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.
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).
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.
The finalized fiscal year (FY) 2021 ICD-10-CM and ICD-10-PCS code sets were recently released in the FY 2021 IPPS final rule, introducing new, revised, and deleted codes for diagnostic and procedural services and accompanying guideline changes.
It’s more important than ever that organizations keep ahead of COVID-19 ICD-10-CM and MS-DRG audits and denials. The financial strain that many organizations are under makes it imperative that they minimize disruptions to revenue.
Valerie A. Rinkle, MPA, CHRI , reviews what providers need to know about the latest payment model from CMS’ Centers for Medicare and Medicaid Innovation.
A few years ago, there was a change of attitude within seizure medicine that manifested itself as new terminology. The older term “pseudoseizure” was replaced by the phrase “psychogenic non-epileptogenic seizure.”
Gloryanne Bryant, RHIA, CDIP, CCS, CCDS , reviews healthcare compliance as a whole, and says it is important to be aware of these healthcare compliance risks, especially in ICD-10-CM reporting.
CMS released the fiscal year (FY) 2021 IPPS final rule on September 2. In this article, we will review key priorities for the coming FY, including a continuing emphasis on addressing disparities in reimbursement between urban and rural hospitals and expanding beneficiary access to cutting-edge technologies.
CMS recently released the fiscal year ( FY) 2021 IPPS final rule , which increased hospital payment rates, created new MS-DRGs, and finalized CC/MCC designations.
Valerie A. Rinkle, MPA, CHRI, reviews what providers need to know about the latest payment model from CMS’ Centers for Medicare and Medicaid Innovation.
CMS continues to focus on site-neutral payment policies and keeping payments down for 340B-acquired drugs in the 2021 OPPS proposed rule, released in early August. Read about these proposals which if finalized, will impact hospital billing and payment starting January 1.
Dee Jones, CFO, describes eight ways 340B covered entities can optimize their 340B programs to gain immediate operational efficiencies while accelerating cash flow and savings.
This increase in alcohol-related deaths is consistent with reports of increases in alcohol-related illnesses and injuries during the same period. This study highlights the fact that alcohol-related admissions are not uncommon, which is why inpatient coders should brush up on reporting these disorders in ICD-10-CM.
CMS continues to focus on site-neutral payment policies and keeping payments down for 340B-acquired drugs in the 2021 OPPS proposed rule, released in early August.
Because of the complexity and frequency of ischemic stroke admissions, inpatient coders should review clinical criteria and ICD-10-CM reporting regularly for this diagnosis to ensure accurate coding and reimbursement.
Familiarize yourself with notable code updates in the 2021 Medicare Physician Fee Schedule (MPFS) proposed rule, including new E/M reporting guidelines and CPT® codes for lung biopsies, auditory testing, and chronic care management.
Medicare’s rules for reporting blood products and applying the Part B blood deductible can be confusing. Judith L. Kares, JD , writes about unique HCPCS reporting and billing rules for blood products and related services reimbursed under the OPPS.
Familiarize yourself with proposed updates to the Medicare Physician Fee Schedule (MPFS), including plans to significantly revise the E/M coding guidelines and extend telehealth flexibilities beyond the COVID-19 public health emergency.
Bill Wagner, CHPS, CPCO , unpacks findings from a survey conducted by KIWI-TEK, a medical coding company in Indianapolis, that asked 157 coders how the novel coronavirus (COVID-19) pandemic has impacted their finances, workflow, and career prospects.
CMS released the calendar year (CY) 2021 MPFS and OPPS proposed rules on August 3, introducing new CPT codes, reducing the PFS conversion factor by nearly 11%, and seeking commentary on how to gradually eliminate the inpatient only list.
HIM directors’ and managers’ salaries have largely held steady, but the economic impact of the COVID-19 pandemic is making itself felt. Learn how your salary compares to your peers’ and what you can do to improve your earning power in the future.
As the U.S. slowly tries to recover from the novel coronavirus (COVID-19) pandemic, the country might not ever be the same. States have been trying to reopen to regain their local economy, but in April, the U.S. unemployment rate was at the highest it’s ever been since the Great Depression.
EHRs have fundamentally changed the healthcare industry. The wealth of data they’ve generated has been a boon to research and population health—and has also helped payers use sophisticated data analytics to drive denials.
Valerie Rinkle, MPA, CHRI , breaks down updated CMS guidance for reporting virtual clinic visits and other telehealth services rendered at on- and excepted off-campus provider-based departments.
Cathy Farraher Nakhoul, RN, BSN, MBA, CCM, CCDS , describes simple actions you can take to show appreciation for providers and make education unobtrusive during the novel coronavirus (COVID-19) public health emergency.
Recently published CMS guidance clarifies billing requirements for services rendered via telecommunications technology during the public health emergency. Valerie Rinkle, MPA, CHRI , breaks down the updated guidance as it applies to outpatient services provided at alternative care sites such as patient homes.
CMS recently issued a major update to frequently asked questions (FAQ) on COVID-19 fee-for-service billing issues. The bulk of the new FAQs concerns hospitals and the ability to invoke various waivers in order to deliver services to patients in their homes using telecommunications technologies.
Abnormalities in the brain and spinal cord can influence all body systems. Therefore, it is not surprising that diagnosis codes for neurologic disorders are widespread throughout the ICD-10-CM manual.
Learn how revenue cycle professionals have managed the constant change and monitored for potential problem areas brought on by the public health emergency.
The American Hospital Association recently published a Coding Clinic Advisor FAQ regarding ICD-10-CM coding for the novel coronavirus (COVID-19). This article takes a closer look at the main topics addressed in the FAQ, including ICD-10-CM coding for COVID-19 antibody testing, virus signs and symptoms, and comorbidities.
Physicians and facilities use the same codes to report E/M levels for ED services, but follow different rules. Outpatient coders must be able to assign E/M codes for both physicians’ work and resources utilized by the facility during emergency visits.
CMS on April 30 released an interim final rule with regulatory relief for hospital outpatient departments. In this article, Kimberly A. Hoy, JD, CPC , reviews Medicare provisions that allow outpatient departments to bill services at alternate locations during the novel coronavirus (COVID-19) public health emergency.
Coding audits are commonly used to determine the need for focused coder education and training. Learn about key considerations for conducting coding audits and summarizing significant audit findings.
Physician practices have started reopening to patients but are not expecting a return to normal anytime soon. They continue to struggle with staffing shortages and lost revenue due to COVID-19 restrictions.
Review up-to-date novel coronavirus (COVID-19) documentation tips, ICD-10-CM and CPT coding guidance, and advice for ensuring billing compliance during the public health emergency.
Prior to 1983, Medicare reimbursed based on actual charges that inpatient healthcare facilities billed (often referred to as “fee-for-service” payments). The more tests, procedures, and services ordered by physicians, the more an organization was paid. This created the potential for unnecessary or excessive services, contributing to rising healthcare costs and the possibility of depleting Medicare funds.
PEPPER is an acronym for the Program for Evaluating Payment Patterns Electronic Report . The PEPPER was originated by the Hospital Payment Monitoring Program (HPMP) and Quality Improvement Organizations.
For FY 2021, CMS projects the rate increase, together with other proposed changes to IPPS payment policies, will increase IPPS operating payments by approximately 2.5%. Proposed changes in uncompensated care payments, new technology add-on payments, and capital payments will decrease IPPS payments by approximately 0.4%, according to the proposed rule. Therefore, CMS estimates a total increase in overall IPPS payments of approximately 1.6%.
On May 11, CMS issued its inpatient prospective payment system (IPPS) proposed rule and policy changes for fiscal year (FY) 2021. The proposed rule includes ambitious policy changes showcasing CMS’ commitment to “transform the healthcare delivery system through competition and innovation while providing patients with better value and results.”
The American Hospital Association recently published a Coding Clinic Advisor FAQ regarding ICD-10-CM coding for the novel coronavirus (COVID-19). This article takes a closer look at the main topics addressed in the FAQ, including ICD-10-CM coding for COVID-19 antibody testing, virus signs and symptoms, and comorbidities.
The following questions were answered by Shannon McCall, RHIA, CCS, CCS-P, CPC, CEMC, CRC, CCDS, HCS-D, director of HIM and coding for HCPro in Middleton, Massachusetts, and Yvette DeVay, MHA, CPC, CPMA, CIC, CPC-I, lead instructor for HCPro’s Medicare Boot Camp®—Physician Services Version.
Read up on new CMS policies that expand COVID-19 care, ramp up diagnostic testing, and loosen restrictions on billing for telehealth services during the public health emergency.
All queries, regardless of their origin, are bound to follow the “ Guidelines for Achieving a Compliant Query Practice .” In order to ensure queries stand up to outside scrutiny and are effective, many CDI and inpatient coding leaders have put query audit practices in place for their departments as they bring on new team members.
Sepsis is a major challenge for patients, hospitals, and coders in America. Three articles first published online by the journal Critical Care Medicine give an update on trends in sepsis in the U.S. through Medicare beneficiary data collected between 2012 and 2018.
Practices that have experienced a shutdown or a near-shutdown during the COVID-19 national public health emergency need to adhere to state regulations for re-opening. In addition, they must consider the impact that re-opening would have on staff members and patients impacted by the pandemic.
Globally, millions of people have been infected by the novel coronavirus (COVID-19), according to the Centers for Disease Control and Prevention (CDC) . There have been hundreds of thousands of confirmed COVID-19 cases, and many thousands of deaths, just in the United States
Navigating Medicare’s rules for charging for ancillary services, bedside procedures, and supplies is no easy task. Get an expert perspective on how to apply the rules.
The Office for Civil Rights’ (OCR) enforcement discretion statement seems to open a whole new world of options for providers and patients. However, experts have warned providers that they can still get in a lot of trouble if they are not careful about how they use technology.
The Centers for Disease Control and Prevention (CDC) is monitoring the rapid spread of a disease caused by the 2019 novel coronavirus, formally named COVID-19 . Recently, the World Health Organization (WHO) declared the COVID-19 outbreak a pandemic.
Providence St. Joseph Health, which cared for the first U.S. novel coronavirus (COVID-19) patient, is sharing how the health system has responded to the crisis.
On January 1, 2021, hospitals will enter a new world of price transparency. CMS put hospitals on track to face expanded price transparency requirements with a final rule released November 15, 2019.
Under both the 1135 waiver and the Coronavirus Preparedness and Response Supplemental Appropriations Act, CMS is increasing access to Medicare’s telehealth services to allow beneficiaries to receive professional healthcare services without having to travel to a healthcare facility.
Coders will find a wide range of CPT and HCPCS Level II codes that have been assigned medically unlikely edits (MUE) this year. Review new MUE values that went live January 1 for codes involving drug injections as well as E/M, radiology, and therapy services.
To enhance efforts to combat the opioid crisis in America, CMS policy allows for a new benefit under Medicare Part B concerning Opioid Treatment Programs.
The Centers for Disease Control and Prevention (CDC) is monitoring the rapid spread of a novel 2019 coronavirus, formally named COVID-19, first identified in Wuhan, Hubei Province, China. On January 30, the International Health Regulations Emergency Committee of the World Health Organization (WHO) declared the COVID-19 outbreak a public health emergency of international concern due to its sustained person-to-person spread within countries and across continental borders.
ICD-10-CM/PCS coding for severe and potentially fatal heart conditions such as aortic valve stenosis (AVS), heart failure (HF), and atrial fibrillation (AF) requires an in-depth understanding of anatomical terminology and clinical indications. Coders need to be able to select the most specific codes based on reported symptoms and the severity of the disease.
Prior to 1983, Medicare reimbursed based on actual charges that inpatient healthcare facilities billed (often referred to as “fee-for-service” payments). The more tests, procedures, and services ordered by physicians, the more an organization was paid. This created the potential for unnecessary or excessive services, contributing to rising healthcare costs and the possibility of depleting Medicare funds.
As with any new clinical documentation integrity (CDI) initiative, there are many possible starting points for outpatient CDI. Review advice from healthcare professionals at Trinity Health on how to successfully implement an outpatient CDI program.
Trey La Charité, MD, FACP, SFHM, CCS, CCDS , writes about conflicting documentation and how coders and clinical documentation integrity specialists can resolve inconsistencies in provider documentation to prevent claim denials.
Coding productivity held steady, but missing documentation and unanswered queries bog down coders, according to the results of our 2019 coding productivity survey
Prevention of the flu is important as this illness can lead to hospitalization and even death. The CDC reports the hospitalization rate due to the flu is 2.7 per every 100,000 persons, and there is a 4.8% mortality rate due to influenza and pneumonia.
Keeping up with commercial payer requirements can stump any revenue integrity department, and commercial payer audits can be an especially tough puzzle to solve.
The fiscal year 2020 inpatient prospective payment system (IPPS) proposed rule threw gas on the population health fire when it proposed giving social determinants of health (SDOH) codes more weight as complications/comorbid conditions (CC).
HCPro’s 2019 coding productivity survey showed that coding productivity held steady for 2019, but facilities continue to struggle with miscommunications between coding and CDI staff and unanswered physician queries.
If you aren’t yet confused by the site-neutral payment policy changes prompted by CMS apparently ignoring both Congressional intent and the American Hospital Association (AHA) and other impacted hospitals filing suit, you are likely to become so now.
One of the most vexing challenges that CDI specialists have is how to engage physicians to completely and precisely document their patients’ conditions and treatments in the language required by ICD-10-CM, which is essential to risk adjustment.
As the cost of healthcare continues to skyrocket, payers are looking for ways to save and want to make sure that claims reflect correct information and that the care provided was clinically justified.
Due to the frequency of diagnoses and treatments for breast cancer, it’s more important than ever for inpatient coders to make sure they are reporting these diagnoses and procedures with the utmost accuracy.
HIM directors’ and managers’ salaries made gains in some areas, but others may be falling behind, according to respondents of HCPro’s 2019 HIM director and manager salary survey.
James S. Kennedy, MD, CCS, CDIP, CCDS , reviews updated policies in the 2020 Medicare Physician Fee Schedule final rule that will affect ICD-10-CM risk-adjustment reporting and documentation for facilities.
Although the dollar figures aren’t big, the Office of Inspector General’s (OIG) report on faulty chronic care management (CCM) billing should be concerning for physician practices billing these codes.
JustCoding’s sister publication, HIM Briefings, conducted a benchmarking survey to shed light on edit and denial management processes across the industry. Review findings from the survey to see how your organization compares to those across the industry.
CPT reporting for surgical heart procedures requires an in-depth understanding of cardiovascular anatomy and terminology. This article reviews CPT reporting for procedures involving cardiac pacemakers and implantable cardioverter-defibrillators based on key details in provider documentation.
Very few diagnoses have caused as much gnashing of teeth as sepsis has for inpatient coders and providers alike. Recently, the Centers for Disease Control and Prevention (CDC) has weighed in on the matter and is proposing coding changes , which, if adopted, will go into effect October 2020.
