When building a successful proactive clinical documentation approach, the effort of setting up communication dynamics is essential and should certainly be a priority.
Just like their inpatient acute care counterparts, inpatient psychiatric facilities use ICD-10-CM codes, but their payment structure, documentation requirements, prevalent clinical conditions, and additional documentation requirements needing capture are vastly different.
Though larger facilities may have had CDI programs for years that work in conjunction with the inpatient coders—some for over a decade—others are only starting now.
Allen Frady, RN-BSN, CCDS, CCS, CRC, reviews proposed changes applicable to coding and CDI teams within the fiscal year (FY) 2019 IPPS proposed rule including HIV disease, ARDS, and CC/MCC changes.
Allen Frady, RN-BSN, CCDS, CCS, CRC, reviews various guidance related to clinical validation to help coders and CDI teams better navigate the complex topic.
When planning to implement a coding auditing program, the type of reviews, focus areas, and review frequency must all be taken into consideration. Rose T. Dunn, MBA, RHIA, CPA/CGMA, FACHE, FHFMA, CHPS , details how to conduct an effective coding audit and ensure compliance with documentation requirements.
Allen Frady, RN-BSN, CCDS, CCS, CRC, writes about guidance related to documenting acute respiratory insufficiency and gives tips to coders and CDI teams on what to do when the conditions are over-documented postoperatively.
Telehealth services continue to expand and claims for these services may already be under scrutiny by Medicare contractors. Debbie Mackaman, RHIA, CPCO, CCDS, writes about the differences between originating site and distant site services in addition to coding, billing, and reimbursement for telehealth services.
Coders and clinical documentation improvement specialists play a key role in the success of quality payment programs such as MIPS. This article describes the financial impact that hierarchical condition category coding has on provider reimbursement and the coder’s role in ensuring complete, accurate, and timely documentation. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Laurie L. Prescott, RN, MSN, CCDS, CDIP, CRC, writes that even though CDI specialists are not coders, it’s important to learn the rules and guidelines that coders follow. CDI teams need to reference guidance and guidelines in their daily work to ensure documentation is clear, concise, and supportive of accurate code assignment true to the patient’s story.
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.
Paul Evans, RHIA, CCDS, CCS, CCS-P, tackles the various characteristics of creating a query and says that while all portions of any program, such as education and metrics, are important, the proper formulation of a query represents the most important task for a CDI professional.
Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CRC, CCDS , writes about discussions at the 2017 AMA CPT Symposium that could impact coders, including issues with the Table of Risk for E/M office visit codes and suggestions for E/M guideline revisions. This article is part two in a series.
Allen Frady, RN-BSN, CCDS, CCS, CRC, explains the value of tracking and understanding key performance indicators (KPI), and gives advice on how facilities can improve on its practices.
The amount of energy it takes to stay up to date on all the relevant payment and coding updates can be overwhelming, taking valuable time away from daily record review duties and activities.
Emergency departments at designated trauma centers encounter some of the most complex patients—and with them, a complicated documentation web that’s difficult to untangle, making trauma case review essential for hospitals.
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.
Lynelle A. Clausen, RN, BSN, writes about the struggles she faces as a CDI specialist when dealing with vague documentation, lack of criteria, and the reporting of malnutrition.
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.
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.
Sharme Brodie, RN, CCDS, reviews the most recent Coding Clinic guidance, which touches on common coding conundrums from subjects such as clostridium difficile, diabetes with ketoacidosis, myocardial infarction, pulmonary hypertension, and more.
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.
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.
Documentation is crucial for the development of data reflecting the healthcare needs of domestic violence victims. Yvette DeVay, MHA, CPMA, CPC, CIC, CPC-I , explains how to properly screen for and code incidents of domestic violence.
A Comprehensive Error Rate Testing (CERT) study showed insufficient documentation causes most improper payments for arthroscopic rotator cuff repairs, according to the October 2017 Medicare Quarterly Compliance Newsletter .
The new ICD-10-CM codes for FY 2018, effective October 1, represent significant changes in some hospital documentation and coding practices. James S. Kennedy, MD, CCS, CDIP, CCDS , reviews some of the most significant revisions to the ICD-10-CM guidelines for 2018.
Compliance is more than just abiding by coding guidelines and payer policy. Coding professionals must become familiar with ethical standards and federal regulations to avoid facing denials or federal penalties. Note: To access this free article, make sure you first register here if you do not have a paid subscription.
Mortality reviews pose a special challenge—not only does the CDI specialist need to know the ins and outs of severity of illness and risk of mortality, but the cases themselves are typically more complicated than an average hospital stay, making these essential reviews even more complex.
Appeal writing, like most things in a hospital, is a learned skill. Keeping things simple, both in terms of the arguments constructed and the language used in the letters themselves, will prevent you from creating horrific monstrosities out of minor gremlins.
Changes to the ICD-10-CM guidelines go into effect October 1, and coders will need to master knowledge of alterations to the general coding guidelines as well as new additions to guidelines on reporting diabetes, substance abuse, and myocardial infarctions. Note: To access this free article, make sure you first register here if you do not have a paid subscription.
The rise of clinical documentation improvement programs was a game changer for inpatient documentation. Now, the Quality Payment Program and similar systems are creating an opportunity for CDI to expand into the outpatient arena.
Outpatient coding’s impact on reimbursement is evolving as healthcare continues its march toward value-based care. Kim Miller, CPC, CHC , and Kerri Wing, RN, MS , detail how coders play a central role in this shift.
Crystal Stalter, CDIP, CCS-P, CPC, writes that with the release of the 2018 IPPS final rule, hospitals around the country are poring over it to see what impact the changes might bring to their case-mix index, quality initiatives, and overall reimbursement. In the midst of this are coders and CDI specialists who need to be kept abreast of these changes.
James S. Kennedy, MD, CCS, CDIP , discusses the new ICD-10-CM codes for FY 2018 and describes some of the changes that could be made to documentation and billing habits for these conditions.
With the increased focus on clinical documentation improvement in the outpatient arena, Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, shares her tips for proving medical necessity on claims.
James S. Kennedy, MD, CCS, CDIP, writes that while you might have thought you’ve finally mastered coding compliance with DRGs and quality measures, now it is time to learn the compliance risks and opportunities with a new risk-adjustment method: Hierarchical Condition Categories.
Daniel E. Catalano, MD, FACOG, says that from the CDI perspective, the ability to communicate pediatric severity of illness is complicated by the fact that pediatricians have a lexicon that is not well captured in ICD-10-CM. This, he writes, is especially true for pediatric cardiology.
In ICD-10-CM, defining, diagnosing, and documenting the various forms of altered mental status and their underlying causes remains an ongoing challenge for physicians and their facilities, according to James S. Kennedy, MD, CCS, CDIP .
The Quality Payment Program proposed rule seems to bring relief to providers anticipating escalation of Medicare Access and CHIP Reauthorization Act (MACRA) requirements, but there are a plethora of reasons for coding professionals to start adapting their workflow for MACRA now. Note: To access this free article, make sure you first register here if you do not have a paid subscription.
When someone decides to enter the world of medical coding, they usually start off coding for obstetric and newborn charts. After coding for a month or two, the newbie coder is transitioned to low-dollar queues; usually encompassing charts $10,000 and less. Gradually, he or she works toward the medium-dollar and moderate-procedure queues between $20,000-$39,000.
Beginning and sustaining a remote CDI program can be a challenge for even seasoned professionals. Traditionally, CDI specialists put in varying amounts of face-to-face time with the physicians. Ideally, that in-person interaction makes the physicians more open to CDI efforts. However, many remote CDI programs and individual specialists have found creative ways around this face-to-face time.
Sharme Brodie, RN, CCDS, reviews 2017 First and Second Quarter Coding Clinic advice, which includes sequencing chronic obstructive pulmonary disease with other respiratory diagnoses and body mass index reporting instructions.
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.
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.
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.
Wound care can be messy, but reimbursement and billing for wound care does not need to be as troublesome if coding and documentation are done correctly. One of the bedrocks in billing for wound care is ensuring medical necessity, and there are a few tricks and standards to learn about medical necessity in order to stay compliant. Note: To access this free article, make sure you first register here if you do not have a paid subscription.
April marks sexually transmitted infections month, and Peggy S. Blue, MPH, CPC, CCS-P, CEMC , gets in the spirit by breaking down the staging, diagnosis, and treatment of syphilis before examining how to code the disease in ICD-10-CM. Note: To access this free article, make sure you first register here if you do not have a paid subscription.
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.
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.
Inpatient coding departments are likely familiar with integrating clinical documentation improvement (CDI) specialists into their processes. Crystal Stalter, CPC, CCS-P, CDIP, looks at how CDI techniques can benefit outpatient settings and what services and codes facilities should target.
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.
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.
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.
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.
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.
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.
With the grace period from CMS for reporting unspecified ICD-10-CM codes over, Erica E. Remer, MD, FACEP, CCDS, writes about diagnoses to target for improvement.
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.
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.
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.
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.
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.
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.
"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.
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.
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.
Following are some ICD-10-PCS documentation and coding tips for three of the most common (and commonly misunderstood/miscoded) procedures performed via bronchoscopy.
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.
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.
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.
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.
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.
With a widespread lack of awareness of national best practice guidelines for malnutrition, Joannie Crotts, RN, BSN, CPC , and Szilvia Kovacs, MS, RD, LDN , explain how identifying and diagnosing the condition is often still difficult, and how important changes can be made to improve a facility’s malnutrition program.
Clinical documentation and coding has a significant impact on value-based quality outcome performance. Such outcomes include risk-adjusted mortality, readmission, patient safety, complication rates, and cost efficiency measures.
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.
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.
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.
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.
Since the dinosaurs roamed the earth (OK, since 1983), coding professionals have been tasked with ensuring that bills for Medicare patients included the proper elements of the diagnosis-related group (DRG) system so that the hospital got as much money as possible from Medicare.
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.
Allen Frady, RN, BSN, CCS, CCDS , and Gwen S. Regenwether, BSN, RN , combat coders’ and clinical documentation improvement (CDI) specialists’ querying bad habits, and show how to support productivity and revenue flow for the facility.
For years, coding professionals have been tasked with ensuring that bills for Medicare patients include the proper elements of the diagnosis-related group (DRG) in order to try to accurately show a patient’s severity, but, as Robert S. Gold, MD , writes, there is much more to coding than DRG maximization.
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.
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.
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.
Even before ICD-10, unclear definitions for certain diagnoses and procedures led to confusion for coders trying to interpret physician documentation. Robert S. Gold, MD, writes about conditions in the new code set that could lead to potential risks for providers.
Laurie L. Prescott, RN, MSN, CCDS, CDIP, looks at the definitions for primary, principal, and secondary diagnoses and how to determine them from provider documentation.
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.