The selection of the principal diagnosis is one of the most important steps when coding an inpatient record. The diagnosis reflects the reason the patient sought medical care, and the principal diagnosis can drive reimbursement.
In today’s ever-changing healthcare landscape, emphasis is shifting away from fee-for-service to pay-for-performance, from volume-based care to value-based reimbursement, and from case-mix index to outcome measures.
Erica E. Remer, MD, FACEP, CCDS , explains what clinical validation denials are, how they are determined, and how a coder can help to limit these rebuffs.
Amber Sterling, RN, BSN, CCDS , and Jana Armstrong, RHIA, CPC , discuss revenue integrity and how it focuses on three operational pillars: clinical coding, clinical documentation improvement, and physician education.
James S. Kennedy, MD, CCS, CDIP, discusses bundled payments and the importance of applying proper ICD-10-CM/PCS-pertinent documentation and coding principles to remain compliant.
Clinical documentation improvement managers discuss their management duties and program priorities and how they strive for the best possible results at their facility.
Crystal R. Stalter, CPC, CCS-P, CDIP, writes about how fully specified documentation is the key to quality care, compliance, and eventual reimbursement, and how documentation software can help to streamline these processes.
Optimal ICD-10 accuracy cannot be achieved by simply looking up a code in an encoder or book. Knowing the rationale for what you are coding, why you are applying one code versus another, and having the knowledge base to correctly apply the 2017 Official Guidelines for Coding and Reporting are the ingredients necessary for accurate clinical coding.
In promoting ICD-10-CM coding integrity and compliance, cerebrovascular disease represents one of the greatest challenges for providers and coders alike. It seems that clinicians, ICD-10-CM, and risk-adjusters (those who create the DRG system), do not sing the same tune.
The 2017 ICD-10-CM Official Guidelines for Coding and Reporting brought many changes and updates for coders, and present-on-admission (POA) reporting was not excluded. Completely understanding POA guidelines is necessary for any inpatient coder.
Clinical validation denials (CVD) result from a review by a clinician, such as a registered nurse, contractor medical director, or therapist, who concludes retrospectively that a patient was not really afflicted by a condition that was documented in the medical record and coded by the coder.
James S. Kennedy, MD, CCS, CDIP, reviews important coding recommendations mentioned in various Medicare Quarterly Provider Compliance Newsletters, covering the MS-DRG postacute discharge policy, readmissions to the same hospital on the day of discharge, and postoperative respiratory failure.
Laura Legg, RHIT, CCS, CDIP, writes about the new round of Recovery Auditor (RA) contracts, and how even the most experienced RA response team will need to understand the new challenges providers face with CMS’ 2017 changes. 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.
The advent of the electronic record changed (EHR) how clinical documentation improvement specialists work with providers and coders. As more healthcare organizations take on the arduous process of implementing an EHR, new challenges and considerations arise.
One of my favorite sayings when teaching clinical documentation integrity, as well as coding, is that a good lawyer knows the law, but a better lawyer knows the law, the judge, and the jury. In learning the judge and the jury, one of my favorite references is the Medicare Quarterly Provider Compliance Newsletter , an official CMS publication written in plain language that serves as a summary of how Medicare and its contractors interpret the Medicare rules, regulations, and policy statements.
Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS , writes about how one of the many coder obligations is to report noncompliant activities and provides information on how to do this anonymously. 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.
James S. Kennedy, MD, CCS, CDIP, says that since the clinical intent and language of physicians does not translate into the administrative language of ICD-10-CM, understanding and embracing both their clinical foundations is essential to accurately measure outcomes and ensure coding compliance.
Shannon Newell, RHIA, CCS, explains that pneumonia discharges impact hospital payments under the Hospital Value-Based Purchasing Program, as well as the Hospital Readmission Reduction Program, and conveys what CDI teams can do to help.
Pneumonia discharges impact hospital payments under the Hospital Value-Based Purchasing Program, as well as the Hospital Readmission Reduction Program.
Trey La Charité, MD, FACP, CCDS , notes that getting a handle on a facilities’ case-mix index (CMI) fluctuations can be difficult, and shares insights to how CDI teams can handle these CMI difficulties.
Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP , writes about how the selection of the code and a principal diagnosis seems fairly straightforward, but there are multiple factors that must be considered and reviewed before a coder can assign a certain diagnosis as principal.
The 30-day all cause acute myocardial infarction (AMI) mortality outcome measure has been linked to hospital payments since the inception of the Hospital Value-Based Purchasing Program (HVBP) in fiscal year 2013. In February 2016, CMS announced that 70% of commercial payers have agreed to use this measure as one of the cardiology outcomes linked to payment.
The world didn’t end on October 1, 2015. After years of postponement, the proverbial “deal with the devil” made between CMS and the AMA to push ahead with ICD-10-CM/PCS implementation was a year’s grace period during which physician practices could continue using unspecified codes without worrying about Medicare denials or auditor reviews.
CMS announced that 70% of commercial payers have agreed to use the 30-day all cause acute myocardial infarction mortality outcome measure as one of the cardiology outcomes linked to payment. Shannon Newell, RHIA, CCS , writes about how CDI teams can best prepare for these upcoming changes.
Since the physician doesn't need to document a specific root operation, coders cannot rely solely on the terms the physician uses; thus it is important for each coder to fully understand each definition. This article takes a look at the root operations Inspection, Map, Dilation, and Bypass. Note: To access this free article, make sure you first register for the free content if you do not have a paid subscription.
After a year full of numerous coding changes, Laurie L. Prescott, RN, MSN, CCDS, CDIP , takes a closer look at 12 new guidelines that will affect CDI and helps coders better understand these recommendations.
Now that we’ve had over a year to get comfortable with our ICD-10-PCS manuals, the 2017 updates to the guidelines and tables turned a lot of what we learned onto its ear. The update brought 3,827 changes to ICD-10-PCS, with the majority of the changes occurring in the heart and great vessels section of the manual. Redefined body part characters, as well as additions of new device characters, left inpatient coders wondering: What does this all mean and how am I supposed to code it?
Bronchopulmonary infections, such as acute bronchitis and pneumonia, are frequent reasons for physician and facility encounters. These encounters result in ICD-10-CM code assignments that factor greatly in severity and risk adjustment inherent to the Patient Protection and Affordable Care Act and the recently implemented Medicare Access & CHIP Reauthorization Act of 2015.
Laura Legg, RHIT, CCS, CDIP, AHIMA-approved ICD-10-CM/PCS trainer, writes that coders need to review the newly released coding guidelines in detail in order to understand the changes and implications the new standard for clinical validation has on their facilities.
Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP , reviews changes that were made in the 2017 ICD-10-PCS Official Guidelines for Coding and Reporting to arteries and stents. Note: To access this free article, make sure you first register for the free content if you do not have a paid subscription.
MS-DRG audits are nothing new, but their frequency has significantly increased over the last two years. In this article, Sam Antonios, MD, FACP, FHM, CPE, CCDS , gives facilities tips to increase the likelihood of overturning MS-DRG denials.
Erica E. Remer, MD, FACEP, CCDS, writes about how using unspecified diagnoses in the inpatient world results in deflated quality metrics. Remer helps clinical documentation specialists remedy the situation and gives advices on how to aid providers in documenting to the level of specificity that is now needed.
Shannon Newell, RHIA, CCS, discusses a refined version of the Patient Safety Indicator (PSI) 90 composite by the Agency for Healthcare Research and Quality, and how it has a significant impact on what discharges are included in PSI 15. Note: To access this free article, make sure you first register for the free content if you do not have a paid subscription.
Providers are still working to understand the impact of the February release of the controversial third international consensus definitions for sepsis and septic shock. James S. Kennedy, MD, CCS, CDIP , tackles this new sepsis definition in part two of his two-part series.
As if coders and clinical documentation improvement specialists aren't under enough pressure as it is, the advent of the 2017 Official Guidelines for Coding and Reporting brings to the table new documentation requirements for pressure ulcer coding. The guidelines can be viewed here: www.cdc.gov/nchs/data/icd/10cmguidelines_2017_final.pdf .
This article is part two of a two-part series on the definition changes for sepsis. Reread part one in the October issue of BCCS. In my October Clinically Speaking column, we discussed the evolution of the definition of sepsis and its implications in clinical care (Sepsis-1, Sepsis-2, and Sepsis-3), quality measurement (CMS' SEP-1 core measure), and ICD-10-CM coding compliance.
The recent adoption of a refined version of the Patient Safety Indicator (PSI) 90 composite by the Agency forHealthcare Research and Quality (AHRQ) has a significant impact on what discharges are included in PSI 15 (Unrecognized Abdominopelvic Accidental Puncture Laceration Rate).
The new guideline for code assignment and clinical criteria in the 2017 ICD-10-CM Official Guidelines for Coding and Reporting does not mean clinical documentation improvement is going away; instead it just upped the ante for continued improvement.
With all the hoopla over sepsis, pressure ulcers, and diabetes coding, there’s a little gem of coding advice that has been overlooked since ICD-10 was released: pneumonia and chronic obstructive pulmonary disease. Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP , writes about these changes and helps to decipher the new guideline changes. Note: To access this free article, make sure you first register for the free content if you do not have a paid subscription.
This October celebrates the eight month anniversary of the February release of the controversial third international consensus definitions for sepsis and septic shock. James S. Kennedy, MD, CCS, CDIP , tackles this new sepsis definition in part one of his two-part series.
Trey La Charité, MD , writes about how he feels the days of merely maintaining compliance with published coding guidelines are gone, and suggests ways to protect a facility and appeal audits.
Since the physician doesn't need to document a specific root operation, coders cannot rely solely on the terms the physician uses; thus it is important for each coder to fully understand each definition, including the root operations that put in, put back, or move some or all of a body part.
Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP, discusses the new documentation requirements for pressure ulcer coding in the 2017 Official Guidelines for Coding and Reporting. Note: To access this free article, make sure you first register for the free content if you do not have a paid subscription.
Shannon Newell, RHIA, CCS, writes about how certain hospitals will be required to participate in the Comprehensive Joint Replacement Model and a new orthopedic payment model called SHFFT if an August 2 proposed rule is finalized.
If your hospital resides in one of the 67 metropolitan statistical areas (MSA) required to participate in the Comprehensive Joint Replacement Model (CJR), you will also be required to participate in a new orthopedic payment model called SHFFT (surgical hip and femur fracture treatment) if an August 2 proposed rule is finalized.
Resiliency is the ability to spring back or rebound. In sports, it's one of the mental attributes a player must have. Coders are resilient: bouncing back from one change after another, deciding to code smarter and faster, and having the patience to do whatever is expected?even amid closing grace periods and guideline controversies.
In our computer-savvy tech world, the medical field has been notoriously slow to respond to newer technologies and applications of computer-assisted enhancements. However, in the HIM market, computer-assisted coding (CAC) has been touted to boost coding accuracy and productivity, in addition to being an important tool for the remote inpatient coder.
Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CRC, CCDS, continues her review of the updated 2017 ICD-10-CM guidelines by explaining how changes to sections for laterality and non-provider documentation will impact coders and physicians. 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.
Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CRC, CCDS, delves into chapter-specific guidance included in the updated 2017 ICD-10-CM guidelines, including changes for diabetes, hypertension, pressure ulcers, and more.
Laurie L. Prescott, MSN, RN, CCDS, CDIP , writes that as many CDI teams work to expand their risk adjustment programs, a melding of two skill sets, that of CDI specialists and coding professionals, are required to succeed.
Laura Legg, RHIT, CCS, CDIP , explains how the coming months will prove to be challenging for coders because of the new ICD-10 codes for both diagnoses and procedures beginning October 1. Along with that, we’ll see the end of the CMS grace period on code specificity for Part B physician payments and updated ICD-10-CM Official Coding Guidelines .
Since the physician doesn't need to document a specific root operation, coders cannot rely solely on the terms the physician uses; thus it is important for each coder to fully understand each root operation, including Restriction and Occlusion. Note: To access this free article, make sure you first register if you do not have a paid subscription.
Sharme Brodie, RN, CCDS , discusses how to decipher between some potentially confusing—and possibly conflicting—information regarding diabetes documentation requirements.
Q: The coders at my facility have started automatically linking congestive heart failure, hypertension, and chronic kidney disease (CKD) to the combination code without any documentation of CHF “due to” hypertension. There is no documentation of hypertensive heart disease anywhere in the record, and the diagnoses are not linked anywhere in the record.
CMS released a national coverage determination recently covering a percutaneous left atrial appendage closure through their “coverage with evidence development” policy. CMS says this policy will be fully implemented on October 3, 2016.
Accurately reporting altered mental status and encephalopathy can be a challenge that requires coordination between coders and providers. James S. Kennedy, MD, CCS, CDIP, explains best practices for coding these tricky conditions. Note: To access this free article, make sure you first register if you do not have a paid subscription.
Shannon Newell, RHIA, CCS, AHIMA-approved ICD-10-CM/PCS trainer, writes that the majority of the 2017 IPPS final rule updates are consistent with those outlined in the proposed rule, but contain a few refinements. She reviews refinements to the number of claims-based outcomes linked to payment.
CMS released the fiscal year (FY) 2017 IPPS final rule August 2, and ICD-10-CM/PCS code changes and the addition of the Medicare Outpatient Observation Notice (MOON) both had starring roles. CMS also made changes to several quality initiatives and reversed the agency's 0.2% payment reduction instituted along with the 2-midnight rule first implemented in the FY 2014 rule.
Last month, I wrote about the role of coding and CDI compliance in ensuring the clinical validity of submitted ICD-10-CM/PCS codes, which impact payment, outcomes measurement (e.g., complications, mortality, and readmissions), and patient safety.
The fiscal year (FY) 2017 IPPS final rule was released August 2 and will be published in the Federal Register August 22. The majority of the finalized updates are consistent with those outlined in the proposed rule, but with a few refinements to applicable time periods. The final rule expands and refines the number of claims-based outcomes linked to payment under these programs. Let's review a few of the key changes to support your CDI program's strategic focus for the coming year.
Robert Stein, MD, CCDS, and Shannon Newell, RHIA, CCS, co-author this article that provides insights into how clinical documentation and reported codes may impact payments and offer guidance on some common CDI challenges to strengthening data quality. Note: To access this free article, make sure you first register if you do not have a paid subscription.
Richard D. Pinson, MD, FACP, CCS , discusses the new Sepsis-3 definition and how the classification has been the subject of great controversy and consternation since its publication in The Journal of the American Medical Association.
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP , writes about how computer-assisted coding software can be used to boost coding accuracy and productivity, in addition to being an important tool for the remote coder.
James Kennedy, MD, CCS, CDIP , offers his take on AHIMA’s recently published clinical validation practice brief. Given that AHIMA is one of the ICD-10 Cooperating Parties, their practice briefs must be read closely, and if agreeable, incorporated into one’s compliance plan. Note: To access this free article, make sure you first register if you do not have a paid subscription.
Shannon Newell, RHIA, CCS, writes about recently proposed modifications to Patient Safety Indicator 90, and how a fact sheet released by the measure's owner, the Agency for Healthcare Research and Quality, provides insights into what changes may lie ahead.
"You are your own best teacher," or so the old adage goes. Sure, goodies and gifts are great for recognizing high-quality documentation, but for CDI teams struggling to obtain physician buy-in, the best strategy may be found in their providers' own records.
The accurate capture of acute respiratory failure has been a long-standing challenge for CDI programs. The accurate reporting of this condition as a post-procedural event can be even more difficult.
We as coders, clinical documentation specialists, and compliance officers, are actively invested in coding compliance, aren't we? AHIMA and ACDIS emphasize coding compliance in their codes of ethics. If we aren't interested in coding compliance, why are we reading newsletters named Briefings in Coding Compliance Strategies and other similar publications?
Since the physician doesn't need to use a specific root operation term in documentation, coders should not rely solely on the term the physician uses. Coders need to know the definitions and the nuances of the root operations, especially those involving a device.
Laurie L. Prescott, MSN, RN, CCDS, CDIP, provides coders with tips on coding heart failure, obstetrics, and linking language, and also offers the latest guidance given by AHA Coding Clinic for ICD-10-CM/PCS ® on these topics.
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP, address the inpatient side of bariatric surgery, and how obesity and body mass index play a role in coding.
Paul Evans, RHIA, CCS, CCS-P, CCDS, give coders ICD-10-PCS documentation and coding tips for three of the most common, and commonly misunderstood, procedures performed via bronchoscopy.
Since the physician doesn't need to document a specific root operation, coders cannot rely solely on the terms the physician uses; thus it is important for each coder to fully understand each root operation, especially Control and Repair. Note: To access this free article, make sure you first register if you do not have a paid subscription.
Allow me to introduce myself as the new columnist for the "Clinically Speaking" section of Briefings on Coding Compliance Strategies after the recent passing of Dr. Bob Gold. My hope is that this column will continue his legacy of helping you promote complete, precise, and clinically congruent ICD-10-CM/PCS code assignments resulting in defendable DRG assignment and applicable severity and risk adjustment. Thank you for this privilege of writing to you; I solicit your feedback and advice.
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.
Following are some ICD-10-PCS documentation and coding tips for three of the most common (and commonly misunderstood/miscoded) procedures performed via bronchoscopy.
If you've ever read an issue of HCPro's flagship newsletter HIM Briefings, if you've ever picked up an issue of Briefings on Coding Compliance Strategies and turned to the column "Clinically Speaking," if you've been a regular listener of HCPro's HIM or CDI audio conferences or webinars, if you're a member of the Association of Clinical Documentation Improvement Specialists (ACDIS) and subscribe to the "CDI Talk" newsgroup or listen to the ACDIS quarterly conference calls, chances are you've encountered the phenomenon known as Robert Gold, MD.
The last few weeks have brought us some direction, though, including the release of approximately 1,900 new ICD-10-CM codes for 2017. (The list can be found on CMS' website.) We also have a list of approximately 3,600 new ICD-10-PCS codes for 2017. (This is also available on CMS' site.) Of course, we will also be looking for changes in DRG mappings and the CC/MCC lists, which will likely appear later this summer.
The fiscal year (FY) 2017 IPPS proposed rule alerted us to some significant changes to Patient Safety Indicator (PSI) 90, one of which is a new name: the Patient Safety and Adverse Events Composite. A fact sheet released by the measure's owner, the Agency for Healthcare Research and Quality (AHRQ), provides insights into what may lie ahead if the proposed rule's content is finalized.
Michelle M. Wieczorek, RN, RHIT, CPHQ, discusses how documentation and coding can impact your facility’s data reported for hospital-acquired conditions and present on admission indicators.
Shannon Newell, RHIA, CCS , AHIMA-approved ICD-10-CM/PCS trainer, writes about significant changes to PSI 90 in the 2017 IPPS proposed rule, one of which is a new name–The Patient Safety and Adverse Events Composite.
Kimberly Cunningham, CPC, CIC, CCS , and other professionals comment on commonly seen MS-DRGs and inpatient conditions, including which terms coders need to look for in documentation to arrive at the most accurate MS-DRG and codes. Note: To access this free article, make sure you first register if you do not have a paid subscription.
Katy Good, RN, BSN, CCDS, CCS, Paul Evans, RHIA, CCS, CCS-P, CCDS, Laurie Prescott, MSN, RN, CCDS, and Gloryanne Bryant, BS, RHIA, CDIP, CCS, CCDS, all comment on how over-querying is a common concern in clinical document improvement, and how over-querying can cause delays in documentation and coding processes.
Shannon Newell, RHIA, CCS , AHIMA-approved ICD-10-CM/PCS trainer discusses modifications and expansions to claims-based quality and cost outcome measures in the 2017 IPPS proposed rule. Note: To access this free article, make sure you first register if you do not have a paid subscription.
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.
The FY 2017 IPPS proposed rule released April 27 is replete with modifications and expansions to claims-based quality and cost outcome measures. Although many of these proposed changes are for future fiscal years, ICD-10 codes reported for current discharges will impact the future financial performance for our organizations.
The FY 2017 IPPS proposed rule includes updates to payment rates and quality initiatives, but some of the most extensive changes pertain to proposals for certain MS-DRG classifications and relative weights.
