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I want to begin this article with a scenario: say sepsis due to MRSA (methicillin-resistant Staphylococcus aureus) is documented by the clinician and ICD-10-CM code A41.02 is captured by the coder. Assume that there are no secondary diagnoses or procedures. This leads to the assignment of MS-DRG (Medicare Severity Diagnosis-Related…
The American Hospital Association’s (AHA’s) second-quarter Coding Clinic for ICD-10-CM/PCS offers key coding advice and code assignments. Reporting on highlights in the official publication that was released May 17 during the next edition of Talk Ten Tuesdays will be Nelly Leon-Chisen, director of coding and classification for the AHA.

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These days, when healthcare IT expert Stanley Nachimson sees a Volkswagen, he’s likely to think of the $155 million whistleblower settlement involving electronic health record (EHR) vendor eClinicalWorks (ECW) announced last week by the U.S. Department of Justice.In its announcement, the Justice Department reported that ECW, headquartered in Westborough, Mass.…
EDITOR’S NOTE: The following a part of a series on outpatient clinical documentation integrity (CDI). Part IV was published on May 16, 2017 in the ICD10monitor e-News.The medical record serves primarily as a physician’s communication tool for patients and all associated healthcare stakeholders. The effectiveness and completeness of the documentation…
EDITOR’S NOTE: The following is part one in a three-part series on outpatient clinical documentation integrity.There is a great push within the healthcare industry to move clinical documentation integrity (CDI) into the outpatient arena. People refer to this as “outpatient CDI,” but I think this is a misnomer. If you…
Las Vegas is best known for its casinos, crowds, and Celine Dion. But now the city can also be recognized for coding and clinical documentation improvement (CDI). Why?The American Association of Professional Coders (AAPC) and HCPro’s Association of Clinical Documentation Improvement Specialists (ACDIS) both convened in Las Vegas during the…
A study just out by researchers at the University of California’s San Francisco Medical Center reviewed more than 23,000 progress notes over an eight-month period and found that less than 15 percent constituted new and unique content. Residents were the worst offenders, with 88.2 percent of their text being copied…
The prevalence of malnutrition in the elderly hospitalized patient; the physical, social, and psychological factors contributing to it; the documentation, treatment, and coding of it; and its impact on outcomes will be our lead story in the next edition of Talk Ten Tuesdays. Charles Winans, MD will be reporting on…

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As a health information management (HIM) coding professional, I always anxiously await the quarterly publication of the American Hospital Association (AHA) Coding Clinic for ICD-10-CM/PCS.  This is something that should be on all coding professionals’ calendars each quarter, and we should all allocate time to read through the content, noting…
Be adaptable and ready for change if you are responsible for payer reimbursements in your healthcare organization. The Centers for Medicare & Medicaid Services (CMS) has announced a large number of changes to diagnosis-related groups DRGs for 2018, along with changes in ICD-10-CM and PCS. Here is a quick summary…
An estimated 20 percent of all healthcare claims in the U.S. are denied each year. The financial impact for some hospitals is estimated to be in the range of $250 million annually.When denials are appealed, success rates can vary from 55 to 98 percent.Some hospitals are moving from denial management…
We continue our series of discussions exploring malnutrition – specifically, undernutrition – in hospitalized patients in more depth. Our topic is malnutrition in the elderly hospitalized patient, including the documentation and coding of it, its impact on outcomes, its treatment, and its prevalence and the physical, social and psychological factors…
Together on Talk Ten Tuesdays for the first time during the next edition of the weekly Internet broadcast will be healthcare IT expert and former Centers for Medicare & Medicaid Services (CMS) official Stanley Nachimson and George Vancore, director of IT integration for Blue Cross Blue Shield Florida. 

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I want to begin with a coding scenario: sepsis and pneumonia are documented, and the coder captures these conditions and assigns MS-DRG 871 and APR-DRG 720 with severity of illness (SOI) 2.  Sepsis presents challenges for coders as well as clinicians. I want to provide insight into the complex molecular…
Much attention and dedicated work have been devoted toward clinical documentation improvement and accurate, specific coding. Clearly, those are of great importance. However, I want to address the physician Part B insurance denials that have nothing to do with how good the clinical documentation is and how accurate the coding…
Recently, Dr. Joseph Cristiano did a Talk Ten Tuesdays DocTalk segment on his experience educating residents on clinical documentation at Wake Forest University. We received a follow-up question from Suzanne, so I am focusing this article on more details about resident training. During my stint as physician advisor (PA) at…
EDITOR’S NOTE: The following is part of a series on outpatient clinical documentation integrity (CDI). Part III was published on May 9, 2017 in the ICD10monitor eNews.Outpatient CDI specialists must first and foremost exhibit the mindset and display characteristics of a businessperson. This individual should be capable of identifying, developing,…
Well-respected coding authority Laudine Markovchick, manager of coding and learning and development for H.I.M. On CALL, Inc., will report our lead story on the rising number of denied claims under ICD-10 during the next edition of Talk Ten Tuesdays. The issue of claim denials is impacting cash flow and revenue…

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Providers, nurses, clinical care specialists, health information management (HIM) and utilization review professionals, clinical coders, and clinical documentation integrity specialists (CDISs) are all key to ensuring the integrity of coding, which is an essential requirement in denials mitigation. Collaboration is the theme of my presentation at the American Academy of…
Now that ICD-10 has been with us a while, the most frustrating tasks that hospitals are dealing with are claims denials. Whether for line items or entire stays, they present significant challenges as it pertains to revenue and resources. Does your facility have the proper process in place to handle…
The Centers for Medicare & Medicaid Services (CMS) and third-party auditors are going after sepsis admissions for which patients are discharged within 72 hours. It may seem preposterous, from the hospital’s perspective, that they are being allegedly unfairly targeted for payment denials for sepsis admissions. But is this actually the…
EDITOR’S NOTE: The following a part of a series on outpatient clinical documentation integrity (CDI). Part II was published on April 25, 2017 in the ICD10monitor eNews.Critical to the successful rollout of an outpatient clinical documentation improvement (CDI) program is the selection and hiring of employees to staff the program.…
The complex and complicated diagnosis of sepsis is still cofounding many in healthcare. But there’s new hope for a better understanding of sepsis. During what is expected to be a remarkable broadcast, Talk Ten Tuesdays special guest Dr. Wilbur Lo will discuss the disease at a molecular and cellular level…

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There is good news and bad tucked away in the details of the 2018 proposed Inpatient Prospective Payment System (IPPS) Final Rule released last week by the Centers for Medicare & Medicaid Services (CMS).Some acute-care hospitals could see a decrease in their case mix index (CMI), as a number of…
EDITOR’S NOTE: The following is a physician’s perspective on the Sandy Brewton article, “LHC vs Coronary Angiography: Take Heart When Coding.”I was one of those physicians who once thought a left heart catheterization was done with the coronary artery angiography procedure. That’s because, in the strictest, semantic sense of the…
Is your provider performing a left heart catheterization every time a coronary angiography is performed? Are you coding a left heart catheterization procedure code every time you code coronary angiography procedures? Can coronary angiography be performed without a left heart catheterization? If you are unable to answer these questions with…
As we reflect on the transformation into spring, with large parts of the country still confronted by temperatures in the mid-30s at night and days when temperatures creep up into the high 70s, we are reminded of the profound disparity that was created between physicians and coders when the Society…
Why is concept of medical necessity a conundrum to so many physicians, coders, and clinical documentation integrity specialists? Why does medical necessity continue to trigger audits? 

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Medical necessity is an important issue. Just review the definition of medical necessity: “a legal doctrine, related to activities which may be justified as reasonable, necessary, and/or appropriate, based on evidence-based clinical standards of care.” So, what does that really mean? A few years ago, I was preparing to speak…
EDITOR’S NOTE: The following a part of a series on outpatient clinical documentation integrity (CDI). Part I was published on April 11, 2017 in the ICD10monitor eNews.The first article of this series provided an overview, identifying and singling out key shortcomings and pitfalls of current programs. This article will focus…
Medical necessity is the concept that healthcare services and supplies must be necessary and appropriate for the evaluation and management of a given disease, condition, illness, or injury. The care must be considered reasonable when judged against current medical standards of care. But clinicians know that guidelines are really not…
I am a physician who writes and edits guidelines designed to assist in determining appropriate utilization of clinical resources. In a nutshell, the issue that pertains to today’s topic, medical necessity, is “unexplained clinical variation in care.”What I mean by that is the fact that patients with similar clinical features…
In the April 22 run-up to Earth Day, Talk Ten Tuesdays recognizes the link between global warning and the physical and mental health of Americans—particularly healthcare professionals. Reporting on this link will be nationally prominent psychiatrist H. Steven Moffic, MD. Dr. Moffic has written extensively about physician burnout and in…

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The Centers for Medicare and Medicaid Services (CMS) has released an update to the ICD-10 and Quality Measures website. The home page covers ambulatory surgical centers, hospital inpatient and outpatient, Centers for Disease Control (CDC) and National Healthcare Safety Network (NHSN) Surgical Site Infections (SSI) Measures, CMS outcome and payment…
I am fortunate to work for a company that begins each of its meetings with the reading of its corporate mission statement, setting the tone for the ensuing discussion. In our tradition of aligning principle and practice, I would like to share the Novant mission statement that will guide this…
EDITOR’S NOTE: This is the second in a two-part series on the subject of secondary diagnosis.Related to last week’s discussion on the Uniform Hospital Discharge Data Set (UHDDS), the more pressing question is what to do with a relevant condition that is a preexisting comorbidity but is not necessarily evaluated,…
EDITOR’S NOTE: The following article was prepared for “Climate Prayer Vigil: City Hall, Milwaukee, Jan. 20, 2017. In the run up to Earth Day, April 22, 2017, Dr. Moffic granted ICD10monitor permission to reproduce this article. Moffic is scheduled to speak on this subject on Talk Ten Tuesdays, April 18.Last…
Ambulatory clinical documentation integrity (CDI) is not simply CDI in the outpatient setting, as you will learn during the next edition of Talk Ten Tuesdays. We have three reports on why the two must be approached differently. Leading the discussion will be Dr. James Kennedy, one of the nation’s frontrunners…

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There has been a wide array of discussion through published articles, forums, webinars, and meetings about the topic of outpatient clinical documentation improvement (CDI) programs. Outpatient CDI is receiving much attention and experiencing traction in the healthcare industry due to providers coming to terms with the fact that documentation truly…
Consider the following scenario: A 25-year-old female presents to the ED with RLQ pain, onset three days ago. She reports that the pain is aggravated by palpation. She had just returned from a visit out of the country when she developed nausea with vomiting and fever. On admission, the patient…
EDITOR’S NOTE: This is the first in a two-part series on the subject of secondary diagnosis. I have read a lot of literature regarding secondary diagnoses, and the typical dogma is that a condition must meet one of the following criteria to be considered codable, according to the ICD-10-CM Official…
First, I want to clarify something about a term used by Medicare for healthcare providers. Value-based purchasing, or VBP, can sound like a good idea unless you realize that it’s actually the purchaser getting the value, along with the Medicare program, and not the provider or patient. It would be…
Are claim rejections impacting reimbursement at your facility? Is your facility experiencing the consequential reduction in revenue stream since the advent of ICD-10?

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One of the most basic of human rights is healthcare. When we talk about documenting appropriately in healthcare, we must keep in mind that documentation is the second step in the process. The first step is the collection of information through subjective discussions with our patients. We, as providers, must…
The Coordination and Maintenance Committee Meeting was held March 7-8 at the Centers for Medicare & Medicaid Services (CMS) headquarters for the purposes of reviewing proposals for new ICD-10-CM (diagnosis) and ICD-10-PCS (procedures) codes for the 2018 and 2019 fiscal years.Comments on the proposals for 2018 are due April 7,…
The definition of a principal procedure is part of the Uniform Hospital Discharge Data Set (UHDDS): the standard set of data elements used for inpatient billing and statistical information. It is also included in some of the core measures from the Centers for Medicare & Medicaid Services (CMS) and the…
EDITOR’S NOTE: Monica Greene came to our attention during a Jan. 13, 2015 edition of ICD10monitor’s Talk Ten Tuesdays. The subject of that broadcast was gender identity disorder, prompted in part by the emerging national consciousness regarding the transgendered population. The LGBTQ community continues to make news, and recently, the…
Now more than ever, it’s important that healthcare and health information management (HIM) professionals work to create a healthcare environment that is non-judgmental and welcoming to patients of all backgrounds. Providers everywhere are seeking ways to ensure that all patients have appropriate resources and documentation.

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One subject brought up several weeks ago on an edition of Talk Ten Tuesdays was the sequencing of J44.0, chronic obstructive pulmonary disease (COPD), with acute lower respiratory infection and pneumonia. Guest Stacey Elliot referred to the Coding Clinic from the third quarter of 2016, which says: “based on the…
Every two years, one of the most interesting perspectives on medicine in America is published by the Physicians Foundation via its biennial physician survey.In the 2016 survey, 17,236 physicians responded to a wide variety of questions about their practice, the state of the healthcare industry, and perspectives on specific topics,…
It is estimated that 80 percent of Americans report back pain at one time or another, and treatment for such issues comes at a cost of $50 billion annually. Roughly 40 percent of those with back pain seek help from a primary care physician; another 40 percent see a chiropractor,…
Now more than ever, it’s critically important that medical and health information management (HIM) professionals work to create a healthcare environment that is non-judgmental and welcoming to patients of all backgrounds, according to a recent practice brief published by the American Health Information Association (AHIMA), the subject of which will…
Who should be involved in residency education? Special guest Dr. Joseph A. Cristiano, a hospitalist at Wake Forest Baptist Medical Center in Winston-Salem, N.C., will make the case for clinical documentation integrity (CDI) leaders during the next edition of Talk Ten Tuesdays. Dr. Cristiano, who has been involved in improving…

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March 17, 2017

ICD10 eNews

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The Coordination and Maintenance (C&M) Committee Meeting was held March 7 and 8 at the Centers for Medicare & Medicaid Services (CMS) headquarters, for the purposes of reviewing proposals for new ICD-10-CM (diagnosis) and ICD-10-PCS (procedures) for fiscal years 2018 and 2019. The agenda was full and required two full…
EDITOR’S NOTE: The following is the last installment in a two-part series on the Uniform Hospital Discharge Data Set.Assigning secondary or “other” diagnoses was a source of confusion in ICD-9 and remains so in ICD-10 today. The Uniform Hospital Discharge Data Set, or UHDDS, is used for reporting inpatient data…
EDITOR’S NOTE: During a recent edition of Talk Ten Tuesdays, Dr. Erica Remer responded to a listener’s question about clinical documentation integrity specialist (CDIS) working remotely. Here is Dr. Remer’s response. As I tell residents, historically, charting and chart review was done on the floor, because that’s where the chart…
EDITOR’S NOTE: Matthew Albright oversaw the certification program at the Center for Affordable Quality Healthcare (CAQH) and Committee on Operating Rules for Information Exchange (CORE) to ensure conformance with the requirements of the Patient Protection and Affordable Care Act (PPACA). He also served as Director of the Administrative Simplification Group…
For comprehensive news and analysis on the recent ICD-10 Coordination and Maintenance Committee (C&M) meeting this past week at the Centers for Medicare & Medicaid Services (CMS) headquarters in Baltimore, be sure to listen to the next edition of Talk Ten Tuesdays: reporting on the two-day meeting will be Gloryanne…

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Now that Secretary Tom Price has been confirmed to head the U.S. Department of Health and Human Services (HHS), other cabinet-level nominees are continuing through the confirmation process. Seema Verma was approved by a Senate committee and is expected to be confirmed by the full Senate as the next Centers…
EDITOR’S NOTE: This is the first in an ongoing series of articles about proposed code changes to the ICD-10-CM/PCS code set that will be published here by Bryant and other contributing editors at ICD10monitor.The ICD-10-CM/PCS Coordination and Maintenance (C&M) Committee met this past week, and there were lots of proposed…
EDITOR’S NOTE: The following is the first in a two-part series on the Uniform Hospital Discharge Data Set.Assigning secondary or “other” diagnoses was a source of confusion in ICD-9 and remains so in ICD-10 today. The Uniform Hospital Discharge Data Set, or UHDDS, is used for reporting inpatient data in…
Twice a year, at the ICD-10-CM Coordination and Maintenance Committee meetings, new codes are discussed and proposed for implementation. Many organizations attend in person to support submissions, often from physician specialty organizations and coding organizations. It’s your chance to make comments and review how these submissions might affect your facility…
The federal ICD-10 Coordination and Maintenance Committee (C&M) will meet this coming Tuesday and Wednesday, March 7 and 8, to discuss proposals for diagnosis code topics. The meeting will be led by the Centers for Disease Control and Prevention (CDC). National correspondent Laurie Johnson will be reporting live from the…

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Many, many years ago, I was working on a clinical documentation (CDI) implementation project at an acute-care facility when I stumbled on what would be a huge impasse in capturing “acute renal failure” (nowadays it’s more appropriately called acute kidney injury, or AKI). There appeared to be a huge difference…
Mumps has been in the news for several years, but is it really occurring more often these days? Mumps is a viral infection that affects the salivary and parotid glands and mostly occurs in children. The disease spreads through infected saliva by sneezing, coughing, sharing drinks, or touching contaminated surfaces.…
With more than a year of ICD-10-CM/PCS experience under their belts, coding managers have begun to turn their attention toward fine-tuning coder education. They’re using audit results to identify knowledge gaps and provide targeted training to enhance coding quality. Basic refresher training as well as education about code updates are…
EDITOR’S NOTE: This article focuses on physician engagement and ICD-10 education. However, the term “physician” includes everyone licensed and credentialed to record a patient diagnosis, such as wound care and other clinical staff.   St. Joseph’s Healthcare System (SJHS)in Paterson and Wayne, N.J. is truly an ICD-10 success story. Under…
The federal ICD-10 Coordination and Maintenance Committee (C&M) is scheduled to meet Wednesday, March 8 to discuss proposals for diagnosis code topics, with the conversation to be led by the Centers for Disease Control and Prevention (CDC). For a report on what to expect from the C&M meeting, join Chuck…

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What does a doctor or other provider know about clinical documentation and integrity? What does a surgeon know? Why is it important? How do surgeons get to where they need to be, and how do we help our surgeons get there? Malnutrition, generally interpreted as undernutrition (although strictly speaking, overnutrition…
The Centers for Medicare & Medicaid Services (CMS) performs diagnosis-related group (DRG) validation to ensure that reported diagnostic, procedural, and discharge status information matches both the attending’s description and the information contained within the beneficiary’s health record. CMS auditors are instructed to validate the principal diagnosis, secondary diagnoses, and procedures…
February 24, 2017

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Free eNews Sign-Up   ICD10monitor e-News is published each Tuesday and delivered right to your email box. With your ICD10monitor subscription you receive the latest news, information and resources on ICD-10 and its impact on coding, clinical documentation improvement and the revenue cycle. Plus, you’ll receive news alerts and special…
EDITOR’S NOTE: What follows is the second piece of a two-part series examining how health risk, severity, and complexity impact healthcare policy, payment, and quality assessment. There are currently many different risk adjustment models in use or under consideration in the healthcare industry. Each model has advantages and disadvantages. It…
It's been a year since the "sepsis-3" definition was released at the Society of Critical Care Medicine (SCCM) meeting and concurrently published in the Journal of the American Medical Association (JAMA). This definition quickly found itself at the intersection of clinical care, Centers for Medicare & Medicaid Services (CMS) quality…
Emerging new payment methodologies are focusing renewed attention on achieving coding quality and accuracy to ensure data integrity. And data integrity drives quality reporting, research, and ultimately, outcomes. During the next edition of Talk Ten Tuesdays with Chuck Buck and Erica Remer, MD, you’ll hear robust points of view on…

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Coded data represents the foundational elements for healthcare decision-making, research, quality of care, monitoring of population health, pay for performance, payment, disease management, clinical registries, fraud and abuse monitoring and identification, and injury monitoring. These few words are similar to those I provided in April 1996, when I gave testimony…
Documentation should paint a picture of the patient’s condition. Medical necessity drives every patient encounter. In fact, the Comprehensive Error Rate Testing Program (CERT) states that “medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code." Diagnosis coding is…
EDITOR’S NOTE: What follows is the first of a two-part series examining how health risk, severity, and complexity impact healthcare policy, payment, and quality assessment.   There is little doubt that healthcare policy is moving away from a service-centric model towards a value-centric model. An article in the New England Journal…
First, let me say that I understand. My nursing life was spent in busy emergency departments as a trauma nurse. I understand distracting injuries. I understand the need to rule out occult injuries. That being said, far too many emergency department orders for diagnostic imaging have zero indications other than…
Join Chuck Buck and Erica Remer, MD as they welcome one of the forerunners of clinical documentation integrity (CDI) during the next edition of Talk Ten Tuesdays: Pamela Bensen, an early adopter and the founding president of the American Society of Medical Advisors, which merged with the American College of…

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With the enormous volume of reporting during recent years on the nation’s healthcare industry implementing the ICD-10 code set, one might conclude that the subject is now old news. After all, ICD10monitor began its coverage of the migration from ICD-9 to ICD-10 in 2011, via both its website as well…
The excitement and anxiety about risk adjustment in the healthcare industry is growing on a daily basis, and we are hearing tremendous hopes to learn and gain new expertise about the shift from fee-for-service (or volume-based) to fee-for-value (or value-based) reimbursement. Everyone in today’s healthcare organizations is feeling an increased…
Whenever articles about coding appeals are written, they always seem to be about the facility or provider not getting paid – but have you ever wondered how it impacts a patient when the proper codes are not utilized? Consider this example: a nursing school patient fell at school and initially…
EDITOR’S NOTE: On the occasion of Valentine’s Day, ICD10monitor is publishing an interview conducted recently by Publisher Chuck Buck with nationally prominent psychiatrist H. Steven Moffic, MD – whose only request was that the interview be dedicated to his wife Rusti. Excerpts from the interview follow.Buck: Let’s talk about love!Moffic:…
Excludes1 and Excludes2 notes challenge coding and clinical documentation improvement (CDI) professionals, given the seemingly endlessly conflicting definitions of these terms and the recent ICD-10-CM guidelines. Who decides if conditions are related or not, the coder or the doctor? Must the physician explicitly document that they are not related? Or…

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Thursday, February 23, 2017 1:30-2:30 PM ET 12:30-1:30 PM CT 10:30-11:30 AM PT

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