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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…
SPECIAL GUEST: Erica E. Remer, MD, FACEP, CCDS Founder and President Erica Remer, MD, Inc.GUEST CO-HOST Dennis Jones PFS Administrator, Nyack Hospital, Nyack, N.Y.

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The subject of the Zika virus continues to be in the news, particularly with the Nov. 9 announcement by the Centers for Medicare & Medicaid Services (CMS) that $66.1 million have been dedicated to Zika prevention and treatment.The American Hospital Association (AHA), through the Coding Clinic edition published for the…
Editor’s Note: With President-Elect Donald Trump nominating U.S. Rep. Tom Price (R-Ga.) to head the U.S. Department of Health and Human Services (HHS) and Indiana’s Seema Verma to serve as administrator of the Centers for Medicare & Medicaid Services (CMS), ICD10monitor Publisher Chuck Buck recently conducted an interview with Stanley Nachimson,…
When reviewing sepsis claims, all too often the primary focus is on searching provider documentation for signs and symptoms and/or clinical indicators that support the diagnosis of sepsis, or that support a query regarding the presence of sepsis.Many times the more subtle details in the sepsis guidelines are overlooked, and…
DITOR’S NOTE: This is the first in a two-part series on the enigma of sepsis.The term “sepsis” was coined by Hippocrates around 400 B.C., derived from the Greek word “sipsi,” which translates as “make rotten,” and it referred to the decomposition of organic matter. In the 19th century, Ignaz Semmelweis deduced…
Rudy Braccili, Jr., MBA, CPAM, CRCE; Kelly V. Canter, BA, RHIT, CCS, AHIMA Approved ICD-10-CM & PCS Trainer; Alice L. Fitts, RHIA, AHIMA Approved ICD-10 Trainer & Ambassador; Barbara Hinkle-Azzara, RHIA; Laurie Johnson, MS, RHIA, FAHIMA, AHIMA Approved ICD-10 CM/PCS Trainer; and Melinda S. Stegman, MBA, CCS, AHIMA Approved ICD-10-CM/PCS…

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ExtStore.AdvPoll.initResult(); What have you been experiencing related to your Case Mix Index since the implementation of ICD-10? jQuery(document).ready(function() { var $wrapper = jQuery('.advpoll-wrapper-9'); $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); }); }); Overall our CMI has increased 15% Overall our CMI…
ICD10monitor and HRS recently collaborated to conduct a survey to assess where Talk Ten Tuesday’s listeners are positioned when it comes to Hierarchical Condition Categories (HCCs) in their workplaces. In line with the Talk Ten Tuesdays’ audience, the majority of the survey respondents were from the hospital setting. Our initial takeaway…
Unfortunately, I have been too busy of late to say much about the two new Coding Clinic editions, which came out nearly at the same time, due to being in the midst of preparing for the new ICD-10 codes that became effective Oct. 1. Certainly there are many that merit…
There is no shortage of uncertainty looming in Washington, D.C. regarding how things will unfold once President-Elect Donald Trump takes office.One of very few predictions that appear to be a safe bet, however, is that Rhonda Taller will be among the busiest people in the nation’s capital next year.The Talk…
Let me rephrase the title of the classic book Fear and Loathing on the Campaign Trail ’72, published around the time Nixon won reelection, to label this article Fear and Gloating on the Campaign Trail of ’16 (and please forgive me if I offend anyone; we psychiatrists sometimes say undesired…
November 28, 2016

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SPECIAL GUEST Erica E. Remer, MD, FACEP, CCDS Founder and President Erica Remer, MD, Inc.ALSO FEATURING Rudy Braccili, Jr., MBA, CRCE;
Laurie Johnson, MS, RHIA, FAHIMA, AHIMA Approved ICD-10 CM/PCS Trainer;
H. Steven Moffic, MD; and Rhonda Taller, BA, MHA, HIMSS ICD-10 Task Force

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Palmetto GBA, a Medicare Administrative Contractor (MAC), will automatically reprocess Medicare Inpatient Prospective Payment System (IPPS) and Long Term Acute Care Hospital (LTCH) claims affected by the MS-DRG v34 Errata beginning Feb. 1, 2017.The recent announcement by Palmetto came on the heels of last week’s Medicare Learning Network MLN Matters…
In the first installment of this series of articles, Exasperation with Clinical Validation Denials (CVDs), I discussed what to do about such denials, which stem from legitimate concerns as to whether a condition is actually present for a patient. Honestly, I wish we had reserved that title for this final…
We always have an eye out for strategies that payers develop to avoid reimbursing providers for things they previously paid for routinely.I know there is a lot going on these days. While we were preoccupied with our kids starting a new school year, the World Series, the fortunes of our…
The insertion of nasogastric (NG) tubes is a common practice in most hospitals. As more facilities begin to capture and code this procedure, correct ICD-10-PCS code assignment is necessary. This article explores key details associated with coding the insertion of nasogastric tubes in ICD-10.Common Procedure for Many PatientsNG intubation is…
SPECIAL GUEST Joseph C. Nichols, MD Health Data ConsultingGUEST CO-HOST Holly Louie, RN, CHBME Healthcare Billing and Management Association ALSO FEATURING Rudy Braccili, Jr., MBA, CRCE; Sarah Laird, RHIA, CCS; Dennis Jones

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It’s so important that we in the healthcare industry continue our discussion regarding the topic of Hierarchical Condition Categories (HCCs), as the risk-adjusted payment models are increasing in prevalence.The assignment of HCCs and risk adjustment has extended beyond Medicare Advantage plans as a result of the Patient Protection and Affordable…
What could be most directly impacting reimbursement among hospitals and health systems? The problem could be, in many cases, the selection of principal diagnoses, since they drive the medical diagnosis-related groups (DRGs).For past 12 months, the health information management (HIM) consulting division at Panacea Healthcare Solutions has been conducting ICD-10 coding reviews among the nation’s…
With more than a full year under ICD-10, it seems it is reasonable to expect local coverage determinations (LCD) to be current and correct. After all, everyone in the industry knew there were errors and omissions in some national and local policies.Many had already been pointed out. And yes, some…
The coding landscape in physician practices is changing rapidly as healthcare moves toward value-based care and quality payment models. Medical practice coding for ICD-10 plays a key role in quality reporting under the new Quality Payment Program (QPP), which was recently solidified by the Medicare Access and CHIP Reauthorization Act…
FEATURING Rudy Braccili Jr. MBA, CPAM, CRCE; Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, RHIT, AHIMA Approved ICD-10-CM/PCS Trainer; Barbara Hinkle-Azzara, RHIA; Laurie Johnson, MS, RHIA, FAHIMA, AHIMA Approved ICD-10-CM/PCS Trainer; and Erica Remer, MD, FACEP, CCDS

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Often we talk about the patient care team and who makes up that special group of professional caregivers. We similarly look at the role that the coding professional plays in healthcare and with that team in particular. Certainly there can be clarifications made regarding the “direct” patient care team, and…
Two major rules published last month included major changes to the healthcare industry. First, the Centers for Medicare & Medicaid Services (CMS) issued its long-awaited Medicare Access and CHIP Reauthorization Act (MACRA) final rule on paying Medicare Part B providers for quality and performance. This new system, titled the Merit-Based Incentive…
It is very important to stay current with the latest coding guidance from official coding resources. Coding Clinic, published by the American Hospital Association (AHA), has released Fourth Quarter 2016. There are six key takeaways from this issue: Diabetes and Osteomyelitis: Previously, the official coding guidelines for this combination stated that…
While most legacy clinical documentation improvement (CDI) programs have been doing a good job at preserving revenue under the MS-DRG system, a potential blind spot exists. Value-based and alternative payment models (APMs) rely on the concept of risk adjustment to determine final payment in acute care. The Centers for Medicare &…
While most legacy CDI programs have been doing a good job at preserving revenue under the MS-DRG system, a potential blind spot exists as Value-Based and Alternative Payment Models rely on the concept of Risk Adjustment to determine final payment in acute care. The Centers for Medicare & Medicaid Services risk…
SPECIAL GUEST Melissa M. Martin, RHIA, CCS, CHTS-IM Chair of the AHIMA Board of DirectorsALSO FEATURING Rudy Braccili, Jr., MBA, CPAM, CRCE; Deborah Grider, CPC, CPC-H, CPC-I, CPC-P, CPMA, CEMC, CCS-P, CDIP, Certified AHIMA Clinical Documentation Improvement Practitioner; Laurie Johnson, MS, RHIA, FAHIMA, AHIMA Approved ICD-10 CM/PCS Trainer; and Stanley…

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This is the second installment in my series of articles addressing clinical validation denials. Clinical validation denials (CVDs) are the derivatives of diagnosis-related group (DRG) coding validation denials. The latter is a rejection of a claim on the basis of reviewing physician documentation and determining that the correct codes or…
With the specificity of ICD-10, it is important to use tools and technology to assist with coding. Computer-assisted coding (CAC) is one method that can benefit a practitioner, but can also harm them if it is not set up or used appropriately. Technology is only as good as it is programmed,…
All healthcare providers must now be (ICD-10) coding to the highest level of specificity. The ICD-10 flexibilities available during the first year of implementation are gone for physician billing.As of Oct. 1, 2016, all providers are required to code to accurately reflect the clinical documentation in as much specificity as…
“Sully,” the Clint Eastwood-directed movie about US Airways Captain Chesley “Sully” Sullenberger, played by Tom Hanks, recounts the dramatic emergency landing Sullenberger made on the Hudson River after his airliner’s two engines were disabled when struck by a flock of geese.While the newest commercial jets feature onboard flight-control computers, making…
Since August, scary clown activities and sightings started to escalate in the United States, and they have spread internationally. In response, McDonald’s announced that it was giving its clown mascot, Ronald McDonald, a break, and Target took some clown masks and costumes off the market.Some of these sightings have turned…
FEATURING Rudy Braccili, Jr., MBA, CPAM, CRCE; Laurie Johnson, MS, RHIA, FAHIMA, AHIMA Approved ICD-10 CM/PCS Trainer; H. Steven Moffic, MD; Erica E. Remer, MD, FACEP, CCDS;
and Michelle Wieczorek, RHIT, RN, CPHQ

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When we look back on what we learned in our first year of ICD-10, it’s clear that some providers were and some were not fazed by the Oct. 1, 2015, implementation date. As I reflect on conversations with our customers (at MediRegs, we service customers across the spectrum, including but…
ICD10monitor’s resident psychiatrist, H. Steven Moffic, MD, who is also a popular guest on Talk Ten Tuesdays, recently received the received the Administrative Psychiatry Award from the American Psychiatric Association (APA) and the American Association of Psychiatrist Administrators (AAPA). The award was presented to Moffic on Oct. 6, during the fall…
Are you familiar with IBM’s supercomputer Watson? IBM’s stated aspiration is to make it “the world’s best diagnostician,” because it can store way more medical information than a human doctor and makes decisions based on evidence, free of cognitive biases. It is consistent, and, according to the company, “given the…
Providers nationwide have been scratching their heads for some time now over how to combat the increasingly problematic issue of clinical downgrading of diagnosis-related groups (DRGs) by auditors.Mount Sinai Health System in New York City might not have the solution – but it sure does have a game plan.The System’s…
Providers nationwide have been scratching their heads for some time now over how to combat the increasingly problematic issue of clinical downgrading of diagnosis-related groups (DRGs) by auditors.Mount Sinai Health System in New York City might not have the solution – but it sure does have a game plan.The System’s…
October 19, 2016

HRS

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SPECIAL GUEST Erica E. Remer, MD, FACEP, CCDS; Founder and President, Erica Remer, MD, Inc.ALSO FEATURING Maria Bounos, RN, MPM, CPC-H, PMC, CSPO; Rudy Braccili, Jr., MBA, CRCE; Sandra L Brewton, RHIT, AHIMA-Approved ICD-10-CM/PCS Trainer; and Laurie Johnson, MS, RHIA, FAHIMA, AHIMA Approved ICD-10 CM/PCS Trainer

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