Facilities can limit their exposure to claim denials and external reviews by implementing a robust internal coding compliance program. This article breaks down components of a coding policy and compliance plan and approaches to monitoring coding quality.
CDI specialists must be able to apply both clinical and coding knowledge in order to discern relevant clinical conditions, and they must be able to analyze the quality of provider documentation and identify any gaps or inconsistencies in information between the health record and the associated data.
Organizations may opt to measure productivity using several methods, such as number of charts coded per day or per month, based on their needs, service lines, and other considerations. Some organizations use different productivity metrics for specific settings or account types.
State and federal prosecutors continue to extract sizable settlements from practices that allegedly submitted fraudulent claims for one type of service—urine drug tests (UDT). In this article, Julia Kyles, CPC , breaks down fraudulent coding and billing patterns for UDT services.
Computer-assisted coding (CAC) technology analyzes healthcare documentation and selects codes based on specific phrases and terms. Review the pros and cons of using this software to perform inpatient coding and billing functions. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
One of the biggest components of a leader’s role is to track, trend, and report on the department’s performance. Learn strategies for balancing priorities and time constraints and presenting key performance indicators to leadership.
ICD-10-CM codes for traumatic fractures specify the type of bone injury, affected area of the body, and in some cases, the degree of soft tissue damage. Review orthopedic terminology and ICD-10-CM documentation requirements for traumatic fractures to resolve the coding challenges.
ACDIS and AHIMA recently released a position paper detailing CDI technology standards. The paper covers information on the variety of technology solutions currently available, strategies to assess compliance with CDI and coding practice guidelines, and methods for creating synergy between CDI and coding departments and novel technology solutions.
Fundamentally, what makes outpatient CDI different from inpatient CDI? A multitude of similarities exist between inpatient CDI basics and reviews, but outpatient CDI has many different areas of opportunity.
Coders continue to be in high demand, and given the importance of this function, evaluating coders’ performance is an essential task for revenue integrity. In this article, Lawrence A. Allen, MBA, CPC, CPMA, CEMA , makes the case for reevaluating coding performance.
Coding for conditions complicating pregnancy and delivery can be challenging, given the number of factors that influence maternal and fetal health. This article details ICD-10-CM coding for cervical incompetence, in vitro fertilization (IVF), and postpartum care complications.
Coding and CDI programs can take many approaches to manage denials, whether they focus on physician documentation education, have a team member dedicated to writing appeals, or anything in between.
Tackling reporting errors early on is an essential component of denials management. Leyna Belcher, MSN, RN, CCDS, CCDS-O , describes strategies that coding and billing professionals can employ to reduce claim denials and increase the success rate of appeals.
Inpatient coders and CDI specialists are usually familiar with ICD-10-CM coding for diabetes mellitus and Cushing’s syndrome. However, they may need a refresher on ICD-10-CM coding for less common endocrine disorders. This article breaks down endocrine anatomy and physiology, and ICD-10-CM coding for thyroid, parathyroid, adrenal, and pineal irregularities.
According to Deanne Wilk, BSN, RN, CCDS, CDIP, CCDS-O, CCS, patient safety and quality of care are forerunning concerns for organizations today, and hospitals need to examine how and when they evaluate that quality of care in order to remain ethical and compliant.
Joe Rivet, Esq., CCS-P, CPC, CEMC, CHC, CCEP, CHRC, CHPC, CICA, CPMA, CAC, CACO , writes about key regulatory updates in the 2022 Outpatient Prospective Payment System (OPPS) final rule, including increased price transparency penalties, changes to the inpatient-only list, and payment changes.
Joe Rivet, Esq., CCS-P, CPC, CEMC, CHC, CCEP, CHRC, CHPC, CICA, CPMA, CAC, CACO , writes about key regulatory updates in the 2022 Outpatient Prospective Payment System (OPPS) final rule, including increased price transparency penalties, changes to the inpatient-only list, and payment changes.
Joe Rivet, Esq., CCS-P, CPC, CEMC, CPMA, CICA, CHRC, CHPC, CHEP, CHC, CACO, CAC, reviews findings from a recent Office of Inspector General audit of claims for neurostimulator implantation surgeries and their implications for coders.
To select the most specific codes for pediatric conditions, inpatient coders must understand the difference between the terms “neonate,” “newborn,” and “infant.”
Applying data governance strategies can help healthcare facilities capture and use social determinants of health (SDOH) data, and a key part of that process is appropriate ICD-10-CM coding, according to a recent AHIMA white paper.
For FY 2022, CMS continues to expand inpatient access to cutting edge health care technologies by increasing the additional payments designed to cover their development costs and streamlining applicable FDA approval processes.
Since the start of the pandemic, HIM, CDI, and coding professionals have focused on understanding acute respiratory distress syndrome (ARDS) as a manifestation of COVID-19.
You may wonder why an article about the coding of Hierarchical Condition Categories (HCCs) in the outpatient wound care setting is appearing in an inpatient periodical. When I first approached this topic, I focused on the outpatient wound care setting. But the more I thought about it, I realized this topic is pertinent for inpatient coders.
CMS recently released the 2022 Medicare Physician Fee Schedule proposed rule, which introduces new guidelines for reporting split/shared visit services. Julia Kyles, CPC , analyzes how the changes would impact physician practices.
CMS recently released the fiscal year (FY) 2022 IPPS final rule which finalizes its efforts to cushion the ongoing impact of the COVID-19 pandemic on hospital revenue and resources. Along with payment rate updates, the final rule also repealed the MS-DRG relative weight methodology and hospital cost-reporting requirement finalized in the 2021 IPPS final rule.
Earlier this year, the Office of Inspector General (OIG) added a new OIG Work Plan item for reporting E/M services with minor surgical procedures. Joe Rivet, Esq., CCS-P, CPC, CEMC, CPMA, CICA, CHRC, CHPC, CHEP, CHC, CICA, CAC, CACO , reviews appropriate use of modifier -25 for separately identifiable E/M services.
HIM and coding directors and managers report some gains in salary but have fewer staff in the department with no plans to hire new staff, according to the results of an HCPro’s 2021 HIM director and manager salary survey. Although directors’ and managers’ salaries and benefits appear to have weathered the financial effects of the COVID-19 pandemic, HIM departments may continue to see resources stretched thinner than ever.
The 2022 Medicare Physician Fee Schedule (MPFS) proposed rule includes significant policy updates affecting physician coding and billing. Review proposals to decrease to the Medicare conversion factor, revise guidelines for critical care services, and loosen telehealth coverage requirements.
With most patient charts now housed in EHRs, technology has become a standard part of the healthcare industry. Growing technological adoption, however, means physicians spend an increasing amount of time on computers and using technology.
The kidneys filter waste and excess fluid from the blood. As kidneys fail, these wastes build up. The symptoms of chronic kidney disease (CKD) generally develop slowly and aren't specific to the disease. Often, there are no noticeable symptoms, and the condition is noted incidentally from a diagnostic testing, or the symptoms first appear once the disease course has reached significant impairment.
In this note, we will review proposed changes to quality programs for inpatient acute and long-term hospital services, and changes to address existing inequities and prevent future inequities in the delivery of these services, including significant improvements to data collection and analysis capabilities.
While technological solutions and electronic health records have made leaps and bounds over the past years in the inpatient setting, there still seems to be much lacking on the outpatient side. Learn how to leverage existing technology to track Hierarchical Condition Category capture and other coding metrics.
In April, CMS released the fiscal year (FY) 2022 IPPS proposed rule. The rule contains proposed payment changes under Medicare Part A for covered inpatient stays in short-term acute care hospitals and inpatient stays in long-term care hospitals.
National Correct Coding Initiative (NCCI) edits and Medically Unlikely Edits (MUE) can throw a wrench in the Medicare billing process, delaying appropriate revenue. Learn how to apply recent guidance and best practices to resolve challenging edits.
Joe Rivet, Esq, CCS-P, CPC, CEMC, CHC, CCEP, CHRC, CHPC, CICA, CPMA, CAC, CACO , summarizes findings from recent Office of Inspector General audits that highlight improper billing of high-level inpatient stays. He also outlines steps hospitals can take to prevent billing errors due to upcoding.
CMS withdrew the split/shared and critical care sections of the Medicare Claims Processing Manual and announced its intent to update coverage policies for these services. Prepare for changes to come by reviewing documentation, CPT coding, and billing guidance for split/shared and critical care services.
CMS offers hospitals some breathing room to recover from the effects of the COVID-19 pandemic in the 2022 IPPS proposed rule. Review proposed updates to complication/comorbidity (CC) and major CC classifications, and a proposed new MS-DRG rate-setting method aimed at alleviating hospital burden.
With the inpatient-only (IPO) list set to be phased out, HIM departments need to prepare for the larger operational and financial impacts. Consider how these changes will affect your organization.
Joe Rivet, Esq., CCS-P, CPC, CEMC, CPMA, CICA, CHRC, CHPC, CHEP, CHC, CICA, CAC, CACO, looks at the implications of a recent OIG brief on how Medicare Advantage organizations could use national provider identifiers (NPI) to monitor for fraud, waste, and abuse.
Laura Evans, CPC, and Julia Kyles, CPC, break down potentially confusing updates to the 2021 E/M guidelines, including new definitions for technical terms and revised guidance for reporting diagnostic laboratory testing with interpretation.
The agency is proposing methods to alleviate burden on hospitals that have been under strain for the past year, while also asking for feedback that may shape future data reporting and rate-setting.
The monetary value of outpatient clinical documentation integrity (CDI) programs is increasing dramatically year after year. Read about steps your facility can take to create and maintain a successful outpatient CDI program.
Monica Tyiska, MBA-PM, RHIA, CCS, CPC, CPMA, CHA, OHCC, CCP-P, offers advice for how organizations can improve hiring practices to ensure candidates from diverse backgrounds that represents the community are brought in.
Hierarchical Condition Categories (HCC) are used to represent risk scores for patients on Medicare Advantage plans. Learn why it’s important for organizations to understand how HCCs are used across settings.
It’s always been easy to show financial return on investment for inpatient CDI endeavors, but the monetary value of outpatient programs is increasing dramatically year after year, making outpatient CDI reviews more attractive to many healthcare organizations.
Effective management of claim edits and denials is a cornerstone of a sound revenue cycle. See how your organization compares to others and what you can do to improve.
Facility E/M coding reflects the volume and intensity of resources utilized by the facility during patient encounters. Joe Rivet, Esq., CCS-P, CPC, CEMC, CHC, CCEP, CHRC, CHPC, CICA, CPMA, CAC, CACO , describes how facilities can create internal guidelines and point systems for determining E/M level section.
Effective management of claim edits and denials is a cornerstone of a sound revenue cycle. See how your organization compares to others and what you can do to improve.
Allen Frady, RN, BSN, CCS, CRC, CCDS, describes steps that coding and clinical documentation integrity managers can take to improve quality metrics and hold staff accountable for reporting errors.
About 1% of children in the U.S. suffer from chronic malnutrition, according to John Hopkin’s Medicine. In this article, Alba Kuqi, MD, CICA, CCS, CDIP, CCDS, CRCR, CSMC, MSHIM, RHIA, breaks down ICD-10-CM coding and documentation requirements for malnutrition.
Regular monitoring and internal auditing are critical to ensure compliance throughout the revenue cycle and protect revenue integrity. Consider the different strategies that can be applied to documentation and chart audits, coding audits, and more.
Let’s face it: Our organizations are under tremendous scrutiny. As the healthcare dollar shrinks, all payers strive to minimize patient care expenses to maintain profit margins.
Strokes are complicated, which is why it is important for inpatient coders to be familiar with the brain’s anatomy and the clinical concepts of a stroke in order to report the most accurate ICD-10-CM codes.
It’s common to see CDI job listings that require applicants to be registered nurses. Often an RN credential is not listed as being “preferred,” but required. There are risks, however, with only seeking candidates from this one background.
Ischemic heart disease has a multifactorial etiology and can be prevented from developing in populations primordially and in individuals at high risk by primary prevention.
The mid-revenue cycle is rife with possibilities to lose earned, appropriate revenue. Learn how to identify common weaknesses and deploy coding and technology to avoid revenue loss.
Supporting accurate Hierarchical Condition Category (HCC) capture is essential to success under the growing number of risk-adjusted payment models. With their strong knowledge of coding and documentation guidelines and insight into emerging trends, coders are a key part of that strategy.
Though the adoption of outpatient CDI has been growing steadily over the years, it’s not always easy to prove the return on investment for such efforts.
In 2005, the International Pediatric Sepsis Consensus Conference published definitions for sepsis, severe sepsis, and septic shock. Sepsis among children is defined as systemic inflammatory response syndrome (SIRS) associated with suspected or proven infection.
Facilities that are not leveraging CDI efforts for denials management and tracking denials as a key performance indicator (KPI) should consider doing so. Denials are the framework for identifying gaps in provider documentation and are a surefire approach to tailoring physician education that is meaningful.
Audit defense is a key strategy to ensure coding and billing compliance and defend earned revenue. It’s more important than ever as the COVID-19 pandemic continues to drain hospital resources, but with HIM departments already stretched thin, it’s also more difficult than ever.
Coding managers use risk assessments to measure their level of compliance with laws, regulations, and internal policies and procedures. Learn about the steps involved in E/M risk assessments and practices used to address E/M coding and billing errors.
Hospitals across the country marked the start of the new year by posting new and more detailed price information online. With the Hospital Price Transparency final rule, which became effective January 1, 2021, CMS completed the most ambitious chapter in its ongoing price transparency efforts.
Malnutrition is notorious for its impact on hospital reimbursement. For example, in 2018 the Office of Inspector General (OIG) conducted an internal audit of the University of Wisconsin Hospitals and Clinics Authority. The audit revealed an overpayment of $9,569,586 for the billing of malnutrition.
In a year of unprecedented disruption and uncertainty, coding productivity managed to hold steady, according to the results of our 2020 Coding Productivity Survey. Learn how facilities adapted and how yours compares.
Read about regulatory updates in the 2021 Medicare Physician Fee Schedule final rule impacting CPT coding for chronic and transitional care management services, and billing for COVID-19-related services.
In a year of unprecedented disruption and uncertainty, coding productivity managed to hold steady, according to the results of HCPro’s 2020 Coding Productivity Survey. Review the survey results, which provide data on facility coding productivity, accuracy benchmarks, and more.
Although the HIM department plays a key role in the revenue cycle, too often it’s placed in a reactive position, limiting the department’s effectiveness. The HIM department can wind up locked in a cycle of cleaning up claims without being empowered to apply process improvements that would reduce errors and facilitate corrections.
Clinical indicators for certain conditions or treatments frequently require greater completeness or specificity in ICD-10-CM, for which concurrent or retrospective query is often required.
Section 1862 (l) and Section 1869 (f)(2)(B) of the Social Security Act (the Act) sets forth general procedures to develop and evaluate Medicare coverage determinations that are either adopted nationally by CMS or created and applied locally by a Medicare Administrative Contractor (MAC) within the MAC’s own jurisdictional boundaries.
Audit defense is a key strategy in protecting earned revenue and ensuring coding and billing compliance. Read about auditing trends during the COVID-19 public health emergency and internal processes that organizations are using to track audit activity.
The HIM department plays a critical role in the revenue cycle, but it’s often placed in a reactive position, limiting its effectiveness. Learn how to improve operations by enhancing the HIM department’s involvement across the revenue cycle.
One concern CDI professionals and inpatient coders say they struggle with is physician engagement and education. Without an engaged physician staff, CDI and coding efforts will languish with unanswered queries and subpar documentation practices.
I received a note from Diane Matysik, a CDI supervisor for Ascension Health in Duluth, Minnesota, who asked a question near and dear to my emergency department (ED) heart: If a patient suffers an out-of-hospital cardiac arrest and is resuscitated before arrival in the ED, should the scenario be described with an ICD-10-CM Z code?
Alicia Kutzer, Esq., LL.M., M.H.A , reviews CMS’ Interim Final Rule with Request for Comments (IFC) concerning coverage, billing, and payment for COVID-19 vaccines and therapeutics. This guidance is imperative for inpatient hospitals to evaluate to ensure proper documentation and reimbursement.
Public comments on 2021 Medicare Physician Fee Schedule (MPFS) proposed rule offer insight into the policy preferences of the medical practice industry. Familiarize yourself with controversial proposed policies to restrict telehealth billing and reduce payment rates for audio-only E/M services.
The COVID-19 public health emergency has not made it easy, but coders and medical practice staff have a lot to be proud of this year. Review key findings from a medical practice salary survey, including data to support medical staff pay increases and expanded job responsibilities.
The fiscal year (FY) 2021 ICD-10-CM code set includes 26 new codes for nervous system conditions such as cerebellar ataxia, Dravet syndrome, and cerebrospinal fluid (CSF) leaks. This article details these code changes and associated updates to the ICD-10-CM Official Guidelines for Coding and Reporting , which went into effect last month.
As we continue seeing an influx of novel coronavirus (COVID-19) cases, there is no better time for inpatient coders to review ICD-10-PCS reporting for extracorporeal membranous oxygenation (ECMO) procedures. Hopefully these procedures are only necessary in rare circumstances for those COVID-19 inpatients.
CMS set the timer on transforming MS-DRGs in the recently released fiscal year (FY) 2021 IPPS final rule . The agency strongly signaled its wish to de-emphasize the role of the chargemaster and the cost-to-charge ratio (CCR) in MS-DRG rate setting and laid out a pathway to a methodology that would align traditional Medicare MS-DRG rates with Medicare Advantage (MA).
