During a recent conference call, the agency described assessing 64,883 ICD-10-CM diagnoses. I participated in the Centers for Medicare & Medicaid Services (CMS) conference call last Tuesday, explicitly focusing on complication and co-morbidity (CC) or major CC (MCC) designation methodology. This process is similar to how CMS originally determined comorbid…
Some payers will take back the fee-for-service payment if the wrong diagnosis code is selected. There have been many conversations had since the healthcare industry moved to ICD-10-CM, and many more guidelines developed regarding when to query a physician, which has sparked even more debate. Guideline 19 in ICD-10-CM states:…
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…
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…
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…