Keeping up with commercial payer requirements can stump any revenue integrity department, and commercial payer audits can be an especially tough puzzle to solve.

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.

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.

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.

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.

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.

Let’s take a deep dive into the recently released coding guidance and documentation tips for these illnesses. Note that since vaping-related guidance and statistics are ever changing, this information is up to date as of October 2019.

In the 2020 Medicare Physician Fee Schedule (MPFS) final rule, CMS put a stamp of approval on its previous proposals to overhaul how medical practices will report office and outpatient E/M services in 2021.

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.

Review finalized changes to relative value units for office visits, new HCPCS codes for chronic care management and opioid treatment services, and future updates to the E/M reporting guidelines.

Now that October 1 has passed, we are in full swing with the updated ICD-10-PCS code set for fiscal year (FY) 2020. There are now 77,559 total ICD-10-PCS codes for us to work with.

Vaping and vaping-related lung injuries have been in the news recently. The occurrence of serious and even fatal lung injuries associated with vaping have been reported this year with an increasing number of cases being reported over the last few months.

With much of the coding workforce working remotely, the inpatient coding manager must implement some control mechanisms to ensure the distractions at home are not interfering with the quality and quantity of work expected from the staff. In this article Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS, gives suggestions on the various ways to monitor your remote coding staff, including tips for conducting coding reviews. Note : To access this free article, make sure you first register here if you do not have a paid subscription.

Managers should not assume that they can review every guideline, every item in Coding Clinic, or every coding-related issue targeted by the OIG or Recovery Auditors. However, those issues that have been identified as the result of denials, external coding audits, or quality initiatives should surface to the top of the audit list for the coding manager.

Reporting sepsis has long been a challenge for many coders even with the continual release of Coding Clinics and guideline revisions.

Internal audits can reveal inconsistencies in provider documentation and coding, reporting errors, and fraudulent billing practices. Review internal auditing basics and advice from regulatory experts on how to effectively educate providers on audit findings. Note : To access this free article, make sure you first register here if you do not have a paid subscription.

Since we have already covered an overview of the final rule and the updates to the ICD-10-CM/PCS code set, for this BCCS article, let’s take a look at some of the key financial updates that hospitals should be aware of.

While the calendar year 2020 OPPS proposed rule is shorter than in prior years (819 pages for the display version), the proposed policies therein pack a punch and may be thought of as a new day dawning for the future of hospital services.

The 2020 Medicare Physician Fee Schedule proposed rule includes significant documentation and payment changes for outpatient office visits reporting using E/M codes 99202-99215. Beginning in 2021, these proposed updates could add billions of dollars to the national E/M revenue stream.

Even if a hospital is not a teaching hospital, it may have services that require National Clinical Trial (NCT) reporting. It is logical for revenue integrity leadership to own this issue, but an explanation of the requirements for NCT reporting should be shared with all staff within the revenue cycle so there is a better appreciation of the fact that clinical trial billing rules apply more broadly than merely just to research or clinical trial studies.

Trey La Charité, MD, FACP, SFHM, CCS, CCDS , explains why physicians may feel that coding and CDI professionals are asking too much and offers potential solutions to ease workplace tensions.

Keeping up with commercial payer requirements can stump any revenue integrity department, and commercial payer audits can be an especially tough puzzle to solve. Review advice from experts on improving internal processes for dealing with commercial audits.

CMS recently released two quarterly updates effective July 1: Medicare Claims Processing Transmittal 4313 , which is the July update to the OPPS, and Medicare Claims Processing Transmittal 4314 , which is the related July update to the Integrated Outpatient Code Editor (I/OCE) Specifications, Attachment B.

Correct documentation and coding are key to accurate reimbursement, but according to the Office of Inspector General, organizations aren’t hitting the mark on either when billing for inpatient rehabilitation facility (IRF) services.

A May report from the Office of Inspector General (OIG) found that some physician practices were at the root of basic coding errors that caused federal overpayments. Although the Essence audit was small, the findings have significant implications for physician coders.

Having taken on more diverse responsibilities, many providers regard medical coding as a necessary evil; their primary focus is caring for their patients. Although many physicians select codes for the work they perform, they rely on specialized coding and auditing professionals to review their documentation and reporting for accuracy.

Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, presents a review of MS-DRG basics to ensure that inpatient coders have a thorough understanding of MS-DRGs’ intricacies, thus perfecting assignment and reimbursement accuracy.

The NCCI manual can be a powerful tool for revenue cycle staff to understand the intricacies of CMS modifier rules and Medicare edits.

The role of the coder has transitioned over the past few years to one that is more auditing-heavy. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC , describes how to effectively perform internal audits and educate providers on coding best practices.

Healthcare organizations and providers are experiencing a shift in outpatient reimbursement: from fee-for-service to Alternative Payment Models and value-based reimbursement based on quality outcomes.

Providers will find significant leeway in how they can report advance care planning (ACP) services for physicians given CMS’ open-ended coding requirements. Review potentially confusing CPT time rules and other obstacles that may be holding back providers from engaging in ACP services.

Telehealth services are likely to promote health, wellness, and disease management, providing an avenue to offer efficient, high-quality care while supporting value-based care in a cost-effective manner. Although the benefit of telehealth is obvious and its value is continually highlighted by CMS, it appears the services are underutilized.

If we look at each element of a coding audit, we can see the benefits these coding reviews provide. Every healthcare organization and hospital should invest in routine, internal coding audits. The alternative is waiting until the payer conducts an audit, denies a claim, and incurs costs for the organization.

In 2018, most organizations held the line on coder productivity, according to the results of sister publication HIM Briefings’ 2018 coding productivity survey.

Even on a small scale, the implementation of an outpatient clinical documentation improvement (CDI) program can be overwhelming. Review advice from CDI specialists on developing successful outpatient CDI programs that facilitate accurate coding and billing.

Establishing an outpatient CDI program can have substantial benefits. Recently, an outpatient CDI review project demonstrated there were many documentation improvement opportunities at a large family practice/internal medicine physician clinic.

Despite facing potential lawsuits and political opposition, CMS finalized some of its most controversial proposals in the 2019 OPPS final rule by implementing several site-neutral payment policies and 340B drug payment reductions.

It's been more than three years since CMS introduced a subset of modifiers it wants providers to report instead of modifier -59 (distinct procedural service), but they're still optional as barely any new guidance has been released.

The CMS risk adjustment model uses Hierarchical Condition Categories (HCC) to calculate risk scores based on ICD-10 diagnoses. Review HCC coding do’s and don’ts to help your facility manage risk effectively, enhance shared savings, and provide patient-centered care.

Remittance processing and appeals are integral parts of the revenue cycle. When facilities submit a claim to Medicare, the hope is that the claim will be paid in full and in a timely manner, but that does not always happen.

Creating a query and knowing when to query can be complicated, and there are a number of continued training tactics that prove successful for the coder when trying to improve upon physician query practices. This article looks at a few of the official sources that offer query guidance for coders. Note : To access this free article, make sure you first register here if you do not have a paid subscription.

Developing an outpatient CDI program isn't just about metrics--departments needs to consider how to engage providers and interact with other teams to be truly effective.

Coding leadership can assist the chargemaster team by providing input, preparing appeals, and tracking coding-related denials. Rose T. Dunn, MBA, RHIA, CPA/CGMA, FACHE, FHFMA, CHPS , describes how to effectively work with a team of coders to combat continued denials.

Allen Frady, RN-BSN, CCDS, CCS, CRC, says that defending code assignment against denials requires more than reviewing the denial to determine if the condition was coded and reported according to the coding guidelines; it requires an understanding of payer requirements as well.

Learn about how providers can adhere to the latest regulations and guidance when coding and reporting chronic care management.

Chris Simons, MS, RHIA, details way to improve querying across health information management (HIM), coding, and CDI departments since querying providers is a key strategy for improving documentation. Note : To access this free article, make sure you first register here if you do not have a paid subscription.

Continuing with numerous specific requests for comment in last year’s OPPS proposed rule, CMS is once again asking stakeholders for feedback on a variety of issues for the 2019 OPPS proposed rule for future potential rulemaking. You may submit comments to the agency until September 24, 2018.