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.

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.

Let’s take a look at some common questions asked about MS-DRG optimization, and review how inpatient coding and documentation plays a significant role in the MS-DRG review process. Learning the ins and outs of this process will ensure that your facility remains educated and compliant on this topic.

In today’s virtual environment, with its focus on flexible schedules, organizing the coding function requires consideration of time zones, team member skills, volume of work, and claim-processing schedules.

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.

I can teach CDI to anyone. Just get the providers in a room with me; they don’t even have to be willing participants. While I have heard many times that physicians only listen to other physicians, I believe my success has less to do with the initials at the end of my name and more with the fact that the CDI cause is just, and I’m passionate when I teach.

As Medicare Advantage makes strides to becoming the new norm, organizations need to establish new processes, educate staff, and advocate for patients. Learn how your organization can keep pace with change before it’s too late to catch up.

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.

Valerie Rinkle, MPA, CHRI, covers important proposals found in the fiscal year (FY) 2020 IPPS proposed rule, including coding updates, new technology payment changes, and increases to low wage index hospitals.

Anthem announced that it may reject claims that contain a subsequent E/M service that’s linked to the same diagnosis as an earlier E/M encounter. Learn what Anthem’s modifier -25 policy means for providers and physician coders.

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.

Follow the steps a hospital should consider when submitting a redetermination request to a Recovery Auditor.

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.

In the 2019 OPPS final rule, released November 2, CMS implemented several site-neutral payment policies, though the agency did delay or shelve other proposals due to stakeholder feedback.

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.

Inpatient coding audits need to be tailored to the type of record being reviewed, the time it may take to complete the audit, and any compliance-related issues that may crop up. This article focuses on how coding managers can streamline these aspects to ensure a successful audit. Note : To access this free article, make sure you first register here if you do not have a paid subscription.

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.

Along with quality measure removals in the 2018 OPPS and MPFS final rules, CMS has continued to propose additional removals in the 2019 proposed rules. In addition, the agency is proposing to add to its ability to remove quality measures in the future.

A common error and audit finding affecting providers is the lack of a physician order or physician signatures on medical documentation. Kimberly A. H. Baker, JD, CPC , reviews CMS guidance for physician signatures on medical documentation.

To succeed in a modern health information management (HIM) environment, coding departments need efficient coding specialists and knowledgeable management to monitor coder performance and provide feedback. Review expert guidance on hiring staff and determining work flow to improve the organizational structure of your coding department.

A July 2018 update to the OPPS clarifies that coders can report HCPCS code C9749 for an inherently bilateral procedure with modifiers -73 or -74 to indicate that the procedure was unilateral. Debbie Mackaman, RHIA, CPCO, CCDS, unpacks this seemingly contradictory guidance and addresses implications for coding and billing professionals.

Provider documentation must meet required standards to support the level of care provided. Rose Dunn, MBA, RHIA, CPA/CGMA, FACHE, FHFMA, CHPS , reviews payer guidelines and medical necessity requirements under Medicare for services performed in the outpatient setting.

Predicting CMS policies can be a foolhardy exercise, especially with a relatively new administration and frequent turnover at the highest levels of HHS over the last year. But it’s safe to say drug payment policy has been and will continue to be a focus of the current regime.

Healthcare providers are often confused about what a commercial or managed care payer would want in order to approve the claim. Much of this confusion comes from the timing of requirements to ensure reimbursement.

When planning to implement a coding auditing program, the type of reviews, focus areas, and review frequency must all be taken into consideration. Rose T. Dunn, MBA, RHIA, CPA/CGMA, FACHE, FHFMA, CHPS , details how to conduct an effective coding audit and ensure compliance with documentation requirements.

CMS recently released MLN Matters SE18001 to provide healthcare practitioners with instructions and coding guidance for specimen validity when performed and billed in combination with drug testing. The article was issued to remind laboratories and other providers performing urine drug testing that specimen validity testing (SVT) is not separately billable.

Telehealth services continue to expand and claims for these services may already be under scrutiny by Medicare contractors. Debbie Mackaman, RHIA, CPCO, CCDS, writes about the differences between originating site and distant site services in addition to coding, billing, and reimbursement for telehealth services.