Search results
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.

Media

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.

Media

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.

Media

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 –…

Media

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.

Media

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…

Media

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…
Painful to recall, yet now burned into the nation’s consciousness, are the gruesome scenes and sounds from last Sunday night’s shooting massacre during an outdoor music festival in Las Vegas, an event that left 59 dead and more than 500 injured.

Media

Puerto Rico hospitals continue to struggle in the aftermath of Hurricane Maria.Reporting that only nine of 61 hospitals in Puerto Rico have electric power, a hospital billing company representative told Talk-Ten-Tuesdays listeners this past Tuesday that the lack of electricity is one of the biggest problems residents of the U.S.…
ICD10monitor is producing a two-day series of broadcasts featuring industry thought leaders presenting at the AHIMA 2017 Conference in Los Angeles next week.ICD10monitor will be broadcasting live from the American Health Information Management (AHIMA) 2017 Conference in Los Angeles next week, with a long lineup of subject matter experts scheduled…
Artificial intelligence is poised to be the next big revolution in healthcare. Are you ready?There isn’t a day that goes by without a story in the news on artificial intelligence, or AI, as we’ve come to know it. From Amazon’s Alexa and Samsung’s Bixby, to Apple’s Siri and IBM’s Watson,…
Now that the compliance deadline for implementing ICD-10 codes has passed, ICD-11 is already on the horizon. For the very latest news on this development, be sure to listen to the upcoming edition of Talk Ten Tuesdays, when Robert Jakob with the World Health Organization (WHO) will provide you with…

Media

A comprehensive look at how clinical documentation improvement and the actual practice of medicine overlap.There are a multitude of business and ancillary healthcare processes that serve to support the practice of medicine. That practice centers on direct patient care, facilitated and dependent upon specific synergistic processes that contribute to cost-effective,…
MACRA continues to be a subject that perplexes providers even as the program evolves.It has been recently confirmed that the Comprehensive Care for Joint Replacement (CJR) bundled payment has been cut from 67 to 34 percent in the program, and the carding rehabilitation incentive with bundled payments has been cancelled.…
October 3, 2017

AHIMA 2017

By

Media

Toting boxes filled with plaques, awards, and photos earned from decades of professional advocacy, speaking, writing, and volunteer work in the field of health information management (HIM), Gloryanne Bryant soon will gather her personal effects, take the elevator from her Oakland-based Kaiser Permanente (KP) office down to the lobby, and…
A new set of codes for blindness and low vision was recently released, and with that brings many changes for documentation and coding. The codes are effective Oct. 1, 2017and come as a result of a campaign by the World Health Organization (WHO), which in 2013 advocated for greater clarity…

Media

Senate Republicans will not vote to repeal and replace Obamacare. Congress must still deal with many other healthcare initiatives before Sept. 30. Who doesn’t love a good to-do list? But when it comes to what Congress is looking to accomplish in September, let alone before the end of the year,…
Hospital CDI managers always look for process improvement. Essentia Health’s outpatient CDI operation provides a practical case study. EDITOR’S NOTE: This the final installment in a two-part series on the clinical documentation integrity department at Essentia Health, a health system that serves Minnesota, Wisconsin, North Dakota, and Idaho.Becker’s Hospital Review…
ICD-10 codes for blindness and low vision are effective Oct. 1, 2017 and reflect parameters from the World Health Organization (WHO). A new set of codes was released for use beginning on Oct. 1, 2017. The category, H54, includes codes for blindness and low vision and with that brings many…
New developments in interoperability and mobile health technology were presented at the Translational Medicine Conference in Northern Ireland where the new Patient Buddy app was revealed. I attended the innovative eighth annual Translational Medicine Conference (http://www.c-tric.com/wp-content/uploads/2017/09/c-tric_conferenceprogramme_tmed8_v19w.pdf) this past week in Derry/Londonderry, Northern Ireland, an event hosted by the Clinical Translational…
EDITOR’S NOTE: As the floodwaters caused by Hurricanes Irma and Harvey recede, anxiety is expected to rise as residents in impacted cities and states recover. Some even could experience post-traumatic stress syndrome (PTSD). During the past two weeks, H. Steven Moffic, a former resident of Houston, has been closely monitoring…
Tens of thousands of Americans are now living in shelters.

Media

Much was covered during the ICD-10 Coordination and Maintenance Committee (C&M) meeting last week at the Centers for Medicare & Medicaid Services (CMS) headquarters in Baltimore.The first striking item was that there were no procedure proposals made during this meeting. There was discussion about three root operations – creation, control,…
EDITOR’S NOTE: This is the second installment in a two-part series on the coding and documenting of social determinants of health (SDoH). It comes on the heels of the aftermath of Hurricanes Harvey and Irma and their impact on victims and survivors in the flood-ravaged states of Texas and Florida.The…
EDITOR’S NOTE: During a recent Talk Ten Tuesdays, Candice, a listener, asked Erica Remer, MD a question about pyloromyotomy root operation. Dr. Remer’s response appears below.Paraphrased, the question posed centered on the notion that references previously recommended using dilation as a root operation because the intent of pyloromyotomy is to…
In the coding and clinical documentation community, we are still trying to sort out sepsis. In my previous article on this topic (https://www.icd10monitor.com/sepsis-then-and-now-how-the-oldest-disease-continues-to-plague-providers-part-ii), I made some recommendations on how to approach sepsis. We need to revisit this.We have now had some time to live with the Sepsis-3 criteria, established by…
EDITOR’S NOTE: This the first in a two-part series on the clinical documentation integrity department at Essentia Health, a health system that serves Minnesota, Wisconsin, North Dakota, and Idaho.Previously, Essentia Health’s clinical documentation improvement (CDI) department consisted of three segregated, separated, regional teams. Employees had minimal interaction with each other.…
EDITOR’S NOTE: This is the first in a two-part series on the coding and documenting of social determinants of health (SdoH). It comes on the heels of the aftermath of Hurricanes Harvey and Irma and their impact on victims and survivors in the flood-ravaged cities of Texas and Florida. Hurricanes…
Now it’s just a little less than three weeks until the beginning of October and when the fiscal year (FY) 2018 changes for ICD-10-CM take effect.  Here is a summary of the new changes for ICD-10-CM: 360 new code additions 142 deletions 250+ revisions The Centers for Medicare and Medicaid…
The next big milestone for ICD-10 is the Coordination and Maintenance Committee meeting in Baltimore this coming Tuesday and Wednesday. The two-day meeting will cover the latest requests for diagnosis and procedure codes. Monitoring and reporting on the meeting during the next edition of Talk Ten Tuesdays will be Gloryanne…

Media

EDITOR’S NOTE: At this hour Laurie Johnson is at the Fort Lauderdale Airport awaiting a Southwest Airline flight that is expected to return her tonight to Pittsburgh, Pa.BOCA RATON---Have you ever experienced preparations for a hurricane in a health information management (HIM) department? I just recently added this experience to…
The outpatient clinical documentation program at Essentia Health will be the subject of a special report during the next edition of Talk Ten Tuesdays. Discussing how the department is organized and staffed will be Tracy Boldt, the system’s manager. Essentia is an integrated health system serving patients in Minnesota, Wisconsin,…

Media

Today my thoughts go out to the people of Texas, especially the first responders and caregivers and all of those being impacted by Hurricane Harvey. Harvey made landfall in Texas on Friday night as the strongest hurricane to hit the U.S. in more than a decade, and because it has…
This is the year of many Centers for Medicare & Medicaid Services (CMS) regulatory requirement changes. This includes the Merit-Based Incentive Program (MIPS), the next steps toward mandatory Authorized Use Criteria (AUC) implementation for advanced imaging, defining more explicitly what is and what is not “quality” care, etc.  It is…
Last week Tracy Boldt contacted me to ask a question about outpatient clinical documentation integrity (CDI), and we are lucky to have her on the Talk-Ten-Tuesdays broadcast today, detailing Essentia Health’s successful outpatient CDI program. She also mentioned that she had been awaiting the third installment of my three-part series…
A recent conversation with a fellow clinical documentation integrity (CDI) specialist about the role of the profession as it pertains to enhancing and affecting positive change in communication of patient care by transitioning to a more holistic approach really struck a chord in me – and it made me question…
For my last article, I wrote about unexplained clinical variation as it pertains to surgical procedures. Today I continue exploring this theme.For men with low-risk prostate cancer, randomized controlled trials have found that active treatment such as radiation or prostatectomy does not improve mortality rates as compared to an initial…
Upon seeing signature attestations of medical scribes on client documents, I became curious as to their duties and training. I was interested in exploring a way in which they may contribute to the goal of clinical documentation improvement (CDI) programs. Since scribes can be employed in any healthcare environment or…
It’s that magical time of year for parents everywhere: back-to-school time. With a return to school comes a flurry of activity and planning and, in addition to obtaining school supplies and new clothes, parents must begin figuring out what their kids are going to eat for lunch. Whether that lunch…
EDITOR’S NOTE: The following is the third and final installment in a three-part series by Dr. Remer on outpatient clinical documentation integrity.In the first two parts of this series, we talked about risk adjustment in general, the shift to population health management, and how quality metrics and reimbursement are linked…
Approximately every five years, the American College of Cardiology, the American Heart Association, the European Society of Cardiology, and the World Heart Federation convene workgroups to try to standardize the definition of myocardial infarction (MI) for both documentation and research purposes.  The last iteration in 2012 produced five different classifications.The…
Join Chuck Buck and Erica Remer, MD, program hosts of Talk Ten Tuesdays, when they welcome Adele Towers, MD to the next edition of the weekly Internet broadcast.  

Media

August 16, 2017

Events Calendar

By
I am in the middle of a heads-down project, but I popped my head up long enough to read the new ICD-10-CM guidelines for 2018 (thanks for the notification, Gloryanne Bryant!). I had to take a moment to comment on the Type 2 myocardial infarction (MI) guidelines.The reasons we should…
The August heat is upon us here in the nation’s capital, and lawmakers have left town for their summer recess. The Senate was able to tie up some loose ends before leaving, including the passage of the Food and Drug Administration Reauthorization Act (FDARA), while leaving uncertainty regarding the reauthorization…
There is an unexplained geographic variation in how often patients are admitted to inpatient hospital care for a given diagnosis, with significant variation identified independent of patient age, insurance coverage, or clinical severity of illness. There is an equally important means by which to measure this variation: how often preference-sensitive…
EDITOR’S NOTE: The acronyms MINOCA (myocardial infarction with non-obstructive coronary arteries) and INOCA (ischemia and no obstructive coronary artery disease) recently have come into use in the healthcare industry. ICD10monitor publisher Chuck Buck caught up to and addressed this topic with board-certified cardiologist Stephen Sokolyk, a graduate of University of…
Two developing stories will be reported during the next edition of Talk Ten Tuesdays. 

Media

Just released on Thursday, Aug. 10 are the Official ICD-10-CM/PCS Coding and Reporting Guidelines for the 2018 fiscal year, totaling 117 pages. The National Center for Health Statistics, via the CDC (Centers for Disease Control and Prevention), has posted the guidelines on its website here: https://www.cdc.gov/nchs/data/icd/10cmguidelines_fy2018_final.pdf.Readers should note that the…
Are the current evaluation and management (E&M) documentation guidelines outdated and burdensome? Evidently, the Centers for Medicare & Medicaid Services (CMS) thinks so.

Media

Last month, the American Health Information Management Association (AHIMA) released a practice brief titled “Impact of Physician Engagement on Clinical Documentation Improvement Programs.” The brief contains some extremely valid and interesting points. Genuine, consistent physician engagement is essential for any clinical documentation improvement program meant to achieve scale and long-term…
There is a 2003 Academy Award-winning movie called Lost in Translation, and that title reminds me of the topic of healthcare claims denial management. Let’s discuss medication and administrative denials. When medication is denied, it can be a costly reimbursement problem for whoever is submitting the appeal. These should be…
Medicare celebrated its birthday on July 30. It was 52 years ago, on the morning of July 30, 1965, that President Lyndon Johnson signed the four-inch-thick Medicare bill into law after it had undergone more than 500 amendments during its passage through the House and Senate. The bill was signed…
It's apparent that the traditional fee-for-service model for reimbursement cannot be sustained. New concepts have been introduced in the industry and some have "died on the vine,” others such as bundled payments are evolving, and new models have erupted, such as those outlined in the Medicare Access and Chip Reauthorization…
The third-quarter 2017 issue of AHA’s (the American Hospital Association’s) Coding Clinic for ICD-10-CM/PCS has been released, and during the next edition of Talk Ten Tuesdays, Gloryanne Bryant will report on its significance and why it’s good news to have this publication earlier than usual.

Media

EDITOR’S NOTE: The following is an outline of a presentation by author Bonnie S. Cassidy scheduled to take place at the American Health Information Management Association (AHIMA) “Advancing the Documentation Journey” Summit, which began Monday, July 31 and continues today, Tuesday, August 1 in Washington, D.C.During my presentation yesterday at…
There is a widespread belief in many circles that if you have enough data, you should be able to derive some meaningful knowledge from it. The healthcare industry has struggled for years trying to get meaningful cross-enterprise information that provides consistent, shareable, and actionable knowledge to guide improvement. This has…
EDITOR’S NOTE: Janice Tarlecki, MBA, RHIA, CCS, is the director of advanced education at Ciox Health. Janice has over 14 years of health information management experience (HIM) experience, with concentrations in acute-care coding, clinical documentation integrity (CDI), recovery audit appeals, coder development, and coder performance improvement. ICD10monitor publisher Chuck Buck…