News

Coders can expect to confront new challenges, including new payment models and HIPAA changes. The new year brings new challenges for the healthcare industry. From new payment models to updates to the Health Insurance Portability and Accountability Act (HIPAA) to 21st Century Cures, hold on to your hats, because it…
Coders are encouraged to query if not sure.The ratio of observed-to-expected deaths is considered a measure of hospital quality. Recording accurate metrics depends on capturing all relevant diagnoses to optimize the expected mortality denominator. The explanatory variables groupings of mortality modeling for institutions include both definitive diagnoses and signs/symptoms. A…
Integrity means moving from a retroactive, transactional approach to one that documentations patient care. There is much discussion and movement in the clinical documentation improvement (CDI) industry regarding using the word “integrity” in describing the discipline. In perusing the Internet for a solid definition of “integrity,” a Huffington Post article…
Coders must ensure documentation supports the service, either moderate sedation or MAC. Coding moderate sedation (or conscious sedation) and monitored anesthesia care (MAC) is not difficult; however, distinguishing what the services provided are and deciphering conflicted information about which physicians can report what codes can be confusing for some coders…
Address documentation and coding issues up front, rather than correct them later. Coders have had many challenges throughout the years.  When I started in the industry, we did not submit claims electronically; they were submitted on paper and we used an IBM Selectric Typewriter to complete what was then the…
New directives from the Administration focused to eliminate unnecessary regulatory burden The Centers for Medicare & Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC) have jointly released a draft titled “Strategy on Reducing Regulatory and Administrative Burden Relating to the Use of Health…
When considering to use the T code, simply tell the truth. Is your institution reluctant to code a T code? Are your quality professionals concerned about being penalized for any complication that crops up during the patient stay? Are they asking the clinical documentation integrity (CDI) team to contrive by…
New initiative is detailed in the OIG work plan. As many of you are aware, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently released a key addition to its work plan announcing an initiative to investigate and validate their concern of hospitals gaming…