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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

realmagnet

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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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With millions of rural Americans at risk of losing health insurance and direct access to care, an unprecedented number of National Rural Health Association (NRHA) members will descend upon Washington, D.C. today to advocate for preserving healthcare access and delivery of services.    Among those attending the NRHA Policy Institute…
Correction:Hierarchical Condition Categories (HCCs) have been a part of our coding, documentation, and reimbursement landscape since their implementation by Medicare in 2004. HCCs were initially put into place by the Centers for Medicare & Medicaid Services (CMS) to provide accurate and timely capture of data, but also to track a…
Approximately three million people suffer from glaucoma in the United States. There is no cure at the present time, but there are treatment options. The options can include anything from medication (eye drops) to various types of surgery. Glaucoma is actually a group of eye diseases that damage the optic…
EDITOR’S NOTE: This is the second and final installment in a two-part series on OB coding. Part I appeared in the Jan. 31, 2017 edition of ICD10monitor news.It is easy to identify an obstetrics inpatient who has delivered a child from the codes on her abstract. The primary diagnosis (PD) is always…
February 1, 2017

Optum360

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Obstetricians and nurse midwives document solely to communicate with each other through their unique alphabet soup of abbreviations. No wonder OB coding is extremely challenging. And since there is no implied delivery in the ICD-10-CM code, it is very important to indicate that a delivery was performed or you might…

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To quote Robert F. Kennedy, “There are those that look at things the way they are, and ask ‘why?’ I dream of things that never were, and ask ‘why not?’”Coders are experts at scanning provider documentation and assigning codes. My approach to chart review is to try to piece together…
During the Jan. 11 Talk Ten Tuesdays broadcast, I talked about the five most expensive conditions and the clinical documentation integrity opportunities associated with them. My topic for this article is the connection between data and population health based on an article by Dr. Anil Jain in Hospitals and Health…
Oct. 1, 2016 brought a very large update to our ICD-10-CM coding system, as everyone is well aware. There were many new codes. Codes that existed in the previous system but lacked specificity were deleted and new codes with much higher levels of detail were added for us.Many of the…
Comprehensive yet pertinent documentation is critical within the medical record.  Beyond data and insight being shared among medical providers caring for a patient, good documentation also allows for accurate representation of patient severity in quality data and appropriate coding, billing, and reimbursement.Clinical documentation improvement (CDI) queries are a critical tool…
January 30, 2017

H.I.M. ON CALL

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The Hierarchical Condition Categories or HCCs are the new reimbursement methodology to which you must quickly adapt as an HIM professional. HCCs are different than DRGs and E&M levels. You need to know how they are different and what documentation qualifies to be used for assigning codes for claims. You…
This is the start of my third year as a physician advisor, after leaving a decade of clinical medicine as a pediatric hospitalist.  Moving from a career I essentially prepared for my entire adult life, into a career I did not even know existed the month before I was hired,…
Of all the stories recently published on ICD10monitor, the one that has been generating plenty of buzz is last Tuesday's feature article on septic shock by Allen Frady, an education specialist for Association of Clinical Documentation Improvement Specialists (ACDIS). Frady will join the Talk Ten Tuesdays broadcast this coming Tuesday…

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As healthcare professionals, we need to personally imagine unfortunate scenarios that affect so many of our patients – for example the sudden loss of capacity, through unexpected illness or injury, to make our own medical decisions. Consider these questions: If I am in a serious accident today, will my receiving healthcare…
Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. “Dysregulated host response” begs for an explanation. In order to do that, we need to lay the foundation on what constitutes a normal physiologic response and contrast it to that of a dysregulated host response.“The normal…
In the coding world, productivity makes the world go round – or, there’s so much emphasis on productivity that it seems that way. Most coders can meet or exceed productivity benchmarks, but are most coders achieving quality productivity? In health information management (HIM), it can be easy to have your…
Dedicated to the late James Jones, MD, who passed away on Dec. 26, the upcoming edition of Talk Ten Tuesdays will focus on the continuing challenge of reaching agreements on accurate coding and DRG assignment while building relationships between providers and payers. Reporting our lead story will be Joel Moorhead,…

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No one relishes a coding query.Mention a query to coding staff and you may get some eye rolls. Coders get anxiety when writing them, leadership wants less of them to keep the discharged not final billed (DNFB) down and revenue flowing, physicians get irritated by receiving them, and the list…
It has been almost a week since I published a rant about my many complaints with regard to ICD-10 or the state of affairs concerning audits and “clinical validation.” In a departure from my usual editorialized op ed, I wanted to shift gears and write about something from a more academic…
While it is now officially calendar year 2017, we are a full quarter into the 2017 federal fiscal year. That said, it is not too late to think about what you as a leader of a clinical documentation improvement (CDI) or coding department can resolve to do to improve your…
Got denials?   This article is about building relationships between hospitals and payers. Hospitals in our country are currently taking one or more of the following three steps in some form, with the goal of reaching agreements with insurance companies and other payers.Step No. 1: Documentation“Code assignment is not based on…
ExtStore.AdvPoll.initResult(); What is your overall ICD-10 coding accuracy? jQuery(document).ready(function() { var $wrapper = jQuery('.advpoll-wrapper-11'); $wrapper.find('.advpoll-answer-graph').each(function() { var $this = jQuery(this); $this.find('.advpoll-answer-line').width(0).animate({ 'width': $this.data('percent') }, 900); $this.find('.advpoll-answer-line-percent').width(0).animate({ 'width': $this.data('percent') }, 900); }); }); 90-100% 41.84% 80-89% 12.24% 70-79% 2.04% 69% or lower 0% We have not done an assessment since the…
The subject of ethics made headline news last week when House Republicans voted in secret to scrap the Office of Congressional Ethics – only to rescind their move to gut the independent body later. Meanwhile, a different move was unfolding recently at the American Health Information Management Association (AHIMA), which…

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Jan. 1 always brings fresh starts, both personal and professional. Many of us focus on how we can make improvements for the new year. Whether it is fitness, motivational, financial, or transformational, they all require the same thing: dedication and consistency. The same holds true in our professional lives, and January…
The Healthcare Cost and Utilization Project (HCUP) released a report in May 2016, National Inpatient Hospital Costs: The Most Expensive Conditions by Payer, 2013, outlining which medical conditions were the most expensive to treat.This report provided statistics by payer as well as overall, and it encompassed 35.6 million inpatient stays…
The American Health Information Management Association (AHIMA) House of Delegates approved the newest version of its Standards of Ethical Coding on Dec. 12, 2016. This document provides a solid foundation of guidance in relation to ethical coding practices and actions. The Standards are a form of guidance that promotes a level…
Well, it has started happening.As I feared, there are coders who want to link any and all hypertensive patients who also happen to have chronic heart failure (CHF) and/or renal failure all together.     “So, what is wrong with that?” You may ask. The problem is that they are doing it even when…
When I first entered the CDI field in 2012, I was taught that the acronym stood for clinical documentation improvement. Several years later, my department at University Hospitals Health System in Cleveland transitioned to calling it clinical documentation integrity, and we got new lab coats! I Googled it to determine when the…
As we know, Hierarchical Condition Categories (HCCs) are used as a reimbursement methodology, quality measurement, and chronic care monitoring tool in Medicare Advantage and Patient Protection and Affordable Care Act (PPACA) health plans, as well as with some Accountable Care Organizations (ACOs) and other value-based, risk-sharing provider groups.But for the…
While I was traveling to the airport last week, our local radio station had an allergist as a guest on their early morning talk show. The allergist was reporting that the holiday season is a very dangerous time for people who have food allergies.For one thing, people are attending parties…
One of the hardest jobs for coders is to translate physician terminology into ICD-10 coding terminology. This has been especially challenging with codes related to mental and behavioral health. In some cases during the year following ICD-10 implementation, there was no way to convert DSM-5 terminology used by psychiatrists and…
There's a national epidemic that is significantly impacting America's hospitals. It is the tyranny of DRG downgrading. No doubt you and your facility are also struggling to comply with professional coding and billing standards while having to address the often arbitrary requirements of third-party vendors. You must adhere to legal…
SPECIAL GUEST James P. Jones, MD Mount Sinai Health System ALSO FEATURING Rudy Braccili, Jr., MBA, CPAM, CRCE; Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS, AHIMA-approved ICD-10-CM/PCS Trainer; Laurie Johnson, MS, RHIA, FAHIMA, AHIMA Approved ICD-10 CM/PCS Trainer; Holly Louie, RN, CHBME; and Edward Roche, PhD, JD

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EDITOR’S NOTE: James Jones, MD, senior medical director of clinical documentation and quality improvement (CDQI) at Mount Sinai Health System in New York, will conduct a webcast on Thursday, Dec. 15, 2016 during which time he will update attendees on Mount Sinai's battle against diagnosis-related group (DRG) downgrading caused by cyber audits.Examination…
EDITOR’S NOTE: Last week, the Senate passed the 21st Century Cures Act by a vote of 94-5. The bill is headed to the White House where it is expected to be signed into law by the President.The Cures Act does many things for improving biomedical research and advancing clinical trials. Subtitle E,…
One question that comes up again and again in the healthcare industry is this: “Why do insurance providers deny based on a diagnosis not being listed in the final discharge summary?”In short, they should not be doing this at all. Under the Health Insurance Portability and Accountability Act of 1996…
EDITOR’S NOTE: This is the final installment in a two-part series on the enigma of sepsis. You can read Part I here.As I thought about writing this article, I was at first going to propose that we figure out a way to marry the old sepsis definition and coding schema with…