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Amid confusion over New Technology codes, much attention was focused on partial knee joint replacements during the recent ICD-10 Coordination and Maintenance Committee meeting, March 8 and 9 at CMS headquarters. The Coordination and Maintenance (C&M) Committee meeting was held March 6 and 7 to discuss potential new codes. The…
Moving beyond CDI to optimize reimbursement requires returning to an optimal and sustainable level of achievable excellence.  A well-guided, thought-out, directed mission is paramount to driving and ensuring success in any professional role – and this particularly holds true for the profession of clinical documentation improvement (CDI). In my travels…
Newly covered treatment offers promising relief for sufferers of condition tied to poor blood circulation in the legs.  The main symptom of peripheral arterial disease (PAD) is intermittent claudication. This is an aching, cramping, tired, and sometimes burning sensation in the legs that comes and goes – it typically occurs when walking…
For implanted cardioverter defibrillators, (ICDs) there is no national coverage determination (NCD), nor is there an implementation date.   As we have reported in past editions of RACmonitor eNews, the national coverage determination (NCD) for placement of implanted cardioverter defibrillators (ICDs) was recently updated. As I reported last week, the…
“Ebony and ivory live together in perfect harmony  Side by side on my piano keyboard, oh Lord, why don't we?”— Sir Paul McCartney and Stevie Wonder, 1982   Left alone in a small examining room, I scrolled the Associated Press news app on my cell phone, waiting for my physician to…
Communication, collaboration, and coding exemplify the tone of last week’s C & M meeting. “Communication, collaboration, and coding” are three words that describe the March 6 and 7 ICD-10 Coordination and Maintenance meetings in Baltimore last Tuesday and Wednesday. The meetings were conducted at the headquarters of the Centers for…
Recently I reviewed a case that triggered an exposition. As a clinician, I am always trying to wrap my head around a coding-clinical disconnect in the ICD-10-CM Official Coding and Reporting Guidelines regarding poisoning versus adverse effects. All medications have side effects; a clinician considers the cost-benefit ratio of each…
EDITOR’S NOTE: This article originally was published March 1, 2018 in the RACmonitor e-News A look back on the difficult end to a cherished friend’s life. “Larry only has a couple of weeks to live,” read the Facebook message from the wife of one of my oldest living friends. “He…
The American Hospital Association (AHA) recently announced that notes from social workers and registered nurses will be considered social determinants of health (SDoH).In 1945, World War II was ending, soldiers were returning home, and my mother graduated from nursing school. Her nursing board exam review book is short; the answer…
Ronald Hirsch, MD reported on this breaking news story during the Feb. 20 edition of Talk Ten Tuesdays. Here are highlights of that reporting.   The Centers for Medicare & Medicaid Services (CMS) released a final decision memo on implantable cardioverter defibrillators, also known as ICDs, to update the national…
In this article, the author examines the implications for the capture of Hierarchical Condition Codes (HCCs) in the inpatient setting.By now, most clinical documentation improvement (CDI) programs have an appreciation for the use of cases reflecting how Hierarchical Condition Codes (HCCs) impact upon quality and reimbursement. For those who do…
March 1, 2018

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The author believes that it is more compliant to assign total knee replacements as outpatient services and then reassess the patient’s progress the next day to determine if there is a need for inpatient status. First of all, in five years I believe what follows will all be a non…
Coding leadership routinely benefits from learning team members' strengths and weaknesses and adjusting plans to match. I began working with Novant Health in 2011, when I used the phrase “best of the best” for my team. This was our department’s vision for our future, and it is a standard we…
Indiscriminate copying and pasting is the enemy of accurate, complete, concise, and relevant documentation. Does copy and paste make you as crazy as it does me?! I have been doing a lot of chart reviews lately, and the only saving grace is that this healthcare system has a mechanism to…
Click here to view this webcast on the webstore Why is This Webcast Relevant? Altered mental status is a common manifestation of illness which often signifies severe physiological derangement. To accurately reflect its importance, clinicians need to use appropriate terminology to capture risk adjustment. Attendees will resolve their confusion about…
Smith preaches collaboration, outreach, advancement on TTT broadcast. EDITOR’S NOTE: The following are remarks made by American Health Information Management Association (AHIMA) President and Board Chair Diann Smith during the live Talk-Ten-Tuesdays broadcast on Feb. 13. The American Health Information Management Association (AHIMA) celebrates its 90-year anniversary this year, and…
The new classification is designed as a database and has up to 13 dimensions. The World Health Organization (WHO) will be releasing the 11th Revision to the International Classification of Diseases, or ICD-11, this May. The WHO and many of its 194-member countries have been working on this since 2007.…
There is a definite need for outpatient CDI programs – provided that hospital administration takes the right approach to its development and implementation. Interest in outpatient clinical documentation integrity (CDI) programs is multiplying as more and more hospital services are moving to the outpatient setting and healthcare reimbursement models are…
Official guidance on ICD-10-CM coding raises questions regarding how to document cardiac care. The first step in choosing the proper ICD-10-CM code is reading the medical documentation to identify the diagnosis the provider has documented and confirmed. If there is no confirmed diagnosis, look for the sign or symptom that…
Smith to lay out plans and vision for 2018 during next edition of weekly Internet radio broadcast. Describing her vision this year for the American Health Information Management Association (AHIMA) on the next edition of Talk Ten Tuesdays will be the recently elected president and chair of the AHIMA Board…
There are now five types of myocardial infarction (MI) code categories, and the author describes these new options and how they will impact reimbursement. For cardiology, the focus of ICD-10 is generally on increased specificity and documenting the downstream effects of the patient’s condition. Acute myocardial infarction, or what is more…
Coding the flu consists of the signs and symptoms of flu, the vaccination, and coding the actual disease and its complications This winter has been a long one for those healthcare workers who have been busy treating flu patients and trying to prevent the flu. On Feb. 7, 2018, the…
If physician training and education on clinical documentation is not done correctly, you might as well not do it at all It is common knowledge that the reason clinical documentation integrity (CDI) programs exist is to bridge the gap between the language physicians speak and what can be accurately captured…
February 9, 2018

RACmonitor

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Erica Remer, MD responds to listeners questions from the Talk Ten Tuesday broadcast Jan. 30th.  Since I am out of town on an empty-nesting trip with my husband, I decided to answer the questions we couldn’t get to last week, in writing. When Linda Holtzman and I were bandying about…
The Centers for Medicare & Medicaid Services along with the Centers for Disease Control and Prevention offer programs to help prevent heart disease. According to the Centers for Medicare & Medicaid Services (CMS), “heart disease can often be prevented by identifying risk factors and making healthy lifestyle choices.” “Help your…
A total transformation of traditional case management assumptions is essential to thrive in the new marketplace of value-based care.  It started out as an innovative nursing care model in the early 1980s and moved to a discharge planning/utilization review model incorporating several peripheral activities after the DRG fiscal meltdown. It…
Why the Highmark decision—since rescinded—was wrong about medical decision-making relative to medical necessity. When payers and coders downcode evaluation and management (E&M) notes based on medical necessity, how do they determine what level of history and exam is medically necessary for a particular presenting problem? The answer: subjectively.  What is…
In this article, the author gives a shout-out to auditors for the good work they do. For those of you who are CEOs, CFOs, medical directors, etc., I would like you to take a moment and read the excerpt below, written by a physician representing a facility, paying close attention…
The following is a summary of two segments during the live broadcast of Talk Ten Tuesdays on Jan. 30, 2018 featuring program co-host Erica Remer, MD, FACEP, CCDS and Linda Holtzman, MHA, RHIA, CCS, CCS-P, CPC, COC.Dr. Erica Remer:I believe coding is as much an art as a science as…
The author’s son was a high school football star in Pennsylvania, and at Dartmouth College who suffered from CTE before he took his own life at the age of 32. CTE, chronic traumatic encephalopathy, is a brain disease that is degenerative and progressive. It occurs as a result of repeated head…
Questions abound when reporting critical care services.Reporting Adult Critical care can be complicated. It is not only the coding but the rules and that go along with critical care.  Many questions come up when reporting critical care services. You would think it would be fairly straightforward since there are only…
Chronic conditions are the driving force in determining healthcare outcomes and costs in today’s value-based world, hence the interest in the Hierarchical Condition Category (HCC) coding payment model. Coding chronic conditions and co-morbidities is becoming increasingly critical as the healthcare landscape shifts toward value-based care. Value-based care attempts to advance…
Answers to listeners’ questions posed during last week’s edition of Talk Ten Tuesdays are provided here by the author. There is a disconnect among coders and clinicians regarding the concept of “chronic” conditions. All clinicians have interviewed a patient who denies any past medical history, but when confronted with their…
Understanding when and how to use clinical documentation integrity internal clinical guidelines (CDI-ICGs) Clinical policies, clinical practice guidelines, best practice advice: there are numerous ways to refer to written recommendations designed to spell out how best to diagnose and treat patients based on the most current evidence. These are developed…
Healthcare quality and data come from clinical documentation.Bricks and mortar are the foundation of many a structure. Clinical documentation and coding are similar, as they are also the supportive building blocks in healthcare and can be thought of as foundational as well. In healthcare, over the past 25-30 years we’ve…
Unfortunately, the quality of data is driven less by opportunity and more by incentives for those creating the data.Prior to the implementation of ICD-10, the key selling point of the new coding set was that it provided the opportunity for more detailed data about the nature of each patient’s condition.…
CTE is coded as postconcussional syndrome which is F07.81January 30th is National CTE Awareness Day according to www.stopcte.org. This organization was founded by the family of Patrick Risha who lost his battle with chronic traumatic encephalopathy (CTE) when he was in his 20’s. This young man lived in the suburbs…
For HIM and CDI professionals, 2018 looks to offer a gift of the tremendous opportunity for success.For movie buffs, the film Darkest Hour offers a tremendous view into the early days of World War II, when the fate of Western Europe hangs on the shoulders of newly appointed British Prime…
From evolving your CDI department to a population-centric approach to understanding the impact of electronic medical record technology on CDI program outcomes are among six resolutions offered by the author.Happy New Year! It’s now officially 2018, and even though we are already a full quarter into the federal fiscal year,…
CDI programs are viewed by most physicians as hospital-led initiatives geared towards increasing reimbursement for the hospital.The majority of clinical documentation improvement (CDI) programs fail to effectively engage physicians as willing participants in the push to accurately capture patient care provided through clear, concise, and contextually consistent reporting. Clinical documentation…
Medical policies are based off of evidence-based medicine. Without proper documentation, however, most providers struggle to get services or procedures covered for patients.Exactly what is medical necessity? To many, it is the belief that a service or procedure is warranted or justified for a patient. Others view it as a…
A paramedic reflects on his career and the challenges he and his EMS team face in the line of duty.His bunker coat, helmet, and rescue gloves will be hanging in his locker on Christmas Eve, alongside his ballistic vest and shatter-resistant goggles. David Nesbit II, AAS, NRP won’t be rolling…
Key criteria govern the search to determine whether a patient is malnourished.EDITOR’S NOTE: The following is a summary of a transcript of Pamela Charney speaking during a recent edition of Talk-Ten-Tuesdays.Right now folks are looking at the American Society for Parental and Enteral Nutrition (ASPEN) consensus criteria for diagnosing malnutrition.…
CDI, used to clearly communicate the clinical status of a patient, comes with the increased scrutiny of third-party payers and federal oversight agencies. EDITOR’S NOTE: Stefani Daniels recently appeared on Talk-Ten-Tuesdays. The following are highlights from her segment on the broadcast.Hospitals are knee-deep in some radical changes in how and where…
New quality measures have been added to the IRF Compare website in order to assist consumers, although some measures are not included.The Inpatient Rehabilitation Facility (IRFs) Prospective Payment System for federal fiscal year 2018 final rule published Aug. 3, 2017 included the addition of additional quality measures to the IRF…
Flash back to healthcare in the 1990s. The hot topic then was clinical documentation improvement; the mantra was optimizing reimbursement.

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Hospital services must positively contribute to the revenue cycle and clinical documentation integrity initiatives. A recent outlook report released by Moody’s Investors Services spells continued ongoing financial challenges for non-profit hospitals next year. (Moody's Survey) The firm downgrade the sector from its current stable status to negative for 2018, attributable…
Leaving 2017 and moving into 2018, three major issues await coders—issues that could be opportunities.As we now come to the end of another year and look towards the next, what are the big issues for coding professionals? I often think about the new Official Coding & Reporting Guidelines and the…
Health information management professionals are fulfilling roles in numerous healthcare settings. “Revenue integrity” is a relatively new buzz-phrase, but it certainly is a concept that should have been in practice since pay-for-service healthcare began. In essence, if it had been religiously practiced, the “fraud” would not be in the healthcare…
Dieticians’ findings must find their way into the medical record to achieve proper care and coding. Diagnosing malnutrition is not diving for dollars.Malnutrition – and I am specifically talking about undernutrition today – is a common but frequently unrecognized problem that leads to difficulty healing from trauma or surgery, or…
Healthcare billing professional operating in storm-torn territory details unique challenges left behind by Hurricane Maria.It was an unusual sight for any hospital in any part of the world, let alone a major hospital in a U.S. territory: a Federal Emergency Management Agency (FEMA) surgeon preparing to go to work while…
An insider’s look at coding Alzheimer’s and its associated symptoms.EDITOR’S NOTE: The following is an edited transcript of Laurie Johnson’s recent appearance on Talk Ten Tuesdays.The late President Ronald Reagan designated November as National Alzheimer’s Disease Awareness Month in 1983 in order to help fight the dreaded condition. As Baby…
Malnutrition is officially on the radar screen of the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG). The OIG is adamant about targeting treatment of the condition for review of suspected fraud, saying in a statement that it will “assess the accuracy of Medicare payments…

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A deep dive into the “toughest type of coding.While you may have dedicated CPT® coders for interventional cardiology (IC) and vascular interventional radiology (VIR) for outpatient coding, you may not have considered the importance of doing the same for inpatient ICD-10-PCS coding. These intricate procedures are extremely difficult to understand…
Eight key guidelines for ensuring proper coding. EDITOR’S NOTE: The following is a summary of a presentation by Margaret Skurka during the 2017 American Health Information Management Association (AHIMA) national convention in Los Angeles. Evaluation and management (E&M) documentation principles have been around a long time – since 1995, in…
Alzheimer’s remains an incurable, fatal disease suffered by more than 5.5 million people. EDITOR’S NOTE: The following article appeared in the RACmonitor on Nov. 16, 2017. The story is reproduced here in recognition that November is National Alzheimer's Disease Awareness Month. On Nov. 2, 1901 Karl Deter brought his 51-year…
Quality coding plays a critical role in protecting revenue and reducing operational costs.Results of the 2nd Annual National Coding Productivity and Accuracy Contest were released in September 2017. Although accuracy rates were higher than reported following the same contest in 2016, quality remains significantly low compared to the 95 percent…
Quality of clinical documentation and ICD-10 diagnosis code accuracy and specificity are essential under MACRA.My presentation at the 2017 American Health Information Management (AHIMA) convention stressed the need for understanding a basic overview of the Medicare Access and CHIP Reauthorization Act (MACRA) and its performance categories. These performance categories and…
Predicting the future of MACRA is difficult as goals continue to change, nonetheless, MACRA appears to be here to stay.According to a recent study reported on in The Lancet, healthcare spending per capita is higher in the United States than in any other country in the world, and is unsustainable…
November is National Alzheimer’s Disease Awareness Month, and the Alzheimer's Association reports that 5.5 million people are currently living with the degenerative and fatal disease.

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The American Medical Association (AMA) released new current procedural terminology (CPT®) codes during its 2018 CPT and RBRVS symposium held in Chicago Nov. 15-17.Significant changes to the 2018 CPT® codes and descriptors were announced late last week by the American Medical Association (AMA), including 170 new CPT codes, 60 revised…
In order to make healthcare effective, safe and affordable, clinical organizations must ensure complete and accurate clinical records.In preparation for my remarks on the Talk Ten Tuesdays broadcast of Oct. 31, 2017, I reviewed my own time served on this topic. I also reflected on the many people I’ve met…
The importance of learning and researching the details of MACRA cannot be overstated, especially since the topic is unknown to many healthcare entities.EDITOR’S NOTE: At the American Health Information Management Association (AHIMA) 2017 Convention and Exhibit, significant attention was given to the Medicare Access and CHIP Reauthorization Act (MACRA). The…
Healthcare is moving from Medicare Fee for Service (FFS) to quality payment models.There has been a shift in our healthcare system, whereby providers are being rewarded for better care, not more care. This transition from fee-for-service to value-based care is not only changing how patients are cared for, but also…
A CDIS recently posed a question that baffled – to say the least. In my consulting practice, I often review provider documentation to identify documentation gaps and to direct my educational efforts. I also get a significant amount of information about the state of the facility’s clinical documentation integrity process.…
He is a nationally recognized scientist. He presented at TEDx in Nashville. He is the chief scientific officer at MyGenetx, a Clinical Laboratory Improvement Amendments- (CLIA)-certified lab focused on molecular and advanced diagnostic testing operating that is on the leading edge of precision-guided medicine.

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Much has been written and documented about the physician query process. The subject is crucially important. And the need to maintain the integrity of a compliant query in any clinical documentation integrity (CDI) program cannot be overstated.

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How CDI transforms documentation from a reimbursement perspective to a tool for patient care and support of quality-based, cost-effective, efficient healthcare.Clinical documentation improvement (CDI) programs have become deeply ingrained in most hospitals as part of a purposely directed strategy to improve financial operations.According to a survey conducted by Black Book…
November is National Diabetes Awareness Month, prompting coders to review the coding guidelines for this disease suffered by more than 10.9 million U.S. residents.During November, the Centers for Medicare & Medicaid Services (CMS) is raising awareness about diabetes, diabetic eye disease, the importance of early disease detection, and related preventive…
Understanding how the principles of Lean Six Sigma can improve healthcare.Healthcare organizations have seen improvement programs come and go over the last few decades (TQM, or total quality management, CQI, or continuous quality improvement, reengineering, benchmarking, etc.). None seemed to have the “stickiness” factor that ultimately led to sustained improvement…
AHA Fourth Quarter Coding Clinic identifies problematic diagnosis codes.Hopefully the subject of the most recently published Coding Clinic will not be too scary to discuss. It is effective for discharges from Oct. 1, 2017 forward. The majority of this issue (94 of the 111 pages) provides some background to the…
The topic of counterfeit or otherwise deeply flawed medical records continues to generate buzz nationwide. The case of “Robert,” a Talk Ten Tuesdays listener, reported during a recent edition of the weekly Internet broadcast revealed that in reviewing his electronic medical record (EMR), a documented physical exam was counterfeit –…

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Congress can’t seem to resist tinkering with healthcare through legislation.As we celebrate Halloween, we are seeing healthcare policy “zombies” here in Washington, D.C. – for as many times as congressional leadership has vowed to move on to other legislative topics, healthcare reform seems to always come back to life.The big…
CDI seen as a key solution to meeting regulatory policy changes.One thing is inevitable this time of year for all of us in healthcare: change is in the air. You either thrive amid it or hide, but even those best at hiding ultimately cannot escape. The question I often ponder…
Poorly designed EHRs likely the culprit for the proliferation of false medical records.Last week Talk Ten Tuesdays listener “Robert” discussed during the weekly Internet broadcast the fact that a physical examination documented in his medical record for a recent hospital visit was false, indicating that the physician never performed an…
Nation’s healthcare infrastructure remains fragile following historic storm.San Juan, Puerto Rico – Hurricane María was the strongest storm to slam Puerto Rico in 89 years, and the devastation it left caused a humanitarian crisis, especially in the field of healthcare and at hospitals around the island. Almost a month after…
Robert, a listener of Talk Ten Tuesdays, reported during last Tuesday’s broadcast that in reviewing his electronic medical record (EMR) the entire physical exam was counterfeit – no exam was performed.

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Mental health diagnoses offer possible insight into the mind of suspected Las Vegas mass murdered Stephen Paddock.EDITOR’S NOTE: The following are remarks by nationally renowned psychiatrist H. Steven Moffic, MD during a recent broadcast of Talk Ten Tuesdays.For reasons of understanding and possibly prevention, the question of what was wrong…
Electronic medical record (EMR) technology offers both advantages and pitfalls, but EMR errors must be investigated nonetheless. EDITOR’S NOTE: In this article Dr. John Irwin, a guest on last week’s Talk-Ten-Tuesdays broadcast, responds to “Robert,” a listener who reported that in reviewing his electronic medical record (EMR) for a recent…
Complexity of medical decision-making is key, but you can’t bill for something you didn’t do.This article was prompted by a Talk Ten Tuesdays listener’s question regarding his personal experience with the healthcare profession. He was evaluated in an emergency department (ED), never examined, but discovered a complete physical examination in…
The American Hospital Association steps in; the American Medical Association steps up.On Sept. 27, 2017, the Centers for Medicare & Medicaid Services (CMS) announced that it would not update its overall hospital quality star ratings in October 2017, as planned. This was primarily based on the public's feedback, but the…
Using the phrase “Hx of” and substituting “F/U of” will  make a difference to the risk profile of outpatient providers.Lately I have been getting more requests from physicians to speak to them about outpatient clinical documentation improvement (CDI) and how to ensure that their risk adjustment profiles accurately reflect the…
High degrees of variation abound in areas of coder productivity, certification.In a recent poll, only 80 percent of respondents to a question of how many evaluation and management (E&M) encounters they could code per hour said that they spent at least some portion of their time at work performing that…
Amid the chaos of the ED, order is needed.EDITOR’S NOTE: This is the final installment in a two-part series on clinical documentation integrity (CDI) in the emergency department (ED).It is my opinion that investing CDI resources into the neglected stepchild that is the hospital system ED is a worthwhile endeavor.…
A Talk Ten Tuesdays listener weighs in on woefully insufficient documentation of a routine visit.EDITOR’S NOTE: During last Tuesday’s Talk Ten Tuesdays broadcast, a listener who prefers to be called “Robert” sent an email message to us describing his recent experience as an emergency department (ED) patient – after which…
“I was an ED patient recently,” wrote Robert, a listener of the last edition of Talk Ten Tuesdays. “After receiving and reviewing my electronic medical record, it (was) revealed (that) the entire physical exam was counterfeit – no exam was performed. I was fully alert and my wife was present, yet (no) complete…

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AHIMA conference programs include subjects designed to improve one’s proficiency in the areas of coding, documentation and compliance.The American Health Information Management Association (AHIMA), holding its annual convention and exhibit in Los Angeles this week, has as a theme, “Inspire, Innovate and Lead.” It  is a joy to attend as…
With two recent major disasters confronting caregivers, the question remains: are caregivers prone to experience PTSD than others? Exhibiting a wealth of knowledge and instinct, honed and sharpened by experience, medical first responders and emergency room professionals triage and treat thousands of emergency department (ED) patients each year in America’s hospitals.…
The mass shooting in Las Vegas has prompted renewed attention on emergency medicine and trauma care and especially on the clinical documentation of care in this setting. I practiced emergency medicine (EM) for twenty-five years before I transitioned to being a physician advisor. My expertise had been in the professional…
Major financial penalties loom for providers not following reporting requirements.We are more than halfway through the first year of the Medicare Access and CHIP Reauthorization Act (MACRA), and a majority of clinicians still do not understand the program.In fact, the Centers for Medicare & Medicaid Services (CMS) reported that an…