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Providers and the CDC may be setting up a coding-clinical disconnect. EDITOR’S NOTE: Dr. Erica Remer reported this story live during the Nov. 19 edition of Talk Ten Tuesday. The following is an edited transcript of her reporting. Since I don’t practice clinically anymore, it is challenging to keep up…
EDITOR’S NOTE: Ten Going on Eleven is a month-long series on ICD10monitor and Talk Ten Tuesdays that examine important issues related to the transition to ICD-11. Melanie Endicott with the American Health Information Management Association (AHIMA) appeared as a special guest on a recent edition of Talk Ten Tuesdays and…
Tips for improving outpatient coding, CDI and billing. In moving from inpatient clinical documentation improvement (CDI) to outpatient CDI, I have been discovering some unique educational pointers. I know we are all very busy, so let’s just dive right into it. Doctors and coders, you should not have diagnoses that…
Providers should review their protocols to prepare for the changes. The 2020 updates to ICD-10-CM contain some significant changes to Chapter 12, Diseases of the Skin and Subcutaneous Tissue. These changes include the addition of new codes for the reporting of pressure-induced deep-tissue damage, also known as deep-tissue pressure injury…
A clinician’s perspective on the AHA’s third-quarter coding clinic. I spoke at the inaugural combined Oregon Health Information Management Association (OHIMA) and ACDIS conference in Albany, Ore. last week. One of the comments I hear often when I speak to coders involves how much they appreciate getting a clinician’s perspective.…
EDITOR’S NOTE: Ten Going on Eleven is a month-long series on ICD10monitor and Talk Ten Tuesdays that examines the importance of data mining, as it pertains to the looming transition to ICD-11. World Health Organization (WHO) Classifications and Terminologies Team Leader Dr. Robert Jakob appeared as a special guest on…
Data mining skills will be a prerequisite in ICD-11.   Medical coding has long been identified as the “signature” skill set or area of expertise of the health information management (HIM) profession, but the new signature skill set is quickly becoming data mining – due in large part to changes…
Queries are simply not enough.  We all read about companies moving jobs overseas to cut costs and drive operating performance, with greater profits. As a result, hundreds, if not thousands, of employees are displaced, forced to seek alternate employment or potentially take early retirement, if offered by the employer. This…
Now is the time to begin preparing for the new code set. It is good to be back to talk about ICD-11. Yes, it’s a reality now, and all providers can start to get prepared for this significant new system.  ICD-11 has been years in the making, and it is…
EDITOR’S NOTE: Five Looking at Ten is a month-long series on ICD10monitor and Talk Ten Tuesdays that examines lessons learned since the nation’s healthcare system adopted ICD-10 – many of which are expected to come into play with the looming transition to ICD-11. Stanley Nachimson of Nachimson Advisors appeared as…
New series to focus on preparing for the new code set. ICD10monitor and Talk Ten Tuesdays are launching a new series today, which will continue through November, focusing on the need for early preparation for the new ICD-11 code set that most expect will be ready for the U.S. implementation…
EDITOR’S NOTE: This is the second portion of a two-part series of articles highlighting detailed examples of two challenged denials that followed third-party healthcare audits. In our second example, a 73-year-old female presented to the hospital with syncope following a fall at a physician office: The provider assigned I67.1 (Cerebral…
EDITOR’S NOTE: Five Looking at Ten is a month-long series on ICD10monitor and Talk Ten Tuesdays that examines lessons learned since the nation’s healthcare system adopted ICD-10 – many of which are expected to come into play with the looming transition to ICD-11. Medical Group Management Association Health Information Technology…
Agencies continue their investigation into the underlying cause of electronic cigarette/vaping-associated lung injury. The Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA) continue to investigate the underlying cause of electronic cigarette/vaping-associated lung injury (EVALI).    In order to assist public health response in recognizing and…
It’s a move sure to stir up controversy.  Under a recently passed Centers for Medicare & Medicaid Services (CMS) Final Rule, your Medicare enrollments will be judged not necessarily on your performance but based on your affiliations with other providers and suppliers. Yes, you read that right: “other providers and…
Approximately $230 billion a year in healthcare costs are directly related to illiteracy and the social factors associated with illiteracy. “Illiteracy” is such a broad term. It states a fact, but the underlying causes and far-reaching life and generational impacts are less well-stated.  The problems are hiding in statistics from…
New guidance for coding vaping is retroactive to Oct. 1 discharges.   The Center for Disease Control and Prevention (CDC) has posted new coding guidance regarding e-cigarette lung injuries. This guidance, posted Oct. 17, 2019, is retroactive to Oct. 1, 2019 discharges.   The guidance states that coding professionals should report…
Conduct coding audits in all settings and check vendors’ coding credentials are among lessons learned under ICD-10. When we left ICD-9-CM, there were around 14,000 diagnosis codes in use across the healthcare industry – and then, on Oct. 1, 2015, we moved to approximately 69,000 codes. ICD-10-CM/PCS implementation was a…
During a recent conference call, the agency described assessing 64,883 ICD-10-CM diagnoses. I participated in the Centers for Medicare & Medicaid Services (CMS) conference call last Tuesday, explicitly focusing on complication and co-morbidity (CC) or major CC (MCC) designation methodology. This process is similar to how CMS originally determined comorbid…
EDITOR’S NOTE: Five Looking at Ten is a month-long series on ICD10monitor and Talk Ten Tuesdays that examines lessons learned since the nation’s healthcare system adopted ICD-10 – many of which are expected to come into play with the looming transition to ICD-11. George Vancore of Blue Cross Blue Shield…
There is a disconnect between what the doctor may have ordered and what the EHR read or translated. In my capacity as a healthcare consultant and auditor, I review patient records from all over the country – actually, the world, with the ever-growing popularity of offshore companies now performing coding…
There is a difference between mortality and morbidity and knowing the difference is essential for coders. Often, when used in the healthcare environment, the terms “mortality,” “morbidity,” and “severity of illness (SOI)” are interwoven. However, by definition, they are quite different. Those within the healthcare industry need to understand the…
Expanding clinical conversations to involve all players can only benefit the entire organization. EDITOR’S NOTE: This article is based upon Dr. Erica Remer’s remarks during a recent live Talk Ten Tuesdays Internet broadcast. A while back, I told readers about a fun activity I do with one of my clients.…
EDITOR’S NOTE: This is the first in a two-part series of articles highlighting detailed examples of two challenged denials that followed third-party healthcare audits. I shouldn’t be surprised.  I have been reviewing denials by insurance companies since the late 1980s. I’ve seen the same things over and over again, such…
It all started with a move from one office to another. Considering the monumental quantities of time and energy expended by the healthcare industry on the shift from the ICD-9 coding classification system to ICD-10 about five years ago, it might have come as a bit of a surprise to…
The risks of using the Internet to self-diagnose and code. A majority of us turn to the Internet for health-related information. According to the Pew Research Center, in 2014, a total of 87 percent of American adults had access to the Internet, and in 2012, a total of 72 percent…
The criteria and definitions for sepsis are presented to help medical staff better understand sepsis. I popped on LinkedIn to repost the details of the Centers for Medicare & Medicaid Services (CMS) listening session regarding complication and comorbidity (CC) and major CC (MCC) comprehensive analysis after a recent edition of…
The actual go-live of ICD-10-CM/PCS was generally smooth, with no major problems.  For health information management (HIM) coding and clinical documentation improvement/integrity (CDI) professionals, the use of and adherence to the ICD-10-CM/PCS Official Guidelines for Coding and Reporting is a must. In addition, the American Hospital Association (AHA) ICD-10-CM/PCS Coding…
October 4, 2019

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The five-week series will highlight progress made during the implementation of the coding set that became effective Oct. 1, 2015. ICD10monitor and Talk Ten Tuesdays are poised to embark on a five-week series, “Five Looking at Ten,” that will focus on the lessons learned during the adoption of ICD-10 that…
Electronic alerts for systemic inflammatory response syndrome (SIRS). EDITOR’S NOTE: Dr. Erica Remer reported this story live during the Sept. 24 edition of Talk Ten Tuesday. The following is an edited transcript of her reporting. Dr. Ronald Hirsch recently brought an article to my attention, and I felt compelled to share…
Confusion persists for the coding of vaping. The issue of vaping continues to generate national and international headlines. On Sept. 18, a teen from London, Ontario in Canada suffered a severe case of pulmonary illness after using e-cigarettes daily. This marked the first reported case in Canada.   In the U.S.,…
Do your physicians and ancillary staff know the ICD-10-CM coding rules? Based on many years of personal experience, most physicians and ancillary staff who do not code really don’t know or understand the coding rules.  This is not particularly surprising, because even the best coders are sometimes confused by the…
Three revenue cycle tips are provided to reduce denied claims. Claim denials represent millions of dollars in lost and delayed net reimbursement annually. According to the American Medical Association (AMA), cost estimates of inefficient healthcare claims processing, payment, and reconciliation top out at $210 billion per year. Denials are so…
The SDoH are an essential element to providing patient care while addressing social needs. What determines health? While medical care is one determinant of one’s health, it plays a minor role in comparison to the economic and social conditions of an individual, otherwise known as social determinants of health (SDoH):…
Oct. 1, 2019, marks the beginning of a new era of billing for skilled nursing facilities (SNFs). EDITOR’S NOTE: This article was published on Aug. 1, 2019, in the RACmonitor news and is reproduced today given the approaching deadline for coding compliance. Say goodbye to RUG-IV, and hello to the…
Late physician signatures pose serious issues. In the last few months, I have had questions about late signatures on documentation come in from several clients. I've been hearing about providers signing their notes a very long time after the encounter – sometimes weeks later, sometimes months,  and sometimes even turning…
The author ruminates on the Fall C&M meeting. EDITOR’S NOTE: Dr. Erica Remer reported this story live during the Sept. 17 edition of Talk Ten Tuesday. The following is an edited transcript of her reporting. I listened to the ICD-10 Coordination and Maintenance Committee Meeting last week. Here are my thoughts.…
Public comments due by Nov. 8 to CMS and CDC. EDITOR’S NOTE: Senior healthcare consultant Laurie Johnson reported this story live during the Sept. 17 edition of Talk Ten Tuesday. The following is an edited transcript of her reporting. The Coordination and Maintenance Committee met on Sept. 10-11, 2019 at the…
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…
EDITOR’S NOTE: This article has been updated to include commercial contract coverage information and CPT® direction to challenge payer contract provisions when necessary. 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…
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…