The fiscal year (FY) 2018 ICD-10-CM changes have now been active for several months. Though the volume of new codes is relatively small compared to previous updates, the impact on reimbursement has the potential to be quite large.
The shift from fee-for-service to value-based programs for outpatient payment systems has increased the need for outpatient CDI staff to review documentation for pertinent clinical factors.
Valerie Rinkle, MPA, writes about CMS’ hospital prohibition of unbundling rules and a new outpatient date of service exception for molecular pathology and advanced diagnostic laboratory tests.
Medical necessity documentation, or lack thereof, is one of the most common reasons for claim denials. This article describes how medical necessity impacts third-party payers and those who work in billing and reimbursement services.
In the 2018 OPPS final rule, CMS finalized a change to the current clinical laboratory date of service policies for outpatient molecular pathology tests and advanced diagnostic laboratory tests.
In the current healthcare climate, the issue of medical necessity documentation, or lack thereof, is one of the most common reasons for claim denials. For a service to be considered medically necessary (by a third-party payer), it must be considered a reasonable and necessary service to diagnose and/or treat a patient’s current and/or chronic medical condition.
Bundled Payments for Care Improvement Advanced, a new voluntary bundled payment model launched by CMS in January, includes 32 clinical episodes encompassing both inpatient admissions and outpatient procedures. Yvette DeVay, MHA, CPC, CPMA, CIC, CPC-I , writes about participation criteria, payment calculations, and quality measures for this program.
Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CRC, CCDS , writes about discussions at the AMA CPT Symposium that could impact coders, including the need for updates to CMS’ E/M Documentation Guidelines and how medical decision making is used as a key component for E/M reporting.
In recent years, numerous pieces of legislation have been passed to limit healthcare spending, combat losses due to fraud, and ensure that dollars are being spent on quality care. Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP , describes different watchdog programs created to promote billing compliance and quality of care.
Creating a query and knowing when to query can be complicated, and there are a number of training tactics that can prove successful for coders when trying to improve upon physician query practices. For this article, let’s take a look at when coders should query and when it’s appropriate for them to cite clinical evidence. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
The advancement of accurate and compliant coding efforts brings unique challenges. As benevolent as a health information management (HIM) department’s mission may seem to be, for many facilities, the focus of physician queries continues to be “optimizing” information in the medical record to increase reimbursement.
CMS' Bundled Payments for Care Improvement Advanced model will qualify as an Advanced Alternative Payment Model under the Quality Payment Program and include outpatient episodes.
In this article, Valerie A. Rinkle, MPA, offers guidance regarding the 340B drug discount program. She provides tips for accurate documentation of drug purchases and reviews frequently asked questions about billing for 340B-acquired drugs in 2018.
Complying with healthcare regulations within a coding department or physician practice involves promoting a positive attitude toward activities such as self-monitoring and staying up-to-date with healthcare regulations. Follow these steps to adhere to sound business ethics and set expectations for behavior across an organization. Note: To access this free article, make sure you first register here if you do not have a paid subscription.
CMS' 340B FAQ reviews modifiers -JG (drug or biological acquired with 340B drug pricing program discount) and -TB (drug or biological acquired with 340B drug pricing program discount, reported for informational purposes) and requires 340B hospitals to report modifiers even on drugs that are not subject to the discount policy.
If ICD-10-CM/PCS is used to its full potential, it will provide greater detail and a more accurate depiction of patient severity. This level of detail is expected to provide more information about the relationship between a provider’s performance and the patient’s condition.
The improper payment rate for hospital outpatient services was 5.4%, accounting for 7.5% of the Medicare Fee-For-Service improper payment rate, according to 2016 Medicare Fee-for-Service Improper Payments Report.
When faced with a claim denial, providers need to understand what is being denied and when an appeal is appropriate. This article outlines basic steps providers need to take before composing an appeal for a claim denial and helpful tips for successfully navigating through the appeals process.
Creating a 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 takes a look at how improving a coder’s knowledge of principal and secondary diagnosis selection can produce a more effective physician query. Note: To access this free article, make sure you first register here if you do not have a paid subscription.
HCCs aren’t new, but for many organizations, their impact hasn’t been apparent until recently. Organizations must educate staff on HCCs to ensure success under reimbursement methodologies such as the Quality Payment Program and Merit-based Incentive Payment System reimbursement.
Hiring top-notch inpatient coders: Is it good luck, great karma, or the power of prayer? Many coding managers say it takes all three to recruit high-quality, experienced medical record coders post-ICD-10.
CMS’ policy in the 2018 OPPS final rule to cut reimbursement for drugs purchased through the 340B drug discount program by nearly 30%, accounting for the decrease from average sales price plus 6% to minus 22.5%, is getting a lot of attention from the provider community—and with good reason.
CMS is moving forward with its plan to drastically cut payments for drugs acquired through the 340B drug discount program, according to the 2018 OPPS final rule, released in November.
While the 2018 OPPS final rule may be controversial for its payment cuts to drugs purchased through the 340B drug discount program, it contains several provisions supported by hospitals and other stakeholders.
A new private payer rate-based Clinical Laboratory Fee Schedule (CLFS) system is estimated to drastically reduce Medicare Part B lab payments in 2018. Valerie A. Rinkle, MPA, details how this revision will impact providers in outpatient settings and payers tied to the Medicare CLFS.
More and more, hospitals are experiencing a shift of services from inpatient to outpatient settings. In this article, Laura Jacquin, RN, MBA , describes common challenges healthcare workers face when providing comprehensive documentation for services across the care continuum.
In July, Utah pain doctor Jahan Imani, MD, and Intermountain Medical Management, P.C., entered into a nearly $400,000 settlement with the OIG to resolve allegations that Imani’s practice submitted false or fraudulent claims due to improper modifier use for payment by improperly using modifier -59 with HCPCS code G0431.
Patient care continues to move from the inpatient setting to outpatient. With this change, the challenge of securing comprehensive documentation that articulates the services rendered and the patient care provided now needs to extend across the care continuum.
Section 216(a) of the Protecting Access to Medicare Act of 2014 (PAMA) added a requirement that will dramatically revise the Medicare Clinical Laboratory Fee Schedule (CLFS) effective January 1, 2018.
Root cause analysis of edits and an understanding of the relationship between the chargemaster and HIM/coding must be supported by overarching principles and best practices for edit management. Processes should be built around the timing of edits, applying edits across payers, and denial management.
In the 2018 OPPS proposed rule, CMS proposed a change to the current clinical laboratory date-of-service policies for molecular pathology tests and for Advanced Diagnostic Laboratory Tests.
CMS wants your thoughts on its 2018 OPPS proposed changes. In various places in the proposed rule, CMS specifically asks providers to comment on the proposals. You may submit comments to the agency until September 11, 2017.
You may find significant changes to E/M reporting in the near future, including a pivot away from two key elements — history and physical exam — that largely determine a given level of service for your most common patient encounters.
The 2018 OPPS proposed rule includes potential changes to 340B drug discount payments, the inpatient-only list, packaging for low-level drug administration services, and more.
It’s that time of year again – when HIM directors, hospital administrators, and coding managers begin to wonder just how they will be affected come October 1.
Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS , explains that as a coding manager, whether your inpatient team is on-site, off-site, or remote, creating the appropriate environment and selecting proper locations are key to any successful team. Note: To access this free article, make sure you first register here if you do not have a paid subscription.
Every now and then, the HCPro Boot Camp instructors are asked similar questions on a specific billing issue from students and clients across the country. The old saying “there must be something in the water” often holds true, and it does in this case, especially regarding recent OIG audits.
In late June, CMS released a major proposed rule that hospitals will need to pay attention to—and no, I don’t mean to say that CMS released the CY 2018 OPPS proposed rule early, though we’ve thought that might happen since it’s been at the Office of Management and Budget (OMB) for several months.
As CMS and third-party payers have looked for ways to treat patients in the outpatient setting and reduce inpatient volumes, CMS has used the 2-midnight rule, in addition to other methods, to treat patients as outpatients or in observation whenever possible.
In today’s virtual environment, with its focus on flexible schedules, organizing an inpatient coding team requires consideration of time zones, team member skills, volume of work, and claim-processing schedules. Note: To access this free article, make sure you first register here if you do not have a paid subscription.
The Ochsner Health System in Louisiana revolutionized the way its clinical documentation excellence (CDE) team captures annual hierarchical condition categories for all patients across its vast system. Now, Ochsner can serve as a case study to educate others on how to create an outpatient focus on CDI in an increasingly risk-adjusted world.
There is an extensive list of coverage requirements that must be met to furnish outpatient services to Medicare beneficiaries. Gina M. Reese, RN, JD, CPHRM , discusses some of the trickier issues that facilities will need to audit more carefully while monitoring for compliance in provider-based departments.
When CMS introduced Hierarchical Condition Categories with risk-adjusted scores, Ochsner Health System began efforts to educate providers and improve documentation across its many facilities.
There is an extensive list of coverage requirements that must be met to furnish outpatient services to Medicare beneficiaries. Hospitals may find that certain coverage requirements for therapeutic and diagnostic service are more difficult to meet than others, especially in off-campus provider-based departments.
Coding plays a large role in claims and therefore is a key factor in reimbursement compliance. As such, coders have a responsibility to be as accurate and up-to-date on coding practices as possible. Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS , explores some of the organizations and regulatory bodies available to assist coders.
Traditionally, the OPPS rulemaking cycle has been the main vehicle for changes to outpatient coding and billing regulations and policy that hospitals need to pay attention to. But increasingly, CMS has been introducing or discussing changes relevant to outpatient hospitals beyond the scope of the OPPS rules.
HCCs are the basis for risk adjustments for reimbursement models like Medicare Advantage, accountable care organizations, and other value-based purchasing measures such as Medicare Spending Per Beneficiary. Poor understanding and application of HCCs mean that a hospital’s patients may be much sicker in reality than they appear to be on paper, and that will hit reimbursement hard.
Accurate clinical documentation is the bedrock of the legal medical record, billing, and coding. It is also the most complex and vulnerable part of revenue cycle because independent providers must document according to intricate and sometimes vague rules.
Medicare recently published revisions to its appeals process, focusing on the Administrative Law Judge (ALJ) level of appeal. These revisions were published in the Federal Register in the form of final regulations on January 17, 2017, and became effective March 20.
The 2017 calendar year marks the beginning of a new approach to physician payment through the Quality Payment Program (QPP), an initiative created by the Medicare Access and CHIP Reauthorization Act to revise the physician payment system previously updated through the Sustainable Growth Rate.
Accurate clinical documentation is the bedrock of the legal medical record, billing, and coding. It is also the most complex and vulnerable part of revenue cycle because independent providers must document according to intricate and sometimes vague rules.
As OPPS packaging has increased, providers may be less likely to appeal claims for certain denied charges based on medically unlikely edits, since it would not increase payments. However, providers should consider appeals when services are medically necessary and appropriate, as CMS bases future payment rates on accepted claims.
The intersection of CMS’ packaged payment policy and the increasing volume of Medically Unlikely Edits (MUE) can be likened to a car crash waiting to happen. Hospitals are having valid, medically necessary claim lines denied – including charges and units below MUE limits. Providers can help stop the crash by ensuring their claims, CPT coding, medical necessity, and the units are all correct.
With a new year underway, providers likely need to get a handle on some key new modifiers, as well as important changes to an existing modifier and the deletion of a modifier that previously raised a lot of questions and operational concerns.
With a new year underway, providers likely need to get a handle on some key new modifiers, as well as important changes to an existing modifier and the deletion of a modifier that previously raised a lot of questions and operational concerns.
The focus for clinical documentation improvement (CDI) specialists has historically been on the inpatient hospital stay. Review of the chart for conditions that are not fully documented and/or evidence of conditions not documented at all has been standard practice.
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP, writes about the challenges faced in OB hospitalist practices and which procedures and services to focus on for coding, billing, and documentation.
Coding managers cannot always monitor every guideline update or coding-related issue targeted by the Office of Inspector General. Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS, reviews what a coding manager can do during a coding audit and how to implement a plan.
Managers should not assume that they can review every guideline, every item in Coding Clinic , or every coding-related issue targeted by the Office of Inspector General (OIG) or Recovery Audit Contractor (RAC).
Chronic care management codes were adopted by CMS in 2015, but relatively few providers use them. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP, writes about the criteria needed to code and bill these services, as well as how coders can work with providers to ensure documentation supports the codes.
The 2017 OPPS final rule brings the end of modifier –L1 for separately reportable laboratory tests, along with changes to CMS’ packaging logic. Jugna Shah, MPH, and Valerie A. Rinkle, MPA, review how these changes will impact providers.
Each year, CMS reviews procedures on the inpatient-only list, which consists of services typically provided on inpatients and not payable under the OPPS, to consider whether they are being performed safely and consistently in outpatient departments.
As it does each year, CMS reviewed its packaging policies and proposed numerous modifications for 2017, finalizing a move to conditionally package at the claim level and deleting the controversial modifier used to identify separately reportable laboratory tests.
CMS made certain concessions from its proposed site-neutral payment policies required by Section 603 of the Bipartisan Budget Act, but it is still moving forward with implementation January 1, 2017, according to the 2017 OPPS final rule.
Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS, writes about methods coders can use to improve the quality and detail of physician documentation to ensure important information is captured.
Providers need to make sure that electronic order templates include all the necessary information to bill correctly and avoid issues during audits. Valerie A. Rinkle, MPA, writes about what must be contained in the order and ICD-10-specific updates providers should consider.
Orders for services are a vital component of ensuring Medicare coverage. With the advent of computerized provider order entry (CPOE), it is important to review order templates in the electronic medical record (EMR) and the resulting order produced or printed in the formal legal medical record to ensure the templates meet requirements.
With only 60 days between the OPPS final rule's release and the January 1 implementation date, providers will be ahead of the curve by spending time now and thinking about the processes they may need to review, change, or implement based on what CMS finalizes and the sort of financial impact the final rule is likely to have.
Facilities may not yet be using clinical documentation improvement staff to review outpatient records, but the increasing number of value-based payment models and Medicare Advantage patients could make the practice worthwhile, according to Angela Carmichael, MBA, RHIA, CDIP, CCS, CCS-P, CRC, and Lena Lizberg, BSN.
The 2017 OPPS final rule is scheduled to be released in just a few weeks. Jugna Shah, MPH, writes about what facilities should be preparing for in case some of CMS’ proposals related to off-campus, provider-based departments, packaging, and device-intensive procedures are finalized.
The Medicare Reporting and Returning of Self-Identified Overpayments final rule (81 Fed. Reg. 7654‑7684), which became effective March 14, is designed to implement Section 1128J(d) of the Social Security Act, which was established under Section 6402(a) of the Affordable Care Act, effective March 23, 2010.
Billing correctly for observation hours is a challenge for many organizations. Getting it right requires knowing how to calculate observation hours for each patient, which is far from straightforward. Janet L. Blondo, LCSW-C, MSW, CMAC, ACM, CCM, C-ASWCM, ACSW, writes about how to properly calculate hours and report observation services properly.
Coders may not be aware of the impact place of service codes can have on coding and billing. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP, writes about how the codes are used and what coders should know about their application.
CMS proposes aligning its conditional packaging logic with how it applies packaging to labs, while also proposing to delete the much-maligned modifier -L1 for separately payable laboratory tests in 2017.
CMS released the 2017 OPPS proposed rule on July 5 without much fanfare. On July 14, the Federal Register version was posted, and upon initial review, it seems rather short at 186 pages.
CMS’ proposed changes to implement Section 603 of the Bipartisan Budget Act of 2015 would reshape payments for off-campus, provider-based departments (PBD) if finalized and represent the most significant changes in the calendar year (CY) 2017 OPPS proposed rule.
Jugna Shah, MPH, and Valerie Rinkle, MPA, recap CMS’ proposed changes to packaging logic in the 2017 OPPS proposed rule, as well as plans for new and deleted modifiers.
Debbie Mackaman, RHIA, CPCO, CCDS, reviews how CMS determines inpatient-only procedures and what changes the agency is considering in the 2017 OPPS proposed rule.
Deciphering documentation is frequently the most difficult aspect of coding. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP, writes about what documented information coders can use to assign codes—and what to do when that information is lacking.
Jugna Shah, MPH, and Valerie Rinkle, MPA, review changes in the 2017 OPPS proposed rule for providers to comment on, including site-neutral payments and comprehensive APC updates.
CMS' Transmittal 3523, issued May 13, is the quarterly July 1 OPPS update. In this transmittal, CMS briefly mentions billing physical and occupational therapy and speech-language pathology services provided in support of or adjunctive to comprehensive APC (C-APC) services under revenue code 0940 (general therapeutic services) rather than the National Uniform Billing Committee--defined revenue codes for these services (i.e., 042x, 043x, and 044x, respectively).
Healthcare organizations have become mass gatherers of data. But without sophisticated analytics, integrated IT tools, and processes to mine that data, they may not be able to take advantage of it.
CMS issued a final rule in June to revamp the way it pays for tests under the Clinical Laboratory Fee Schedule (CLFS), though the agency has pushed the start date back a year and worked to ease administrative burden based on public comments.
Comprehensive APCs (C-APC) have added another complication to coding and billing for outpatient services. Valerie A. Rinkle, MPA, writes about recent changes that could impact the reporting of physical and occupational therapy and speech-language pathology services provided in support of or adjunctive to a C-APC.
Congressional legislation is often written in a way that obfuscates or, at the very least, makes it difficult to discern the impact or intent of a bill.
When compared to data from past surveys, HCPro's 2016 HIM director and manager salary survey revealed a harsh truth that many HIM professionals already know: There has been little movement in HIM manager and director salaries over the years.
The value modifier is having an increasing effect on physician payments and coding each patient’s severity is key to accuracy. Richard D. Pinson, MD, FACP, CCS, writes about how the value modifier impacts payment and conditions coders should be aware of that quality scores.
CMS recently announced changes to require providers to report modifier -JW (drug amount discarded/not administered to any patient) when appropriate. Jugna Shah, MPH, looks at when providers will need to use the modifier and how to remain compliant.
As healthcare providers increasingly accept financial risk associated with patient management due to the transition from fee-for-service to risk-/value-based reimbursement, the traditional model of healthcare reimbursement has been flipped upside down.
The April 2016 I/OCE update brought a host of code and status indicator changes, as well as corrections to CMS' large January update that instituted policies and codes from the 2016 OPPS final rule.
On April 18, CMS issued its anticipated IPPS proposed rule for FY 2017. This year's proposed rule is very dense, including multiple coding fixes and updates, changes to payment provisions, quality updates, and even something for utilization review.
CMS’ April I/OCE update includes numerous code and status indicator changes, as well as corrections to its January release. Kimberly Anderwood Hoy Baker, JD, CPC, looks at the changes providers should review to ensure claims including these codes are processed correctly.
Which services should clinical documentation improvement (CDI) specialists target in outpatient facilities? Anny Pang Yuen, RHIA, CCS, CCDS, CDIP , writes about how outpatient CDI differs from inpatient CDI and how it can be applied in hospitals or physician practices.
