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March 26, 2019
Revisions on the Horizon for E&M in 2021
By Terry Fletcher, BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMSCS, CMCS, ACS-CA, SCP-CA, QMGC, QMCRC
AMA is on track to revise E&M codes, set new documentation guidelines. The American Medical Association’s (AMA’s) CPT® Editorial Panel has approved many changes to the evaluation and management (E&M) documentation and coding guidelines. If finalized, the changes will shift the way practices select codes for both office and facility visits as…
Semantics aside, clinicians must recognize sepsis and treat it aggressively, to save lives. A few weeks ago, I had a fascinating discussion with Tim Brundage, a physician friend, and fellow clinical documentation improvement (CDI) expert, my co-chair on the American College of Physician Advisors (ACPA) CDI committee, and I’d like…
National healthcare entities are teaming up and speaking out on how to make healthcare better. EDITOR’S NOTE: The following was discussed by Nachimson during last Tuesday’s Talk Ten Tuesdays live broadcast. There are two major and complementary rules to advance interoperability being proposed by U.S. Department of Health and Human…
March 19, 2019
AHIMA Chief Shares Vision in Talk Ten Tuesdays Appearance
By Valerie J. Watzlaf, PhD, MPH, RHIA, FAHIMA
Change was a key topic cited by the head of the national HIM advocacy organization. EDITOR’S NOTE: Valerie Watzlaf, 2019 American Health Information Management Association (AHIMA) President and Chair, was a guest on the most recent Talk Ten Tuesdays broadcast. Here are her remarks from that broadcast. Thank you so…
March 19, 2019
“Virtual Check-Ins:” Medicare’s New Communication Technology-Based Payable Service
By Terry Fletcher, BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMSCS, CMCS, ACS-CA, SCP-CA, QMGC, QMCRC
New strategy holds promise for future extensions of this technology.A medical practice can now bill and collect for a specific telehealth service without the strict rules of the originating sites being outside of a Metropolitan Statistical Area (MSA) or in a rural Health Professional Shortage Area (HSPA) located in a…
March 19, 2019
A CDI Revolution Unfolding
By Glenn Krauss, RHIA, BBA, CCS, CCS-P, CPUR, CCDS, C-CDI, PCS, FC
As the provision of healthcare changes, so too must clinical documentation improvement. I have always been convinced of the strong capabilities of current clinical documentation integrity (CDI) initiatives to achieve tremendous improvement in the completeness and quality of documentation and communication of patient care in the electronic health record. Today’s…
E&M code changes are expected to become effective in 2021. The American Medical Association (AMA) released on March 8 the summary of panel actions that took place at the February 2019 CPT® panel meeting. The exact wording is not considered to be finalized until just prior to the release of…
March 12, 2019
Newly elected AHIMA Leader Making Guest Appearance on Talk Ten Tuesdays
By Mark Spivey
Valerie Watzlaf, PhD returns for a second appearance tomorrow during the live broadcast. Valerie J. Watzlaf, PhD, MPH, RHIA, FAHIMA, recently elected American Health Information Management Association (AHIMA) President/Chair of the group’s 2019 Board of Directors, will be the special guest today on Talk Ten Tuesdays, according to Chuck Buck,…
March 12, 2019
New Versus Established Patients Visits: 2.0
By Terry Fletcher, BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMSCS, CMCS, ACS-CA, SCP-CA, QMGC, QMCRC
Confusion persists in understanding the definition of the two visits. We created a lot of buzz the past two weeks on our Talk Ten Tuesday broadcast an article on new versus established patient visits: so much, in fact, it was hard to keep up with all the email feedback, which…
Computer-assisted coding depends on the accuracy of the input. There is considerable interest in computer-assisted coding or “CAC.” The proponents say it will reduce costs, coding backlogs and discharged not final billed claims. There are several companies in this space, the largest being 3M with more than $30 billion in…
March 12, 2019
Chronic Diseases Creating Coding and CDI Implications
By Laurie M. Johnson, MS, RHIA, FAHIMA AHIMA Approved ICD-10-CM/PCS Trainer
These conditions should be on the radar for coding and clinical documentation integrity. There has been much discussion about healthcare expenses in recent months. The Centers for Medicare & Medicaid Services (CMS) is focusing on value-based purchasing (VBP), and payors are focused on reducing costs through Hierarchical Condition Categories (HCCs)…
March 5, 2019
Getting into the Revenue Cycle Groove: Part 1
By Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS, AHIMA-approved ICD-10-CM/PCS Trainer
Pursuing revenue cycle roles could be an ideal path for HIM professionals. Often, we see patient financial services staff progress to leadership positions in the revenue cycle. When I have the opportunity to serve in such positions, I always wonder why we don’t see more health information professionals in these…
Prime Healthcare lawsuit reveals a huge risk for unethical practice. A few weeks ago, Dr. Ronald Hirsch brought to my attention (as is his custom) a False Claims Act complaint and settlement involving Prime Healthcare Services, a for-profit healthcare system. By way of background, last August, the U.S. Department of…
March 5, 2019
Coding Chronic Conditions During the Patient Journey
By Rhonda Buckholtz, CPC, CPMA, CPC-I, CRC, CDEO, CHPSE, COPC, CPEDC, CGSC
Coding of chronic conditions: Part 2 This article addresses concerns regarding the coding of chronic conditions during a patient’s journey. The truth of the matter is that depending on your role in the coding process, your experience coding chronic conditions can differ greatly from that of others. As indicated in…
March 5, 2019
HAC Coding Impacts Hospital Financial Performance
By Laurie M. Johnson, MS, RHIA, FAHIMA AHIMA Approved ICD-10-CM/PCS Trainer
HAC coding impacts hospital financial performance. Hospital-acquired conditions (HACs) have been reported on hospital claims since FY 2008. Payments to hospitals ranking in the lowest-performing quartile were adjusted by 1-percent reductions beginning Oct. 1, 2014. This program is known as the Hospital-Acquired Conditions Reduction Program, and it is part of…
February 25, 2019
The High-Stake Risks of High-Priced Pharmaceuticals
By Denise M. Nash, MD, CCS, CIM
Audits are being conducted by payers on being cost-effective with “wastage” of medication. When it comes to the JW modifier for discarded medication, there are things of which you might not be aware, especially, the administration of expensive pharmaceuticals such as chemotherapy. The verbiage that everyone is familiar with is…
The goal should be a 100 percent response rate. On a recent onsite, one of the clinical documentation integrity specialists (CDISs) asked me my opinion on how assiduous a clinical documentation integrity (CDI) professional should be to get a query answered. My response may surprise some of you. I must…
February 25, 2019
Coding “Separate Procedures:” What Coders Need to Know
By Terry Fletcher, BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMSCS, CMCS, ACS-CA, SCP-CA, QMGC, QMCRC
“Separate procedure” may not mean what you think. Many procedural codes in the CPT® Book are designated as “separate procedures.” However, the common misinterpretation of this is that coders can report such codes as such in every case. Not true. First, you must consider: Were there other procedures performed during…
February 25, 2019
Coding Quality: Obstacles and Solutions
By Heidi Hillstrom, MS, MBA, RN, PHN, CCDS, CCS
Developing a team approach can positively impact coding quality and reduce coding errors. Coding professionals are faced with a myriad of challenges that can significantly impede coding quality. Such challenges include ongoing, increasing pressure to meet management productivity standards and CFO expectations to drop bills in a timely manner to…
February 19, 2019
Survey Reveals Clues About Physician Burnout but Who is Listening?
By Holly Louie, RN, BSN, CHBME
Is the healthcare industry tone deaf to physicians’ complaints? The Physicians Foundation 2018 Physician Survey, published on Sept. 18, 2018, features opinions of our nation’s physicians—opinions that are sobering and should sound a loud wake-up call. When distilled down to the very essence of the report, the “fixes” for our…
February 19, 2019
Chronic Conditions: Code or Not to Code MCCs
By Rhonda Buckholtz, CPC, CPMA, CPC-I, CRC, CDEO, CHPSE, COPC, CPEDC, CGSC
Understanding the correct use of chronic condition codes in the coding process. Coders are often confused regarding when they should code co-morbid chronic conditions and when they should not. This leads to inaccurate coding of levels, or sometimes missing out on the opportunity of stressing each patient’s true clinical conditions,…
CMS and ONC get serious about interoperability during HIMSS.During the HIMSS 19 conference in Orlando last week, the heads of the Office of the National Coordinator (ONC) for Health Information Technology and the Centers for Medicare & Medicaid Services (CMS) took extraordinary steps by discussing the content of two proposed…
A National Coverage Determination (NCD) will reimburse providers for diagnostic tests using sequencing.Today’s topic is DNA sequencing and its effect on society as a whole, on healthcare, and on Medicare. Sequencing is a laboratory procedure that maps the pattern of nucleotides in DNA. In 2003, sequencing an individual cost $2.7…
February 12, 2019
Clinical Documentation Integrity Programs Eroding Net Patient Revenue
By Glenn Krauss, RHIA, BBA, CCS, CCS-P, CPUR, CCDS, C-CDI, PCS, FC
CDI professionals can’t mitigate the magnitude of medical necessity denials by third-party payers. Clinical documentation integrity (CDI) programs, combined with the actions of third-party payers, can erode net patient revenue for inpatient and outpatient services through process design. In reviewing one particular inpatient case with $118,000 in charges denied by…
February 12, 2019
AHIMA Coding Productivity Study and Preparing for ICD-11
By Julie A. Dooling, MSHI, RHIA, CHDA, FAHIMA and Melanie Endicott, MBA/HCM, RHIA, CDIP, CHDA, CPHI, CCS, CCS-P, FAHIMA
Planning is underway now for ICD-11.The American Health Information Management Association (AHIMA) has been getting involved in the development of ICD-11 through its participation in the World Health Organization’s (WHO’s) activities, as well as providing members with high-level overviews of what to expect with the new classification system. ICD-11 has…
February 12, 2019
Outbreak of Yellow Fever Reported
By Laurie M. Johnson, MS, RHIA, FAHIMA AHIMA Approved ICD-10-CM/PCS Trainer
Consider your health in your travel plans. The Pan American Health Organization (PAHO), which is in Washington D.C., is reminding travelers to get vaccinated if you are planning a trip to areas in which yellow fever is present. Which countries are affected by yellow fever? In the Americas, the countries…
February 12, 2019
New versus Established Patients: Do you Know the Rules and Exceptions?
By Terry Fletcher, BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMSCS, CMCS, ACS-CA, SCP-CA, QMGC, QMCRC
Not knowing the difference could amount to shortchanging yourself.It seems like the simpler the question, the harder it can be to answer. When we ask the question, “is this a new or established patient?” it amazes me that it is not a black-and-white answer. But when we look at the…
A new white paper from the industry bellwether looks back, forward in framing big picture of coding. Benchmarking, the term that encompasses performance measurement in the healthcare industry, will be key for providers seeking to refine their efforts to master ICD-10 as ICD-11 implementation looms in the distance, according to…
February 5, 2019
Cardiac Arrest in the ED: What to Document and Code
By Erica E. Remer, MD, FACEP, CCDS
Coders need to know when and how the cardiac arrest occurred. There are approximately 350,000-400,000 cases of cardiac arrest arising outside of the hospital setting per year, and not all of these patients make it to the emergency department. The incidence in any given hospital on any given shift is…
February 5, 2019
Polar Vortex Hastens Need for ICD-10 Cold Codes
By Laurie M. Johnson, MS, RHIA, FAHIMA AHIMA Approved ICD-10-CM/PCS Trainer
There are ICD-10 codes for cold weather injuries.The weather has been rough for the people living in the Midwest and Northeast. The reported temperatures have been as low as -60 with the wind chill factor applied. Such severity of temperatures does calls to mind some injuries and illnesses such as…
Which definition of the deadly condition will be applied in the Empire State has been a hot topic of late. EDITOR’S NOTE: The following is partial transcript of remarks made by Dennis Jones during a recent RACmonitor-produced Monitor Mondays broadcast. First, let me remind everyone that I am in the…
Jan. 30, 2019 is CTE Awareness Day. It has been four years since we started the Patrick Risha CTE (chronic traumatic encephalopathy) Awareness Foundation at stopcte.org. My son, Patrick Risha, was a great high-school football running back and free safety. He started playing at age 10 and over time broke…
January 29, 2019
Is the ACA (Affordable Care Act) Really Going Away?
By Terry Fletcher, BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMSCS, CMCS, ACS-CA, SCP-CA, QMGC, QMCRC
Recommended next steps for physician practices are discussed by the author. As you have probably heard by now, a federal judge in Texas, U.S. District Judge Reed O'Connor, on Friday, Dec. 14, 2018 struck down the Patient Protection and Affordable Care Act (PPACA) as unconstitutional, ruling that the individual mandate…
January 29, 2019
Payers and Clinicians Should use Clinically Accepted Criteria when Diagnosing Sepsis
By Erica E. Remer, MD, FACEP, CCDS
The accurate diagnosis of sepsis is not for DRG assignment. There has been quite a bit of controversy stirred up by UnitedHealthcare (UHC) and its approach to sepsis, and since I am wrapping up a fascinating targeted sepsis project, I want to share what I have learned with you. I…
January 29, 2019
Appealing Clinical Validation Denials in the Era of Sepsis-3
By Denise Wilson MS, RN, RRT
Higher overturn rates noted when the appeal is filed outside of the payer’s internal appeal process. I’d like to share some information gained from appealing over 2,000 clinical validation denials for sepsis in the state of New York since the time of the release of the Sepsis-3 criteria in February…
The code assignment is not based on clinical criteria used by the provider to establish the diagnosis. Referring to the contentious ICD-10-CM Guideline I.A.19, which indicates that assignment of a diagnosis code is based on the provider’s diagnostic statement that a condition exists, Erica Remer, MD said during Tuesday’s Talk-Ten-Tuesdays…
January 22, 2019
Understanding CMS Advanced Practitioner Professional Billing
By Deborah Grider, CPC, CPC-H, CPC-I, CPC-P, CPMA, CEMC, CCS-P, CDIP, Certified Clinical Documentation Improvement Practitioner
Not billing the APP service can result in serious revenue cycle errors. Many providers are still struggling with the non-physician practitioner (NPP) billing rules from the Centers for Medicare & Medicaid Services (CMS). Most facilities are now referring to NPPs as Advanced Practitioner Professionals or APPs. I get questions all…
January 22, 2019
GAO Issues Long-Awaited Report on Patient Matching
By Julie A. Dooling, MSHI, RHIA, CHDA, FAHIMA
The report cites the need for more work by providers. The Government Accountability Office (GAO) report on patient matching dropped last Wednesday. The industry had been waiting for the report since the 2016 passage of the 21st Century Cures Act, which included a provision for the GAO to report on…
January 22, 2019
How Public Health Crises Affect Us All
By Laurie M. Johnson, MS, RHIA, FAHIMA AHIMA Approved ICD-10-CM/PCS Trainer
The U.S. is in the middle of flu season this month and the opioid crisis appears unabated. There are several public health issues that are impacting the United States at the moment, and this article will focus on two of them: flu immunization and the opioid epidemic, in particular. Have…
January 21, 2019
ICD-10: Pitfalls of Noncompliant Queries
By Glenn Krauss, RHIA, BBA, CCS, CCS-P, CPUR, CCDS, C-CDI, PCS, FC
Noncompliant queries can be overt or subtle.The underlying hallmark of clinical documentation integrity (CDI) programs is the query process utilized to clarify documentation from a diagnosis perspective. Much emphasis is placed upon ensuring the issuing of a compliant query by the clinical documentation integrity specialists, reinforced by the American Health…
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…
January 15, 2019
The Changing Face of the Social Determinants of Health: Implications for Hospitals
By Ellen Fink-Samnick, MSW, ACSW, LCSW, CCM, CRP
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…
January 15, 2019
Appealing Clinical Validation Denials is a Team Effort
By Juliet B. Ugarte Hopkins, MD, CHCQM
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…
January 14, 2019
A New Year Brings New Challenges
By Laurie M. Johnson, MS, RHIA, FAHIMA AHIMA Approved ICD-10-CM/PCS Trainer
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…
December 11, 2018
Integrity: The Missing Component in CDI
By Glenn Krauss, RHIA, BBA, CCS, CCS-P, CPUR, CCDS, C-CDI, PCS, FC
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…
December 11, 2018
ICD-10 Coding: Moderate “Conscious” Sedation vs. “Monitored” Sedation – Are you compliant?
By Terry Fletcher, BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMSCS, CMCS, ACS-CA, SCP-CA, QMGC, QMCRC
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…
December 11, 2018
Major Challenges Face Coders in 2019 and Beyond
By Deborah Grider, CPC, CPC-H, CPC-I, CPC-P, CPMA, CEMC, CCS-P, CDIP, Certified Clinical Documentation Improvement Practitioner
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…
December 4, 2018
Will Adverse Drug Effects Adversely Affect Your Institution?
By Erica E. Remer, MD, FACEP, CCDS
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…
December 4, 2018
CDI Seen in New Light as OIG is Poised to Validate DRGs
By Glenn Krauss, RHIA, BBA, CCS, CCS-P, CPUR, CCDS, C-CDI, PCS, FC
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…
December 4, 2018
High-Cost, High-Frequency Cases Challenge New Coders
By Laurie M. Johnson, MS, RHIA, FAHIMA AHIMA Approved ICD-10-CM/PCS Trainer
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…
November 27, 2018
Documenting a Dilemma: Inherent vs. Event vs. Effect
By Sharon Lee Savinsky, MSN, RN CDIS
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,…
November 27, 2018
Newly Released Criteria Strives for a Global Consensus of Malnutrition
By Erica E. Remer, MD, FACEP, CCDS
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,…
November 27, 2018
Outsourcing Healthcare-Related Services is one Thing…but Offshoring? That’s Another
By Terry Fletcher, BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMSCS, CMCS, ACS-CA, SCP-CA, QMGC, QMCRC
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…
November 27, 2018
2019 Physician Fee Schedule: Big Changes Ahead
By Jeffrey D. Lehrman, DPM, FASPS, MAPWCA, CPC
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…
November 27, 2018
ICD-10 Coding: New Character Surfaces in Spinal Fusion Codes
By Laurie M. Johnson, MS, RHIA, FAHIMA AHIMA Approved ICD-10-CM/PCS Trainer
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…
November 18, 2018
Using the 2019 CC/MCC List to Capture Accurate Clinical Documentation and Avoid Audits
By Odin Mayland
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.
November 13, 2018
Lessons Learn from Hurricane Michael
By Julie A. Dooling, MSHI, RHIA, CHDA, FAHIMA
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…
November 13, 2018
2019 ICD-10-CM Coding for Diabetes: November is National Diabetes Month
By Laurie M. Johnson, MS, RHIA, FAHIMA AHIMA Approved ICD-10-CM/PCS Trainer
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…
November 13, 2018
Things Your Mother Never Told You About HCC: Version 23
By William L Jonakin, MD, CPC, CRC
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…
November 6, 2018
Tracing the Evolution of Clinical Documentation Integrity
By Mel Tully MSN, CCDS, CDIP
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…
November 6, 2018
Supporting Medical Necessity of Investigative Tests
By Erica E. Remer, MD, FACEP, CCDS
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…
November 2, 2018
E&M Flat Rate Reimbursement Delayed to 2021
By Shannon DeConda CPC, CPC-I, CEMC, CMSCS, CPMA®
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…
October 30, 2018
Telehealth and the Impact of ICD-10-CM
By Terry Fletcher, BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMSCS, CMCS, ACS-CA, SCP-CA, QMGC, QMCRC
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…
October 30, 2018
ICD-10 Coding for the Flu
By Laurie M. Johnson, MS, RHIA, FAHIMA AHIMA Approved ICD-10-CM/PCS Trainer
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 in 2018, as I got my first flu shot! I…
October 30, 2018
Random Thoughts about ICD-11
By Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS, AHIMA-approved ICD-10-CM/PCS Trainer
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…
October 23, 2018
ICD-10 Coding: Diabetic Foot Ulcer or Pressure Ulcer?
By Erica E. Remer, MD, FACEP, CCDS
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…
October 23, 2018
ICD-10 Coding: Fourth Quarter Coding Clinic Sheds Light on BMI
By Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, AHIMA-Approved ICD-10-CM/PCS Trainer
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.…
October 23, 2018
The Latest Disease Scare: Acute Flaccid Myelitis
By Laurie M. Johnson, MS, RHIA, FAHIMA AHIMA Approved ICD-10-CM/PCS Trainer
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…
October 16, 2018
Clinical Documentation Integrity: Reporting the Over-Reliance on the Query Process
By Glenn Krauss, RHIA, BBA, CCS, CCS-P, CPUR, CCDS, C-CDI, PCS, FC
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…
October 16, 2018
AHA Releases 3rd Quarter Coding Clinic
By Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, AHIMA-Approved ICD-10-CM/PCS Trainer
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…
October 16, 2018
CDI: Documenting the Need to Generate Compliant and Meaningful Queries
By Erica E. Remer, MD, FACEP, CCDS
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…
October 16, 2018
ICD-10 Coding: HPV Cancers
By Laurie M. Johnson, MS, RHIA, FAHIMA AHIMA Approved ICD-10-CM/PCS Trainer
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…
October 9, 2018
Navigate Medical Marijuana with your Eyes Wide Open
By Terry Fletcher, BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMSCS, CMCS, ACS-CA, SCP-CA, QMGC, QMCRC
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…
October 9, 2018
Clinical Documentation Improvement: Moving to Improve Patient Outcomes
By Glenn Krauss, RHIA, BBA, CCS, CCS-P, CPUR, CCDS, C-CDI, PCS, FC
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…
October 2, 2018
LGBTQ Patients Are Focus of AHIMA Support
By Julie A. Dooling, MSHI, RHIA, CHDA, FAHIMA
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…
October 2, 2018
Leadership and Ethics during Challenging Times
By Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, AHIMA-Approved ICD-10-CM/PCS Trainer
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…
October 2, 2018
Understanding Presumptive Linkage for Code Titles “With” or “In”
By Erica E. Remer, MD, FACEP, CCDS
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…
September 25, 2018
Human Trafficking: New ICD-10 Codes Empower Efforts to Identify and Aid Victims
By Ellen Fink-Samnick, MSW, ACSW, LCSW, CCM, CRP
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…
September 25, 2018
Are There ICD-10-CM or CPT® Coding Implications to Clarify Fourth Universal Definition of AMI?
By Terry Fletcher, BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMSCS, CMCS, ACS-CA, SCP-CA, QMGC, QMCRC
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…
September 25, 2018
Moving in the Right Direction in Getting to the Root Cause of Clinical Documentation Improvement
By Glenn Krauss, RHIA, BBA, CCS, CCS-P, CPUR, CCDS, C-CDI, PCS, FC
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…
September 24, 2018
The Value of a Certified Coder and CDI in our Practices
By Rhonda Buckholtz, CPC, CPMA, CPC-I, CRC, CDEO, CHPSE, COPC, CPEDC, CGSC
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…
September 18, 2018
Capturing the Spirit of Coding: Part II
By Laurie M. Johnson, MS, RHIA, FAHIMA AHIMA Approved ICD-10-CM/PCS Trainer
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.…
September 18, 2018
Healthcare and Hurricane Preparedness
By Sharon Easterling, MHA, RHIA, CCS, CDIP, CRC, FAHIMA
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…
September 18, 2018
2019 CPT® Coding for Skin Biopsies
By Deborah Grider, CPC, CPC-H, CPC-I, CPC-P, CPMA, CEMC, CCS-P, CDIP, Certified Clinical Documentation Improvement Practitioner
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…
September 17, 2018
2019 IPPS Updates from the Perspective of a Pulmonary/Critical Care Physician
By Emmel “Sonny” Golden, MD, FCCP, CCDS
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…
