explained that some programs…
New patient management service codes. The Medicare Physician Fee Schedule (MPFS) recently added several patient management service codes that have face to face and non-face-to-face components to them for physician reimbursement. One of those services is transition care management (TCM). These CPT® codes allow for reimbursement of the care provided…
Progress has been noted on this issue since first reported last July by ICD10monitor. Since the last Talk Ten Tuesday’s segment in August 2018 about whether HIM Coding Professionals are qualified to query for clinical validity, I am happy to announce that we are seeing some positive changes. Some organizations…
Burnout of medical and nursing professionals is not only a ‘long’ disease but a fatal one. In a book, “Epistle to Dr. Arbutnot,” which is today only read by students and scholars of 18th century English literature, Alexander Pope wrote, “This long disease, my life.” This is not a misanthropic…
Cutting and pasting functions in the EMR and EHR can damage the integrity of the medical record. The practice of cloned or copied-and-pasted documentation is a significant issue in the use of electronic health records (EHRs). A recent study in the Journal of the American Medical Association (JAMA) found that…
Quality work reduces the burden of the denial management process. When my children were young, they really enjoyed the movie “The Neverending Story.” It’s about a boy who reads a magical book that tells a story of a young warrior whose task is to stop a dark force called “The…
The author shares her thoughts on atrial fibrillation in the AHA Q2 Coding Clinic. I reviewed the Coding Clinic from Second Quarter and disagree with the reasoning for the first question regarding atrial fibrillation, although I do not have a problem with their solution. Fortunately, after October 2019, the advice…
Congress can’t seem to resist tinkering with healthcare through legislation. EDITOR’S NOTE: The following is a lightly edited transcript of remarks made by the College of Healthcare Information Management Executives (CHIME) Vice President of Congressional Affairs Leslie Krigstein during last week’s edition of Talk Ten Tuesdays. As the sultry D.C.…
The author shares highlights from the annual conference. I am continuing my reporting on tidbits I learned at the Association of Clinical Documentation Improvement Specialists (ACDIS) annual conference in May. As I mentioned last week, I was honored to make closing remarks on the first day. I shared my grand…
CDISs urged to be prepared for changes. There is much to do on listserves and various conversations with colleagues to be had regarding the Centers for Medicare & Medicaid Services (CMS) Inpatient Prospective Payment System (IPPS) proposed rule for the 2020 fiscal year, wherein Medicare has outlined sweeping changes to…
Final ICD-10-CM codes for FY 2020 includes new and deleted codes.  The Centers for Medicare & Medicaid Services (CMS) released the final ICD-10-CM codes for the 2020 fiscal year on June 21, 2019.    This release included a total of 72,184 diagnosis codes for the MS-DRG V37. The changes include 273…
CMS provides updates and insight during the HBMA meeting. The Healthcare Business Management Association’s (HBMA) Government Relations Committee has been extremely fortunate to be invited to meet with many CMS representatives each summer. The 2019 meeting offered many insights into issues of physician and industry concern and the CMS thoughts…
The author shares highlights from the annual conference. From May 20-23, I was in Kissimmee, Fla. with many of you at the ACDIS annual conference. It was really affirming for so many of you to come up to me and express your appreciation for Talk-Ten-Tuesdays. It’s nice to know there…
Big ICD-10 changes coming soon to the SNF world. In July 2018, the Centers for Medicare & Medicaid Services (CMS) finalized a new case-mix classification model, the Patient-Driven Payment Model (PDPM), which, effective beginning Oct. 1, 2019, will be used under the Skilled Nursing Facility (SNF) Prospective Payment System (PPS)…
How to enhance edits to achieve clean claims. The effective use of edits within a healthcare organization’s billing system may permit such organizations to not only identify documentation, billing, and coding issues to address, but also facilitate achieving an improved clean claim rate. A clean claim is one that meets…
The public comment period closes June 24, 2019.Earlier this year, the Centers for Medicare & Medicaid Services (CMS) announced its proposed rule changes for Inpatient Prospective Payment System (IPPS) rates and Medicare payment policies. The rule will be finalized in September, and CMS is currently accepting public comments until June…
Is your data as secure as you assume it to be? I recently saw an image on the Internet depicting the iconic “cloud.” Under it, the caption read “there is no cloud; it is just someone else’s computer.”  I want to let that sink in, and get past the humor…
New billable CPT® codes for monitoring patients who are taking blood-thinning medications. In 2018, CPT® deleted codes 99363 and 99364 and replaced them with codes 93792 and 93793. There are two important things to know about coding for international normalized ratio (INR) monitoring, also known as a “protime check” (PT).…
Final ICD-10-PCS codes for FY 2020 are here. The Centers for Medicare & Medicaid Services (CMS) released the final FY 2020 ICD-10-PCS codes on May 31. This included a total of 77,559 procedure codes for the MS-DRG V37.    The changes include 734 new codes, 2,056 deleted codes, and two…
Maybe it is time for physicians to stop being S.O.A.P. bubbleheads. There is no denying that poor documentation is a serious, universal problem. However, most of our documenting colleagues are in serious denial about the problem. But some of the denials flying about in the locust cloud of insurance denials…
More than half of physicians have experienced burnout, according to WHO. The World Health Organization (WHO) has classified physician burnout as an occupational phenomenon.     The WHO is clear that this is not a medical diagnosis. There are some estimates that more than half of physicians have experienced burnout. This…
The public comment period ends June 24, 2019 on the CMS proposed changes to CCs and MCCs. The Centers for Medicare & Medicaid Services (CMS) Inpatient Prospective Payment System (IPPS) proposed changes for acute-care hospitals in the 2020 fiscal year were announced on April 23 and released through the Federal…
Proposed new codes were introduced at the CMS Coordination and Maintenance Committee meeting. The need for expanding the ICD-10-CM code choices for corneal dystrophy was a topic covered at the Centers for Medicare & Medicaid Services (CMS) ICD-10 Coordination and Maintenance Committee meeting in March when multiple new codes were…
ACP can occur anytime, according to the author. We’d like to think that our loved ones will always be healthy, independent, and able to make decisions for themselves, but things can change suddenly. They might have an accident or a serious illness and no longer be able to speak. When…
Providers should have the choice of bringing into the record what they deem to be relevant and important. I am currently doing a project assessing emergency physicians’ documentation from disparate sites, and I am finding that they each have a different electronic health record (EHR) and/or template. Some are pleasing,…
The mid-revenue cycle has been under-resourced. When a revenue integrity (RI) program in a healthcare enterprise is appropriately designed and implemented, providers can expect a higher clean claim rate, coding compliance, proactive identification and resolution of claim issues, and improved financial results. As Rose Dunn stated in her article “HIM’s…
Creating a new vision for CDI. There has certainly been much discussion in the revenue cycle community regarding the “I” in CDI, with the idea of changing clinical documentation “improvement” to “clinical documentation integrity.” Rather than centering on “improvement” versus “integrity,” though, fundamentally, the discussion should focus upon defining what…
Contest indicates coding accuracy is below expectations. Central Learning is a web-based coding assessment and education application. Since 2016, the company has conducted an annual national coding contest to measure ICD-10 coding accuracy and production. The initial premise was to evaluate how coding accuracy and production work, compared to ICD-9.…
Sleep disorders can impact a healthy lifestyle. Are you getting enough sleep? So often we sacrifice sleep for work, housework, family demands, or watching that good movie or basketball game. Sleep is just as important as a healthy diet and regular physical activity. Poor sleep habits can lead to an…
CMS IPPS for 2020 takes a giant step forward. For those who somehow missed it, there are 88 current ICD-10-CM Z codes and subcategories that encompass psychosocial and socioeconomic circumstances: Z55-65. One of these codes is Z59: Problems related to housing and economic circumstances. These Z codes have been part…
Meanwhile, the House of Representatives holds a hearing on the topic. Although the U.S. House of Representatives has seemed preoccupied with other issues in Washington D.C., it also recently held a hearing on H.R. 1384, the “Medicare for All Act of 2019.” This bill was introduced by Rep. Pramila Jayapal…
The saga continues between UPMC hospitals and Highmark. UPMC reported revenue of $5.1 billion in the quarter ending March 31, 2019, up 10 percent from the $4.6 billion reported in the first quarter of last year. At the same time, expenses rose by more than 11 percent. Since revenues are…
Proposed rules also include new payment models. The Centers for Medicare & Medicaid Services (CMS) has been quite busy these last few weeks issuing the proposed payment rules for 2020 and making some other announcements.  Here is an update on other regulatory activities of interest. On April 22, 2019, the…
Guidance and advice effective with discharges occurring on and after March 20, 2019.  For coding and CDI (clinical documentation improvement/integrity) professionals, it’s exciting to read over the American Hospital Association (AHA) Coding Clinic on ICD-10-CM/PCS. This publication is a must-have document with must-follow guidance. Although ICD10 University held a webinar regarding…
Confusion exists in coding grief in ICD-10 and DMS-5. In a moment of despair, I recently called the nationally renowned psychiatrist and author H. Steven Moffic, MD. My wife of some 20 years had passed away only a few days earlier, following a brief and unexpected illness. Dr. Moffic, as…
The FY 2020 IPPS proposed changes could bode well for many facilities. There has been much discussion about the Centers for Medicare and Medicaid (CMS) Inpatient Prospective Payment System (IPPS) for fiscal year (FY) 2020 proposed rule and its suggested changes. Good news can be found in the 1,824 pages…
HIM professionals touch many functions of the revenue cycle. As we continue this segment on health information management (HIM) in the revenue cycle, I’d like to share some thoughts I discussed at the recent Missouri Health Information Management meeting. When we think about the functions that compose the revenue cycle…
2020 IPPS proposed rule has a total of 149,405 ICD-10 codes. The Inpatient Prospective Payment System (IPPS) Proposed Rule for fiscal year (FY) 2020 comes with a great many changes to the ICD-10-CM/PCS classification systems as well as the MS-DRGs.  While the IPPS applies to inpatient services for acute care…
The Medicare Hospice Benefit proposed rule includes payment rates, wage index, and cap amount.  The Centers for Medicare & Medicaid Services (CMS) is proposing to increase hospice payments to $540 million in the 2020 fiscal year, an increase of 2.7 percent. CMS said the rate is based on the proposed…
Mobilization against changes is proposed. The 2020 Proposed Inpatient Prospective Payment System Rule (IPPS) came out on April 23, 2019, and we need to mobilize. The comments page says we only have until 11:59 pm on May 3, 2019, although the rule itself quotes June 24 as the deadline to…
CMS pledging improved healthcare quality and expanded access for patients. The release of the Inpatient Prospective Payment System (IPPS) proposed rule for the 2020 fiscal year came with a bit of branding. “Rethinking Rural Health” and “Unleashing Innovations” were the two catchy slogans unveiled by the Centers for Medicare &…
Documenting challenges with EHR usage. Last week, I started telling you about a Law-Medicine combined conference I attended through Case Western Reserve University School of Medicine about EHRs and Safety concerns. I am going to continue with the speakers and review the assigned readings. The speakers referred to, and the…
Healthcare IT executives are monitoring interoperability decisions. EDITOR’S NOTE:  At press time, the U.S. Department of Health and Human Services (HHS) announced it is extending the public comment period by 30 days for two proposed regulations aimed at promoting the interoperability of health information technology (health IT).  The government is…
Understanding why a culture of compliance in coding and documentation is so important. Compliance is a large part of our duties in healthcare. It is especially true for coding. With so many regulations, the audit atmosphere and payment nightmares, quite simply we are a moving target. For those of us…
“Virtual" peer reviews are a covered benefit for most payers. In keeping with our theme of “communication-based services,” let’s take a closer look at the inter-professional consults and referrals that do not include a face-to-face encounter with a patient. Some are existing CPT® codes, and two new codes, in this…
CMS has released the inpatient psychiatric facility proposed rule. Approximately $75million is projected to be paid to inpatient psychiatric facilities (IPF), according to the Centers for Medicare & Medicaid Services (CMS) proposed 2020 inpatient prospective payment system (IPPS) released on April 19. IPF-PPS applies to inpatient services for psychiatric hospitals…
Documenting challenges with EHR usage. At the beginning of the month, I attended an interesting conference through Case Western Reserve University School of Medicine called, “Electronic Health Records and Patient Safety: Legal Challenges and Solutions.” I am going to unpack it for you in a two-part series. I have included…
April showers bring social determinants of health flowers The showers of April have brought a burst of blooms in the Social Determinants of Health (SDoH) reimbursement garden. First, the Centers of Medicare and Medicaid Services (CMS) released its 2020 rate sheet. As expected by the industry, Medicare Advantage and Part…
Body mass index is a heavy topic. Spring has arrived in the Northeast and people are getting back to their exercise schedules. I was thinking about this topic as I was reading Coding Clinic, Fourth Quarter 2018. One of the big topics in this issue is body mass index (BMI)…
CAC is not AI. I know that numerous articles and even some books have listed the pros and cons of artificial intelligence (AI). Discussion of the technology in relation to computer-assisted coding (CAC) dramatically ramped up with the implementation of the 10th version of the International Classification of Disease (ICD)…