Beginning April 1, approximately 800 hospitals will be required to participate in CMS’ new joint replacement payment model. Shannon Newell, RHIA, CCS, outlines the requirements and what providers need to do in order to prepare.
To charge or not to charge--that is the question. Determining whether a hospital can charge for certain services and procedures provided at a patient's bedside is a task often fraught with confusion and uncertainty.
Approximately 800 hospitals across the country that perform inpatient total hip and knee joint replacements will be required to participate in the latest value-based payment initiative launched by CMS, the Comprehensive Care for Joint Replacement (CJR) model, which becomes effective April 1.
The new ICD-10 system and its inherent errors, especially in ICD-10-PCS, has provided fertile ground for honest errors. But for this article, I'm going to talk about the other side of the coin, where new codes or descriptions of codes come out, often with inadequate definitions or directions, and people make up reasons to try to rook the system and bilk Medicare?that is, until enough caregivers get caught or advice comes out to squelch the "experts" who want to help you get denials by the hundreds or get hassled by Recovery Auditors.
Denials are on the rise for certain diagnoses, procedures, and regulations. Sarah C. Mendiola, Esq., LPN, CPC, outlines steps providers can take to reduce denials by focusing on certain documentation details.
CMS audits for meaningful use could mean collecting information across the coding and HIM departments. David Holtzman, JD, CIPP, and Darice Grzybowski, MA, RHIA, FAHIMA, review what auditors could request and how to prepare your facility.
The government recently approved changes for physician payment systems. Is your clinical documentation improvement (CDI) team ready to tackle these challenges? More importantly, are your physicians ready?
Gwen S. Regenwether, BSN, RN, and Cheree A. Lueck, BSN, RN, look at how to use audit and query rate information to improve documentation at a facility and how to encourage continuing education and collaboration going forward.
Gwen S. Regenwether, BSN, RN, and Cheree A. Lueck, BSN, RN, discuss how the clinical documentation improvement department at their facility operates and their process for conducting a baseline audit and determining query rates across specialties.
I first attended a lecture on the "upcoming" ICD-10 changes that were expected in 1991 (when the rest of the world started transitioning). On October 1, 2015, a mere 24 years and countless lectures later, the U.S. finally adopted ICD-10 (via ICD-10-CM and PCS, which are both unique to the U.S. at this time).
Jugna Shah, MPH, and Valerie A. Rinkle, MPA, review new comprehensive APCs (C-APC) CMS added in the 2016 OPPS final rule as well as the negative payment update due to a CMS overestimation in 2014.
Providers will only have to report one data collection modifier related to a C-APC in 2016. Jugna Shah, MPH, and Valerie A. Rinkle MPA, examine the requirements behind the modifier and how APCs will also be restructured next year.
Before the new year begins, Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, recommends taking a look at post-implementation risks CMS and third-party payers have identified. She also offers solutions on auditing and reviewing these risks. Note: To access this free article, make sure you first register here if you do not have a paid subscription. Once you have set up your free registration, you can log in and access this article by clicking here.
Marianne Durling, MHA, RHIA, CDIP, CCS, CPC, CIC, an HIM director for a health system in North Carolina, provides her wish list for her department and coders, including thoughts on implementing a CDI program, working with payers, and hiring staff.
The holidays can be a stressful time for coding departments, especially this year with the implementation of ICD-10. Raemarie Jimenez, CPC, CPMA, CPC-I, CANPC, CRHC, and Darice Grzybowski, MA, RHIA, FAHIMA, provide methods for HIM managers to keep coders engaged and productive this time of year and beyond.
After several delays, ICD-10 implementation is finally upon us. The healthcare industry has spent years planning, training, and testing?and now the moment we have all been waiting for has arrived. But don't breathe a sigh of relief just yet.
After years of delays, industry and legislative pushback, and millions spent on technology upgrades and education, ICD-10 is finally here. Even though the fundamental process of coding and billing claims has not changed, providers will still need to pay close attention to their processes to keep the revenue cycle going and reduce denials.
Joel Moorhead, MD, PhD, CPC, and Faye Kelly, RHIT, CCS, write about the importance of clinical anatomy to coding in ICD-10 and how to best use encoders along with the code set.
While focusing on documentation and coding, providers might not have considered the impact of MS-DRG shifts as a result ICD-10 implementation. Gloryanne Bryant, RHIA, RHIT, CCS, CDIP, CCDS, and Lori P. Jayne, RHIA, review how the new code set will affect several diagnoses.
Robert S. Gold, MD, discusses educational opportunities for sequencing viral gastroenteritis, coding past medical conditions, and reporting neonatal codes.
Medical record audits provide opportunities to educate coders, physicians, and/or clinical documentation improvement specialists. Robert S. Gold, MD, offers tidbits about volume overload and heart failure from recent reviews he’s done.
With Recovery Auditor audits on hold, hospitals may have experienced a decrease in the number of audits that must be addressed. Cathie Wilde, RHIA, CCS, and Kim Carr, RHIT, CCS, CDIP, CCDS, explain why organizations still need to be able to justify code assignment.
It's great, identifying opportunities to teach. Whenever I do medical record audits, I always look for chances to educate coders, physicians, and/or CDI specialists about areas of misunderstanding by coding professionals or elements of patient experience that require specific documentation for proper code assignment.
Ask a physician why he or she documents in the medical record and you'll get a variety of answers. Some physicians will say they document because the medical records people hound them for the information, or they do it so they get paid. They may also say they do it to complete the medical record.
Many organizations still lag in ICD-10 implementation, but it's not too late to prepare. Gloryanne Bryant, BS, RHIA, RHIT, CCS, CCDS; Jean S. Clark, RHIA, CSHA; and Caroline Piselli, MBA, RN, FACHE, detail the steps organizations should take in order to be ready by October 1.
Taxonomy codes play a very important role in medical billing and credentialing for providers or group specialties.HIPAA-standard code sets specify a "standard" for transactions. In many cases, a taxonomy code is required to reimburse a claim; however, the reporting requirements for a taxonomy code may vary between insurance carriers and your third-party payers.
PSI 7 evaluates the hospital’s risk-adjusted rate of central venous catheter-related bloodstream infections. Shannon Newell, RHIA, CCS, Steve Weichhand , and Sean Johnson explain inclusions, exclusions, and risk adjustment factors for this measure.
When providers use different definitions for the same disease, confusion and chaos result. Trey La Charité, MD , discusses how coding and clinical documentation improvement specialists can clear up the situation.
PSI 15 measures the hospital’s risk-adjusted rate of accidental punctures and lacerations. Shannon Newell, RHIA, CCS, Steve Weichhand , and Sean Johnson explain inclusions, exclusions, and risk adjustment factors for this measure.
Coders and clinical documentation specialists can use queries to improve physician documentation of a patient’s severity of illness and risk of mortality. Rhonda Peppers, RN, BS, CCDS, and Sara Baine, MSN-Ed, CCDS, walk through a case study to highlight query opportunities.
Coronary artery disease (CAD) develops when the arteries that supply the blood to the heart muscles become hardened and narrowed due to a buildup of cholesterol and other materials, such as plaque, on their inner wall. It's also called atherosclerosis.
Our sister website JustCoding.com recently published its 2014 Coder Salary Survey. Since many of our readers responded to the survey, we would like to share some of the results with you.
A hiatus from Recovery Auditor scrutiny may have allowed HIM professionals to focus on other issues, but Laura Legg, RHIT, CCS, explores why HIM departments need to gear up for Recovery Auditors’ return.
ICD-10 implementation requires organizational coordination from a variety of departments. Chloe Phillips, MHA, RHIA, and Kayce Dover, MSHI, RHIA, discuss how organizations can overcome challenges regarding staffing, productivity, and data analytics as they prepare for the change.
We've compiled the numbers from the latest JustCoding Salary Survey and now you can see how you compare to the average coder in terms of salary, experience, and other factors. Monica Lenahan, CCS, and Susan E. Garrison, CHCA, CHCAS, CHC, CCS-P, CPC, CPC-H , analyze the results and discuss the future of coder salary and responsibilities.
In the first part of a two-part series, Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer, discusses the use of Z codes in ICD-10-CM.
With quarterly code updates and other regulatory changes from CMS throughout the year, the chargemaster coordinator has to constantly monitor the healthcare landscape, but the final few months of the year remain the most challenging.
Coders often talk about guidelines and coding conventions, but what about ethics? Robert S. Gold, MD , discusses the value of following ethical coding standards.
CMS designates a certain set of procedures as inpatient-only, meaning it will only reimburse facilities for these procedures when they are performed in the inpatient setting. Inpatient-only procedures present numerous problems for hospitals.
In part 2 of his series on medical necessity and coding, Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI, examines medical necessity and the 2-midnight rule using a case study.
The Official ICD-9-CM Guidelines for Coding and Reporting talk about the perinatal and newborn period as being the first 28 days of life. Robert S. Gold, MD, explains when neonatal really is—and isn’t—neonatal.
Coders now incorporate consideration of medical necessity when coding for inpatient admissions. Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI , explains the importance of understanding the concept of medical necessity as it relates to coding.
The complexity of coding rules and the quality of documentation in facilities sometimes make correct DRG assignment a daunting task. Laura Legg, RHIT, CCS, highlights current DRGs that are subject to Recovery Auditor scrutiny and provides tips for accurate DRG assignment.
ICD-10-PCS will be a big change for inpatient coders. The best way to learn the new coding system is to practice, practice, practice. See how well you know ICD-10-PCS by assigning all applicable ICD-10-PCS codes for the following case.
CMS' introduction of the 2-midnight rule in the 2014 IPPS final rule makes properly identifying inpatient-only procedures even more important for hospitals.
The April 1 confirmation of the delay in implementing the ICD-10 code set until at least October 1, 2015, certainly took the wind out of many healthcare organizations' sails.
CMS' 2015 IPPS proposed rule, released April 30, focuses on quality measures, such as HAC reduction, readmissions reduction, and hospital value-based purchasing (VBP) programs.
Healthcare facilities are subjected to a myriad of auditorswho scrutinize everything from how many units of a drug were billed to whether or not a patient actually needed to be admitted to the hospital. Trey La Charité, MD , explains how to turn every denial into a learning experience.
Plenty of uncertainty surrounds the ICD-10 implementation delay, but healthcare organizations shouldn’t put the brakes on their plans. Cheryl Ericson, MS, RN, CCDS, CDIP , William E. Haik, MD, FCCP, CDIP , Monica Lenahan, CCS , Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, and James S. Kennedy, MD, CCS, CDIP, offer thoughts on how to keep moving forward with ICD-10.
In an ideal world, all coders and CDI specialists would get along well and work together with minimal conflict. No one is going to agree all of the time, nor should they. A healthy, respectful dialogue can lead to a better understanding of the patient's clinical condition and result in more accurately coded records.
You all know that I have been unhappy with some code definitions in ICD-9 and have ucceeded in getting some changes made in ICD-9 and ICD-10-CM code sets.
Inpatient coders will have a new coding system on October 1, but they won’t have to learn new MS-DRGs. They aren’t changing. However, coders will see some shift in MS-DRG assignment in ICD-10. Donna M. Smith, RHIA, and Lori P. Jayne, RHIA, reveal why the MS-DRG shifts will occur.
Whether you work in a dedicated children’s hospital or a general hospital with a pediatric service line, you will likely come into contact with coding charts of kids. Sometimes they are easy (e.g., an inguinal hernia repair without obstruction or gangrene is an inguinal hernia repair without obstruction or gangrene—except it has to be identified as right or left in ICD-10). Sometimes they are not so easy (e.g., complex congenital diseases and their manifestations and complications).
With the ICD-10-CM implementation date approaching, training and retaining staff that knows the new system is paramount for coding departments. Sabita Ramnarace, MS, RHIA, CCS, CHP , and Rudy Braccili, Jr., MBA, CPAM, review strategies that can help providers develop retention plans in their organization.
Drug-resistant bugs are becoming more common as antibiotic use increases. Shelley C. Safian, PhD, CPC-H, CPC-I, CCS-P , AHIMA-approved ICD-10-CM/PCS trainer, explains why and how microbes become antibiotic resistant and compares ICD-9-CM and ICD-10-CM coding for these infections.
Different studies using different methodologies all point to the same conclusion: Coder productivity will decrease after the switch to ICD-10. However, no one knows what will happen to coding accuracy.
In order to report accurate evaluation and management codes, coders need accurate, complete documentation. Coders can play a critical role in ensuring proper documentation. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, looks at methods coders can use to promote better documentation.
The audit landscape continues to change as Recovery Auditors expand prepayment reviews and CMS implements its new 2-midnight rule. Debbie Mackaman, RHIA, CPCO, Ralph Wuebker, MD, MBA, and Kimberly Hoy Baker, JD, review some of the recent changes to audit focus areas.
The Cooperating Parties made the last regular update to the ICD-9-CM codes October 1, 2011, but they are still adding codes for new technologies each year. The updates are considerably smaller than the regular updates, but coders still need to be aware of them.
Physicians are never going to like receiving queries from coders and CDI specialists. They really won't like all the queries they will receive after the transition to ICD-10.
The ICD-10 implementation will result in a slowdown at every level of coding. Elaine O’Bleness, MBA, RHIA, CHP, Migdalia Hernandez, RHIT, Kimberly Carr, RHIT, CCS, CDIP, and Rachel Chebeleu, MBA, RHIA, provide suggestions on how to minimize that productivity decline.
How well could you code in ICD-10 using your current physician documentation? Do your physicians document the specificity and detail coders need to select the correct ICD-10-PCS code? Do your physicians document laterality, which coders will need for many ICD-10-CM codes?
If you're not already actively using your hospital's PEPPER (Program for Evaluating Payment Patterns Electronic Report), you're missing out on a lot of valuable data.
The implementation of ICD-10-CM will bring more specificity to coding, which will mean more data for facilities. Michael Gallagher, MD, MBA, MPH, and Andrea Clark, RHIA, CCS, CPC-H, look at how to handle that data and its benefits for providers and patients.
ICD codes are the ultimate source of information for the healthcare industry. Coders in every setting-inpatient, outpatient, and physician services-report the exact same ICD codes to describe a patient's condition.
Does the patient really have sepsis? Experts say coders often struggle with this question because physicians don't sufficiently document clinical indicators.
CMS released its FY 2014 IPPS final rule in August, and with it comes a whole slew of changes for inpatient hospitals. Set aside a good amount of time to scroll through the 2,000-plus page document. Yes, that's right: There are more than 2,000 pages of information to absorb before the rule goes into effect on October 1, 2013.
The best way to decrease denials or increase overturn rates begins with a compliant concurrent review of documentation. Marilyn S. Palmer, DO, and Jonathan G. Wiik, MSHA, MBA, review common Recovery Audit targets and provide tips for successfully appealing denials.
No one is perfect, including coders. Mistakes aren’t necessarily a reflection on one’s abilities or attention to detail. James S. Kennedy, MD, CCS, and Laura Legg, RHIT, CCS, highlight some common problem areas and provide tips for compliance.
When it comes to ICD-10-CM/PCS, coders may be the hardest and most directly hit employees. Yet some experts say that aside from technical training, hospitals may be lagging behind in terms of actually managing the change for these individuals.
It took some time to break down the wall between coders and CDI specialists at New Hanover Regional Medical Center in Wilmington, N.C. However, that wall eventually crumbled. Linda Rhodes, RN, BSN, CCDS, manager of CDI, says an increased emphasis on communication and respect is what did the trick.
When Paul Belton, RHIA, MBA, JD, LLM, speaks about the culture at Sharp HealthCare in San Diego, you can hear the pride and enthusiasm swelling in his voice. Having served as the vice president of corporate compliance for the past 15 years, Belton has led the ongoing effort to ensure that all employees "do the right thing" at all times.
Recovery Auditors audit the MS-DRG, principle diagnosis, any secondary diagnoses, and any procedures that affect—or could affect—DRGs. Christina Benjamin, MA, RHIA, CCS, CCS-P, reveals the most important documentation pitfalls and coding guidelines challenges related to MS-DRGs under auditor scrutiny.
Healthcare data continues to become the industry’s newest hot commodity. Ralph Wuebker, MD, MBA, and Yvonne Focke, RN, BSN, MBA, explain what information facilities can extract from PEPPER reports.
Ancillary department staff may think they don’t need ICD-10 training, but they’re wrong. Lori Purcell, RHIA, CCS, and Kathy DeVault, RHIA, CCS, CCS-P, offer tips for preparing ancillary department staff for ICD-10-CM.
When coding guidelines are murky and open for interpretation, coders can sometimes feel as though they're pinned between a rock and a hard place. Discussing the gray areas of coding during a coding roundtable not only helps relieve this tension, but it also helps to establish policies that ensure consistency and continuity.
Charging for inpatient ancillary procedures and supplies has always been confusing. "CMS provides very little guidance ... Its theory is that it's up to the provider to figure it out," says Kimberly Anderwood Hoy, JC, CPC, director of Medicare and compliance at HCPro, Inc., in Danvers, Mass.
Do EHRs enable fraud and abuse by encouraging upcoding? What other factors could have led to higher levels of E/M coding over the past decade? Who or what organizations are responsible for ensuring compliance?
Coders will see plenty of changes when they start using ICD-10-CM codes. Many codes require more specific information, such as laterality, stage, or encounter.
