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Health of teenage girls is in the nation’s spotlight on women’s health issues. We would be remiss to focus on National Women’s Health Week and not include topics specific to teenaged girls. Having said that, my first of two items admittedly pertains to girls and boys. But, given the higher…
AHIMA hopes data gathering and sharing will help address the issue. Every day, more than 115 people in the United States die as a result of opioid overdose, according to the National Institute on Drug Abuse (NDA). Tracing the origin of the crisis to the widespread distribution of opioid pain…
May 8, 2018
Auditing Issues Uncovered in Physician Documentation: Part II
By Terry Fletcher, BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMSCS, CMCS, ACS-CA, SCP-CA, QMGC, QMCRC
Physician documentation issues during an audit go beyond CDI. The issues are the chief complaint and HPI. Editor’s Note: This is the second piece in a four-part series that examines physician documentation issues as seen by an auditor. As I discussed in the first portion of our series on physician…
May 8, 2018
Sexually Transmitted Disease Awareness
By Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, AHIMA-Approved ICD-10-CM/PCS Trainer
CMS encourages providers to talk, test, and treat STDs. When it comes to sexually transmitted disease (STD) awareness, the Centers for Medicare & Medicaid Services (CMS) is encouraging providers to take three simple steps in protecting their patients through talk, testing, and treating: Talk openly about STDs with your partners…
May 8, 2018
News Alert: MS-DRG Changes Prevalent in IPPS FY19 Proposed Rule
By Laurie Johnson, MS, RHIA, CPC-H, FAHIMA, AHIMA-Approved ICD-10-CM/PCS Trainer
Expansion of new ICD-10 codes has slowed. The 2019 Inpatient Prospective Payment System proposed rule covers many Medicare Severity Diagnosis-Related Groups (MS-DRGs) changes, in addition to changes to the Value-Based Purchasing (VBP), Hospital-Acquired Conditions (HACs), and Hospital Readmission Reduction program, as well as the post-acute care transfer policy. The length…
The importance of an effective outpatient CDI program cannot be overstated When working with a member of the sales force for a previous employer, I was asked, “What is the biggest problem coders encounter?” My answer, very simply put, was “physician documentation!” I should have added “or lack thereof!” We…
May 1, 2018
Auditing Issues Uncovered in Physician Documentation: Part I
By Terry Fletcher, BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMSCS, CMCS, ACS-CA, SCP-CA, QMGC, QMCRC
Physician documentation issues during an audit go beyond CDI. EDITOR’S NOTE: This is the first in a four-part series that examines physician documentation issues as seen by an auditor. One of the services I offer, aside from coding and billing education, is practice audits for evaluation and management (E&M) procedural…
May 1, 2018
Feeling the Burn: Confessions of a Formerly Burned Out Coder
By Kristi Pollard, RHIT, CCS, CPC, CIRCC, AHIMA-Approved ICD-10-CM/PCS Trainer
Ten strategies for avoiding burnout are provided by the author. On any given day, if you walked into my home office, you might think you were in a spa. The walls are painted a soothing aqua color (at least, I think it’s soothing), a scent diffuser releases a pleasant tea…
May 1, 2018
News Alert: 2019 IPPS Proposed Rule for IRFs Removes Requirement to Collect FIM and Quality Indicator Functional Data
By Angela Phillips, PT
Removal of the requirement, if adopted, becomes effective FY 2020. Our early review of the document and accompanying fact sheets has identified a number of provisions of interest to inpatient rehabilitation facility (IRF) providers. One of the key provisions, the removal of the Functional Independence Measure (FIMTM) Instrument and associated…
Subscribe to our show to get the latest episode every week. Recent episodes of our show are available to stream or download via these podcast apps: See what’s coming up on Talk Ten Tuesdays > function ready(fn) { if (document.attachEvent ? document.readyState === "complete" : document.readyState !== "loading") { fn();…
April 24, 2018
Advocating for Better Physician Documentation: Do No Harm
By Erica E. Remer, MD, FACEP, CCDS
Early documentation instruction sorely lacking Last week, during ICD10monitor’s Talk Ten Tuesdays broadcast, Larry Field, DO, treasurer of the American College of Physician Advisors (ACPE), shared the tale of a relatively new hospitalist who was disenchanted with medicine and considering a transition into physician advising after only three years of…
April 24, 2018
Coding Mental and Behavioral Health Issues
By Rhonda Buckholtz, CPC, CPMA, CPC-I, CRC, CDEO, CHPSE, COPC, CPEDC, CGSC
Achieving accurate and comprehensive coding of such issues is an imperative. Mental and behavioral disorders have recently had a media spotlight shone on them, and coding of these disorders can sometimes be tricky. Learning the nuances can help achieve accurate coding, which will enhance data necessary to make improvements in…
April 24, 2018
Anxiety Builds Over Release of 2019 ICD-10-CM/PCS
By Laurie Johnson, MS, RHIA, CPC-H, FAHIMA, AHIMA-Approved ICD-10-CM/PCS Trainer
Anticipated schedule of the posting of new ICD-10 codes, including dates for public comment. Typically, after the annual Coordination and Maintenance Committee meeting, the next question is this: when will the new codes be published? The short answer is potentially near late April or early May. Final decisions regarding the…
April 24, 2018
Holistic Approach to CDI Appears Promising
By Glenn Krauss, RHIA, BBA, CCS, CCS-P, CPUR, CCDS, C-CDI, PCS, FCS, C-CDAM
Each patient’s story should be told in the official record. The clinical documentation integrity (CDI) profession has only scratched the surface of instilling positive change in patterns of physician documentation and communication of patient care. There exists a myriad of opportunities for CDI specialists to capitalize upon and truly improve…
She had chosen palliative care as the medical therapy. EDITOR’S NOTE: Former First Lady Barbara Bush died Tuesday at age 92 at her home in Houston, having decided to decline further medical treatment for health problems and instead to focus on “comfort care.” The ‘Great Man Theory’ of history was…
Women earn less than men in nearly every single occupation. Recently, I left my home base in southeastern Wisconsin and landed in the warm and humid landscape that is Orlando to attend Hospital Medicine 2018, hosted by the Society of Hospital Medicine. It’s a bit of a homecoming as this…
April 17, 2018
Coding-Clinical Disconnect: Type 2 Myocardial Infarction Part II
By Erica E. Remer, MD, FACEP, CCDS
CCD is when the typical and customary documentation of a condition does not line up with the available codes or the indexing. Last week, I discussed the Type 2 MI issue. This week, I will address the higher-level problem of the “coding-clinical disconnect,” which I am going to refer to…
April 17, 2018
Coding and Documenting Child Abuse and Neglect
By Laurie Johnson, MS, RHIA, CPC-H, FAHIMA, AHIMA-Approved ICD-10-CM/PCS Trainer
HIM coding can play a part in stopping the abuse and neglect of children Marking April as National Child Abuse Prevention Month, we note that the Center for Disease Control (CDC) reports that child abuse and neglect are significant public health issues in the United States. The CDC reports that…
April 17, 2018
Auditing Issues Uncovered in Physician Documentation: Part I
By Terry Fletcher, BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMSCS, CMCS, ACS-CA, SCP-CA, QMGC, QMCRC
It is highly recommended to self-audit first, internally, with qualified staff. EDITOR’S NOTE: This is the first in a four-part series on the importance of passing or failing an audit and avoiding being a red-flag to payers. One of the services I offer, aside from coding and billing education, is…
A recent study on gender wage discrepancy sheds new light on an old issue. EDITOR’S NOTE: Opinions expressed by ICD10monitor contributors are their own. Following the sea of knitted pink hats worn by some of the hundreds of thousands of women who took to the streets in cities across…
April 10, 2018
Coding-Clinical Disconnect Part I: Type 2 Myocardial Infarction
By Erica E. Remer, MD, FACEP, CCDS
Type 2 MI is not a coding construct. I received some correspondence regarding my Type 2 myocardial infarction article last week which prompted me to ponder the coding-clinical disconnect. Let us address the Type 2 MI concerns this week, and next week, I will tackle the broader picture. Historically, the…
April 10, 2018
ICD-10 Coding of Parkinson’s Disease: Code Carefully
By Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, AHIMA-Approved ICD-10-CM/PCS Trainer
This disease of the brain is the most common neurological disorder Parkinson’s awareness is being addressed tomorrow, April 11, as “World Parkinson’s Day,” also making April national Parkinson’s awareness month here in the U.S. As a neurodegenerative disease of the brain, which impacts an individual’s motor function, Parkinson’s Disease (PD)…
April 10, 2018
Coding Trigger Point Injections for Pain Management
By Deborah Grider, CPC, CPC-H, CPC-I, CPC-P, CPMA, CEMC, CCS-P, CDIP, Certified Clinical Documentation Improvement Practitioner
Review your payer policies when performing these services. Pain management coding can be tricky. Trigger point injection therapy is a common procedure performed by pain management specialists, orthopedic surgeons, physical medicine and rehab and other specialties. Trigger point injection therapy is used for the treatment of myofascial pain syndrome (MPS).…
Frustrations arise over inconsistent guidance from MACs and CMS. Every single day, I get numerous email notices from the Centers for Medicare & Medicaid Services (CMS) and the Medicare Administrative Contractor (MAC) for our jurisdiction on a wide variety of “priorities:” correct coding, quality measures, new reporting initiatives, and a…
The main burden for this change is on healthcare providers such as physicians, clinics, hospitals. The Centers for Medicare & Medicaid Services (CMS) will start issuing the new Medicare cards with the MBI (Medicare Beneficiary Identifier) number beginning April 1. The Social Security Number (SSN) based HICN (Health Insurance Claim…
April 3, 2018
C&M Meeting, Part II: Providers Urged to Comment on Proposals to CMS
By Laurie Johnson, MS, RHIA, CPC-H, FAHIMA, AHIMA-Approved ICD-10-CM/PCS Trainer
The ICD-10 code set is growing, and feedback from the medical community on the changes is needed. This is the second piece in a series of articles encompassing a review of the Coordination and Maintenance (C&M) Committee meeting held March 6 and 7, 2018. What follows is a review of…
Complicated coding of type 2 myocardial infarctions. Advancing technology often leads to evolution of medicine. As our laboratory studies become more sensitive, we need to evaluate what the clinical significance of a positive test is. Such is the case with troponin. In October 2012, the Third Universal Definition of Myocardial…
March 27, 2018
Continuing Struggle: Correct Code Assignment
By Rhonda Buckholtz, CPC, CPMA, CPC-I, CRC, CDEO, CHPSE, COPC, CPEDC, CGSC
Coders are encouraged to learn more about the clinical conditions associated with the patient encounters they are coding. As coders, we often struggle with assigning the correct codes. There are many gray areas in the guidelines and instructional notes, and sometimes even conflicting information can be found. This leads to…
March 27, 2018
C&M Meeting, Part I: The Latest Update on Procedure Code Proposals
By Laurie Johnson, MS, RHIA, CPC-H, FAHIMA, AHIMA-Approved ICD-10-CM/PCS Trainer
The ICD-10 code set is growing, and feedback from the medical community on the changes is needed. This is the first in a series of articles encompassing a review of the Coordination and Maintenance Committee meeting, which was held March 6 and 7, 2018. First, we will review the procedure…
March 27, 2018
UnitedHealthcare Begins Crackdown on Level 4 and 5 ED Codes
By Shannon DeConda CPC, CPC-I, CEMC, CMSCS, CPMA®
Three key takeaways from this effort by healthcare giant UnitedHealthcare UnitedHealthcare (UHC) is continuing its quest to revamp many facets of our healthcare industry. Last year, they adapted mandatory policies for the use of the SA modifier to indicate that a professional service was performed as incident-to, and now the…
March 20, 2018
2018 HIP Week Underway Nationally
By Melanie Endicott, MBA/HCM, RHIA, CDIP, CCS, CCS-P, FAHIMA, AHIMA-Approved ICD-10-CM/PCS Trainer
AHIMA is recognizing the contributions being made by healthcare information professionals throughout the country this week. The American Health Information Association (AHIMA) is celebrating health information professionals during the 29th annual Health Information Professionals (HIP) this week (March 18–24, 2018). Each year, HIP Week provides a platform to celebrate the…
March 20, 2018
ICD-10 C&M Meeting: Understanding the Spirit of the Code
By Laurie Johnson, MS, RHIA, CPC-H, FAHIMA, AHIMA-Approved ICD-10-CM/PCS Trainer
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…
March 20, 2018
Why CDI Often Times Goes off the Rails
By Glenn Krauss, RHIA, BBA, CCS, CCS-P, CPUR, CCDS, C-CDI, PCS, FCS, C-CDAM
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…
March 20, 2018
Get Set for SET: Supervised Exercise Therapy
By Terry Fletcher, BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMSCS, CMCS, ACS-CA, SCP-CA, QMGC, QMCRC
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…
March 13, 2018
No National Coverage Determination for Implanted Cardioverter Defibrillators
By Ronald Hirsch, MD, FACP, CHCQM
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…
March 13, 2018
News Alert: C & M Meeting: List of Requests for New Codes Smaller This Year
By Laurie A. McBrierty, MLT ASCP, CICA
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…
March 12, 2018
Adverse Effects or Poisoning? The Twin Horns of a Dilemma
By Erica E. Remer, MD, FACEP, CCDS
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…
March 6, 2018
A Long Journey: Origins of Social Workers as Social Determinants of Health
By Diane Iverson, RN, BSN, BS, ACM, CCM
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…
March 6, 2018
Implantable Cardioverter Defibrillators Now Require Shared Decision-Making
By Ronald Hirsch, MD, FACP, CHCQM
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…
March 6, 2018
Improving Risk Adjustment through Inpatient HCC Capture
By Michelle M. Wieczorek RN RHIT CPHQ
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…
February 27, 2018
Documenting Total Knee Replacements: A Different Approach
By Lisa Banker, MD, FACP
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…
February 27, 2018
Medical Coding: Generational Differences in a Remote Environment
By Sarah Laird, RHIA, CCS
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…
February 20, 2018
Great Future Ahead, Says New AHIMA President
By Diann Smith, MS, RHIA, CHP, FAHIMA AHIMA
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…
February 20, 2018
ICD-11 is Coming – Take Time to Adjust
By Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS, AHIMA-approved ICD-10-CM/PCS Trainer
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.…
February 20, 2018
Outpatient CDI Programs Grow as Hospitals Move to Value-based Care
By Glenn Krauss, RHIA, BBA, CCS, CCS-P, CPUR, CCDS, C-CDI, PCS, FCS, C-CDAM
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…
February 20, 2018
“Assumptive” Coding for Heart Disease – A Coder’s Perspective
By Terry Fletcher, BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMSCS, CMCS, ACS-CA, SCP-CA, QMGC, QMCRC
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…
February 13, 2018
How 2018 Impacts ICD-10-CM Cardiology Diagnosis Coding
By Terry Fletcher, BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMSCS, CMCS, ACS-CA, SCP-CA, QMGC, QMCRC
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…
February 13, 2018
How to Code the Flu in ICD-10
By Laurie Johnson, MS, RHIA, CPC-H, FAHIMA, AHIMA-Approved ICD-10-CM/PCS Trainer
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…
February 13, 2018
Three Key Initiatives for Improving Physician Education for CDI
By Terrance Govender, MD
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…
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…
February 6, 2018
February is American Heart Month – CMS Provides Resources for the Healthcare Community
By Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, AHIMA-Approved ICD-10-CM/PCS Trainer
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…
February 6, 2018
Hardwiring Excellence into Care Coordination
By Stefani Daniels, RN, MSNA, ACM, CMAC
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…
January 29, 2018
Mother of College Football Star Who Committed Suicide Speaks Out About CTE
By Karen Zegel
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…
January 29, 2018
Risks Associated with Critical Care Coding
By Deborah Grider, CPC, CPC-H, CPC-I, CPC-P, CPMA, CEMC, CCS-P, CDIP, Certified Clinical Documentation Improvement Practitioner
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…
January 29, 2018
Properly Coding Chronic Conditions Is Essential in Today’s Value-Based World
By Machaelle Diaz, CMA, CPC, CRC, CPMA, ICD-10CM, CGSC
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…
January 22, 2018
Exclusive: Guidelines on Internal Clinical Guidelines
By Erica E. Remer, MD, FACEP, CCDS
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…
January 22, 2018
Clinical Documentation and Coding: The Foundation of Healthcare
By Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, AHIMA-Approved ICD-10-CM/PCS Trainer
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.…
January 22, 2018
January 30: Stop CTE Awareness
By Laurie Johnson, MS, RHIA, CPC-H, FAHIMA, AHIMA-Approved ICD-10-CM/PCS Trainer
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…
January 16, 2018
A Call for Victory for HIM Professionals in 2018
By Bonnie S. Cassidy, MPA, RHIA, FAHIMA, FHIMSS
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…
January 15, 2018
Six New Year’s Resolutions for Coding and CDI Departments
By Michelle M. Wieczorek RN RHIT CPHQ
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,…
January 15, 2018
Why Most CDI Programs Fail to Engage Physicians
By Glenn Krauss, RHIA, BBA, CCS, CCS-P, CPUR, CCDS, C-CDI, PCS, FCS, C-CDAM
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…
January 15, 2018
CDI and Medical Necessity: Closing the Gap Could Prevent Denials
By Rhonda Buckholtz, CPC, CPMA, CPC-I, CRC, CDEO, CHPSE, COPC, CPEDC, CGSC
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.
Media
December 12, 2017
CDI: Is Your Toolkit Well Stocked?
By Glenn Krauss, RHIA, BBA, CCS, CCS-P, CPUR, CCDS, C-CDI, PCS, FCS, C-CDAM
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…
December 12, 2017
2018 Three Major Concerns Await Coders
By Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, AHIMA-Approved ICD-10-CM/PCS Trainer
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…
December 12, 2017
HIM’s Role in Revving up Revenue Integrity
By Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS, AHIMA-approved ICD-10-CM/PCS Trainer
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…
December 5, 2017
Puerto Rico’s Healthcare Industry Still Slowly Recovering from Maria’s Wrath
By Mark Spivey
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…
December 5, 2017
Alzheimer’s, Up Close and Personal
By Laurie Johnson, MS, RHIA, CPC-H, FAHIMA, AHIMA-Approved ICD-10-CM/PCS Trainer
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…
Media
December 5, 2017
Cardiovascular and Vascular Interventional Radiology Specialization Improves Coding Performance
By Kristi Pollard, RHIT, CCS, CPC, CIRCC, AHIMA-Approved ICD-10-CM/PCS Trainer
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…
December 5, 2017
E&M Coding and Documentation: CDI and Physician Buy-in
By Margaret A. Skurka, MS, RHIA, CCS, FAHIMA
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…
December 4, 2017
