CMS proposed an extensive five-year, two-phase plan to overhaul Part B drug payments for physicians and hospitals in March outside of the normal OPPS rulemaking cycle that could be implemented as early as this fall.
Few in the healthcare industry would argue that the way the government currently pays for drugs is the most cost-effective, efficient, and equitable method possible.
Q: Our providers are reluctant to document a correlation between symptoms and a true diagnosis. Do you have any good ways to get them to do this? For example, our providers document "diabetes" but they often don't include additional details that should be there (e.g., gestational diabetes or type II diabetes mellitus in pregnancy).
Jugna Shah, MPH, looks at CMS’ new proposal to implement a new drug payment model for certain providers and how they can comment in order to the agency about its impact on their facilities.
CMS released a list of the thousands of new ICD-10-CM and ICD-10-PCS codes set to be activated October 1, 2016, as part of the 2017 IPPS proposed rule.
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP, writes about terminology coders will encounter in documentation for Pap tests and other cervical cancer screening report
CMS allows, and sometimes requires, providers to report certain modifiers in order to identify when a service has been provided by different types of therapists. Review the requirements for reporting modifiers –GN, -GO, -GP, and –KX.
Q: We have a teenager with systemic lupus erythematosus and history of lupus nephritis who came into the ED with seizures. The physician admitted the patient with documentation of with status epilepticus and hypertensive urgency. The intensivists then documented hypertensive encephalopathy. What should we choose as the principal diagnosis?
CMS issued the fiscal year 2017 IPPS proposed rule yesterday with updates to several quality initiatives and a reversal of the agency’s 0.2% payment reduction instituted along with the 2-midnight rule in the FY 2014 rule.
ICD-10-PCS defines the root operations in very specific ways and coders need to know the definitions and the nuances of the root operations. Learn more about root operations that involve the physician looking at a patient, Inspection and Map.
Anny Pang Yuen, RHIA, CCS, CCDS, CDIP and Laurie Prescott, MSN, RN, CCDS, CDIP discuss how for the past few years, healthcare professionals have focused on ICD-10 preparation, and while prep work paid off and the transition has been largely successful, facilities are experiencing a few bumps as their focus shifts from preparation to improvement of clinical documentation and coding.
Robert S. Gold, MD, writes about the significant changes in documentation needs for diseases of the brain and how this can affect patient data, as well as the treatment needs of the patients both during a hospital stay and afterward.
Pregnant patients with other health issues can lead to complicated coding scenarios. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP, writes about the clinical documentation necessary to identify certain complications and how coders can report these diagnoses. 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.
CMS has proposed a new drug payment model that could impact providers nationwide. Jugna Shah, MPH, reviews the multiple stages of the rule and how providers can comment to CMS about the proposed changes.
Q: Can CPT® code 76700 (ultrasound, abdominal, real time with image documentation; complete) be coded with 76770 (ultrasound, retroperitoneal [e.g., renal, aorta, nodes], real time with image documentation; limited) on the same date of service during the same session?
E/M services resulted in a projected $4.5 billion in improper Medicare payments in 2014, according to the April 2016 Medicare Quarterly Compliance Newsletter, accounting for 9.3% of the overall Medicare fee-for-service improper payment rate.
Richard D. Pinson, MD, FACP, CCS , describes the Third International Consensus Definitions for sepsis and septic shock as published on February 23 in the Journal of the American Medical Association , and what the impact will be for both clinicians and coders.
When the Quality Improvement Organizations (QIO) took over the role of education and enforcement for the 2-midnight rule on October 1, 2015, many anticipated that their reviews would only look at records from that date forward, but some hospitals have reported QIO record requests zeroing in on cases as far back as May 2015 and requesting charts for inpatient-only surgeries.
An infographic newly released by CMS guides healthcare providers toward better assessing, addressing, and maintaining progress since ICD-10 implementation. Identifying key performance indicators and creating baselines for KPI analysis are important steps in tracking progress, says CMS.
Q: We are having trouble determining how to assign a code for a pressure ulcer that begins as a Stage I concern that is present on admission (POA) but advances during the patient’s stay to a Stage II or a Stage III. Coding Clinic, Fourth Quarter 2008, p. 194, tells us that even if the ulcer advances it would still be coded as POA, but would even an advanced stage still be considered POA?
Shannon Newell, RHIA, CCS, AHIMA-approved ICD-10-CM/PCS trainer, explains how under the Comprehensive Care for Joint Replacement, acute care hospitals in selected geographic areas assume quality and payment accountability for retrospectively calculated bundled payments for lower extremity joint replacement episodes, and how this now requires a CDI evolution.
There have been some significant changes in documentation needs for diseases of the brain since October 2015. These can affect accurate patient data as well as providing information for the treatment needs of the patients both during a hospital stay and afterwards. They will enable patient information to be available to all providers and ensure that you get paid appropriately for the complexity of the patients under your care.
The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)¹ as published on February 23 in the Journal of the American Medical Association represents a radical departure from the prior sepsis definitions in 1991² (identified as Sepsis-1) and 2001³ (identified as Sepsis-2) and subsequent Surviving Sepsis Campaign (SSC) guidelines through 2015.
Under the CJR, which began April 1, acute care hospitals in selected geographic areas assume quality and payment accountability for retrospectively calculated bundled payments for lower extremity joint replacement (LEJR) episodes. Episodes begin with admission to an acute care hospital for an LEJR procedure that is paid under the IPPS through MS-DRGs 469 or 470 (Major joint replacement or reattachment of lower extremity with or without MCC, respectively) and end 90 days after the date of discharge from the hospital.
In February 2016, just four months after ICD-10 go-live, sister publication HIM Briefings (formerly Medical Records Briefing ) asked a range of healthcare professionals to weigh in on their productivity in ICD-9 versus ICD-10.
The new modifier -PO (services, procedures, and/or surgeries furnished at off-campus provider-based outpatient departments [PBD]) and the alternative payment provisions under the Bipartisan Budget Act Section 603 are both related to off-campus PBDs but define "off-campus PBD" slightly differently.
ICD-10 implementation represented an unprecedented challenge for the U.S. healthcare system. Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, writes about the impact of the change by looking at survey results that compare ICD-10 productivity benchmarks to ICD-9-CM.
Providers need to keep more in mind than just diagnosis and procedure coding when performing sterilizations for men and women. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP, reviews the requirements for sterilizations and the part coders can play in avoiding denials.
Respondents to HCPro’s 2016 ICD-10 survey share their challenges and successes since implementation, while Monica Pappas, RHIA, and Darice M. Grzybowski, MA, RHIA, FAHIMA, offer their thoughts on the impact of ICD-10.
Q: What is the proper ICD-10-CM coding for bilateral hip pain? Should we report M25.551 (pain in right hip) and M25.552 (pain in left hip) or M25.559 (pain in unspecified hip)?
The Centers for Disease Control and Prevention released new guidance last week with updated clinical recommendations for patients exposed to the Zika virus and also announced a registry for pregnant women infected with the virus.
On March 9 and 10, CMS held the ICD-10 Coordination and Maintenance Committee meeting to discuss approving changes, additions, and other modifications to the ICD-10 code set.
The AHA's Coding Clinic for ICD-10-CM/PCS , Third Quarter 2015, opens with a discussion of the differences between excisional and non-excisional debridement-diagnoses with a long history of coding and clinical documentation confusion, explains Sharme Brodie, RN, CCDS.
Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I , AHIMA-approved ICD-10-CM/PCS trainer, writes about key details in documentation that coders will need to look for in order to report procedures using the root operation Dilation.
Q: Can you clarify the expectations related to documenting the discussion between a physician and a clinical documentation improvement specialist when a query is done verbally? The 2013 ACDIS/AHIMA physician query practice brief Guidelines for Achieving a Compliant Query Practice expanded on the need to document this interaction and we’re wondering if our process is compliant.
Barbara A. Anderson, RN, MSM, says that in 2014, 66% of 318 hospitals surveyed by AHIMA had a CDI program in place. Anderson explains how CDI programs can be a valuable bridge between clinical care and coding at hospitals, and gives examples on how to improve upon a facility’s program.
Q: Our physicians sign off on diagnoses that the nursing staff prepares on admission of a new patient, can you suggest a process to capture all relevant diagnoses?
A recent Association of Clinical Documentation Improvement Specialists poll says that 53% of respondents are not experiencing any real problems with ICD-10-CM/PCS, but coding experts have identified a few tricky diagnoses for coders to be aware of.
Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I , and AHIMA-approved ICD-10-CM/PCS trainer, writes that reporting imaging, nuclear medicine, and radiation therapy procedures will dramatically change depending upon whether the patient has been admitted into a hospital or is being cared for as an outpatient
According to the American Hospital Association’s 2015 fourth quarter RACTrac survey, the most commonly cited reason for a Recovery Auditor’s complex claim denial is due to an inpatient coding error.
Cyndi Pickney, DO, FACP explains that as ICD-10 implementation approached last year, organizations reported varying levels of readiness and understanding of the impact on physician workflow, and now, there are unforeseen consequences.
Drug administration services follow a hierarchy for reporting, but coding can become complex when providers administer multiple drugs. Review these tips to help tackle tough injection and infusion scenarios.
Implementation of electronic health record (EHR) systems can reduce queries and create more standardized documentation for providers, but now, according to a study published by the Journal of Patient Safety , EHRs are also linked to fewer in-hospital patient complications.
Q: When a foreign body is removed from the eye, does it matter what instrumentation is used to remove it? We recently had two cases in which the ED physician stated that the foreign body was easily removed with a cotton swab. She is questioning whether we should charge (facility and professional) for this type of removal or whether it should just be considered when determining the E/M level.
Reporting modifier –PO (services, procedures, and/or surgeries furnished at off-campus provider-based outpatient departments) only recently became mandatory, but new rules and regulations could change the requirements in certain settings. Kimberly Anderwood Hoy Baker, JD, CPC, reviews recent legislation that could have an impact on modifier –PO and looks ahead to when CMS intends to offer more guidance.
