Coders play a crucial role in addressing clinical and coding denials, but they are far from alone in this effort. All HIM professionals are working together to create and implement comprehensive strategies that effectively reduce denials, fostering a unified approach to overcoming these challenges.
Although typically associated with outpatient services due to their use of HCPCS codes, chargemasters are also crucial in inpatient settings, as they serve as the foundation for billing services rendered during a patient’s hospital stay. Learn how inpatient coders can help maintain the financial health of their organizations through the proper understanding of chargemasters. Note : To access this free article, make sure you first register if you do not have a paid subscription.
The Centers for Medicare & Medicaid Services has pulled information on health-related social needs (HRSN), a subset of broader social determinants of health factors, for state Medicaid and the Children’s Health Insurance Program, potentially making it harder for services that address HRSNs to be covered by these affected programs.
Research of multiple countries on various continents and with varied complexity of healthcare environments reveals significant disparities in health outcomes and access to healthcare, and a staggering percentage of health outcomes are attributed to social determinants of health. Studying these countries shows differences in how socioeconomic issues are captured in documentation and coded using different patient classification systems, guidelines, and regulations.
One of the most frequent causes of hospital-acquired AKI is acute tubular necrosis (ATN). Improving documentation and coding practices for ATN involves not only recognizing the condition but also realizing the impact of coding ATN versus AKI, addressing common misconceptions in the HIM field, and fostering collaboration among CDI specialists, coding professionals, and providers. Note : To access this free article, make sure you first register if you do not have a paid subscription.
ICD-10-CM official guidelines once stated that if there is conflicting documentation in the health record, the documentation of the attending physician supersedes that of any other provider. With that rule now gone, Cheryl Ericson, RN, MS, CCDS, CDIP , helps clarify who should be determining diagnoses.
Artificial intelligence is revolutionizing healthcare administration by enhancing efficiency, accuracy, and decision-making across various processes, with medical coding standing at the forefront of this transformation. Understanding AI-driven programs and the evolution of medical coding is essential for coders to thrive in this rapidly changing landscape. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Leveraging tools like clinical decision support (CDS) systems and physician queries can improve patient care and ensure documentation integrity. Yet medical coders need to ensure they use automated guidance without overstepping into clinical decision-making, maintaining the integrity of both documentation and coding while avoiding potential misinterpretations or misrepresentations of a patient’s condition.
Because discrepancies among payers’ diagnostic standards can lead to documentation issues, coding errors, and denials, revenue integrity professionals are encouraged to increase collaboration between CDI, coding, and clinical staff when addressing varying criteria. Discover further how coders play a key role in analyzing criteria, identifying denial trends, and ensuring providers receive proper training and education.
Review a study published in a recent edition of Health Affairs that discovered which type of hospitals are not evaluating their AI tools internally for accuracy or potential biases and explored whether models developed in-house or by external developers were supported more by local evaluations.
Cheryl Ericson, RN, MS, CCDS, CDIP , explores why CMS will begin collecting data in 2025 to measure performance on the Hospital Harm from Acute Kidney Injury (HH-AKI) electronic clinical quality measures (eCQM), particularly for those who may be less familiar with eCQM.
Penny Jefferson, MSN, RN, CCDS, CCDS-O, CDIP, CCS, CRC, CPHQ, CHDA, CRCR, ACPA-C , explores the complexities surrounding the classification of hospital admit types and the challenges caused by inconsistent definitions. By being aware of admit types, coders can ensure accurate reporting, benchmarking, and quality measurement.
When denials are not justified, coding compliance auditors participate in the preparation of appeals using the content of the medical record and official reference materials that justify the coding that was submitted. Discover more about the important role coding compliance auditors play in denials management. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Follow the career journey of Patricia Shirley, CPC-I, CPC , who started as a front office staff member and advanced through billing and coding roles before transitioning to the CDI field. Her experience highlights the benefits of adaptability and continuing education, demonstrating how a solid foundation in coding and compliance can help improve patient care and ensure accurate clinical documentation.
If denials are not going anywhere anytime soon, increasing at an alarming rate, and causing organizations to close, how do hospitals ameliorate this issue? Hospitals, including coders, can work to stem it by understanding the different types of denials, the problems they pose, and the tactics required to fight them.
Q: What were the AMA’s goals for revising evaluation and management (E/M) services that were implemented starting in January 2021 and continued in January 2023?
Marc Hartstein, MA , brings together all the major highlights of Medicare’s newest Inpatient Prospective Payment System, allowing coders to stay informed about key updates and navigate the changes throughout the year.
Health information management occupies a pinnacle position in the revenue cycle, and although the span of coding’s influence throughout a healthcare organization is very broad, its effects can also be found in numerous revenue cycle spokes, including preregistration and scheduling, coverage approvals, and case management. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Coding certification can offer valuable benefits across various medical roles, improving accuracy and communication in clinical settings. Hassan Rao, MD, CPC, CCS , explores how coding knowledge can specifically enhance the effectiveness of CDI physician advisors in optimizing documentation and compliance.
Trey La Charité, MD, FACP, SFHM, CCS, CCDS , invites a deeper understanding for diagnosing and documenting acute renal failure and any other related diagnoses—before exploring the plethora of denial strategies medical staff may face. Not to worry as there are opportunities for successful appeals!
An upcoming audit reviewing Medicare inpatient hospital billing for sepsis underscores the critical importance of accurate coding and clinical validation. With guidance from Leigh Poland, RHIA, CCS, CDIP, CIC , coders can help prevent costly coding errors, reduce the risk of audits, and ensure hospitals are appropriately reimbursed for the care they provide. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
A new separate payment is available under the FY 2025 IPPS for small, independent hospitals who choose to establish and maintain access to buffer stocks of essential medicines. Learn why this initiative was created and the potential impacts on future drug shortages.
Coding professionals are critical to the compliance initiatives of any healthcare organization, and the application of codes to a claim ignites the compliance ember. Discover how key initiatives not only ensure coders act ethically and responsibly but also enhance the accuracy of coding. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Coding professionals are critical to the compliance initiatives of any healthcare organization, and the application of codes to a claim ignites the compliance ember. Discover how key initiatives not only ensure coders act ethically and responsibly but also enhance the accuracy of coding.
Certain diagnosis-related groups (DRGs) remain vulnerable to audits and denials, not only for DRG and clinical validation, but for medical necessity as well. Kim Conner, BSN, CCDS, CCDS-O , explores areas coding professionals can support when being proactive against these denials.
Denials continue to be a pain point and significant challenge for every hospital across the nation, but Angelica Cage, MBA, BSN, RN, CCDS, CCS, CDIP , provides denial-proofed queries to show how establishing a diagnosis that is strongly supported by the available clinical evidence can reduce or eliminate clinical doubt with respect to the treated condition.
To comply with a summer court order, the FY 2025 Hospital Inpatient Prospective Payment System was revised to reduce payments for low wage hospitals. Review the updated policy to understand why these adjustments were implemented and what hospitals can expect going forward.
Certain diagnosis-related groups (DRG) remain vulnerable to audits and denials, not only for DRG and clinical validation, but for medical necessity as well. Kim Conner, BSN, CCDS, CCDS-O , explores areas coding professionals can support when being proactive against these denials.
Whether the discussion is about reimbursement, quality metrics, patient outcomes, or CC/MCC capture rates, the whispers of risk adjustment have grown to a roar. Jennifer Brettler, DO, FACP, CHCQM-PHYADV , reveals just how much risk adjustment plays a role in documentation and coding integrity, impacting patient care.
Review a cross-sectional study published in the Journal of the American Medical Association that revealed people experiencing homelessness were significantly less likely to receive inpatient systemic therapy or procedures despite having a higher prevalence of more aggressive cancers and longer lengths of stay.
The majority of U.S. healthcare organizations struggle with denials and underpayments in all care settings, making it difficult to keep up with a meaningful manual appeals process. Learn how coding professionals can leverage technology to accurately capture and validate clinical data, ensuring proper coding and documentation while reducing the likelihood of denials. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Successfully managing inpatient stay denials should begin long before they occur and depends on having excellent case management, CDI, and coding departments. Although these departments have differing duties, Cathy Farraher Nakhoul, RN, BSN, MBA, CCM, CCDS , shows how they all play a part in ensuring that the final coded data is compliant and accurate.
Our experts answer questions on linking cellulitis and diabetes, coding COPD and associated conditions, and applying clinical criteria guidelines for sepsis.
The majority of U.S. healthcare organizations struggle with denials and underpayments in all care settings, making it difficult to keep up with a meaningful manual appeals process. Learn how coding professionals can leverage technology to accurately capture and validate clinical data, ensuring proper coding and documentation while reducing the likelihood of denials.
The decision to implement AI in one’s health system is no small matter, but Katie Parsley, MSN, RN, CCDS, CPHQ, a CDI manager at Providence Health and Services in Oregon, shows how technology solutions employed at her organization have had an overall positive impact on clinical accuracy, prioritization, querying, and the efficiency of CDI staff.
Shelley C. Safian, PhD, MAOM/HSM/HI, RHIA , explains ways administration can establish an organizational culture of legal and ethical responsibilities to maintain compliance and honor patients and staff.
Organizations need to decide how to manage the clinical validation conundrum effectively and consistently. Trey La Charité, MD, FACP, SFHM, CCS, CCDS, explores one denial prevention tactic that has proved most effective for his organization.
HIPAA has protocols for when patients’ protected health information can be used for research and marketing. This means you must understand privacy rule limitations and your organization’s policies and procedures before releasing any PHI in these situations. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
The best technical security in the world cannot prevent breaches of protected health information if people are careless. Coders, billers, and HIM professionals should then learn to protect confidential health information by following proper security procedures and creating effective passwords.
CMS recently finalized a multitude of new price transparency requirements in the 2024 Outpatient Prospective Payment System (OPPS) final rule. These requirements have staggered enforcement deadlines, which means that revenue integrity professionals have their work cut out for them in the coming year to ensure their organization is in compliance.
CMS recently finalized a multitude of new price transparency requirements in the 2024 Outpatient Prospective Payment System (OPPS) final rule. These requirements have staggered enforcement deadlines, which means that revenue integrity professionals have their work cut out for them in the coming year to ensure their organization is in compliance.
Shelley C. Safian, PhD, MAOM/HSM/HI, RHIA , explains ways administration can establish an organizational culture of legal and ethical responsibilities to maintain compliance and honor patients and staff.
The success of coding and CDI departments depends on collaboration with multiple entities. Laurie L. Prescott, RN, MSN, CCDS, CCDS-O, CDIP, CRC , illuminates how to promote healthy partnership.
Kathy Dorich, MSN, RN, CCDS, CPHQ , explains two types of DRG reconciliation processes that she has implemented to alleviate conflict between coding and CDI departments.
Verbal conversations with providers regarding reportable conditions and procedures are considered verbal queries. Refresh how they should be memorialized within the record to maintain compliance. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
by Sareem Wani, MD I recently took a personality test and, after answering a series of questions based on various case scenarios, learned that my strengths are in collaboration and education. It took...
Make sure staff who handle audit requests understand when a missing signature should—or should not—trigger an automatic denial of your claims or prior authorization requests. Recent guidance from CMS clarifies how auditors should proceed when a medical record lacks a signature.
Penny Jefferson, MSN, RN, CCDS, CCDS-O, CCS, CDIP, CRC, CHDA, CRCR, CPHQ , and Mercedes K. C. Dullum, MD, FACS, FACC , describe the advantages of creating CDI programs in outpatient settings and how they can decrease gaps in patient care and improve financial management.
Merle Zuel, RN, CCDS , explains how healthcare leaders can improve in their roles by understanding all coding and clinical data available and knowing how to analyze it.
