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Note from the Associate Editorial Director: Consider the peer audit

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Associate Editorial Director Melissa Varnavas

By Melissa Varnavas

Back in 2015, 40% of ACDIS Radio listeners (of the October 28, 2015, broadcast) indicated their CDI program had an established query auditing process in place. Another 29% said they had some type of query review practices established but they only informally or occasionally take the time to examine the efforts of CDI specialists.

ACDIS has long advocated for some type of regular query practice audit and review—be that driven by the CDI program manager or director or peer-to-peer amongst the CDI team. Donald A. Butler, RN, BSN, then the CDI manager at North Carolina facility authored a White Paper regarding the auditing process and provided an in-depth PowerPoint presentation regarding the benefits back in 2012. In 2013, a number of professionals described the importance of such reviews and pulled the lid off for a glimpse inside their own processes in a CDI Journal article. [more]

Book excerpt: Peer review to ensure compliant query practices

Start your weekend with some CDI reading!

Start your weekend with some CDI reading!

By Marion Kruse, BSN, RN, MBA, and Jennifer Cavagnac, CCDS

Every CDI program should objectively evaluate the outcomes, processes, and compliance of their CDI efforts. Auditing and monitoring provides oversight for the CDI program, insight into physician documentation and collaboration, and objective evaluation of the performance and effectiveness of individual CDI staff members as measured against your facility’s policies and priorities.

According to AHIMA’s “Managing an Effective Query Process” “Healthcare entities should consider establishing an auditing and monitoring program as a means to improve their query processes.” [more]

Guest post: Compliance risks abound in HCCs

James Kennedy, MD, CCS, CDIP

James Kennedy, MD, CCS, CDIP

by James S. Kennedy, MD, CCS, CDIP

Let’s discuss the compliance risks CDI and coding professionals need to address related with hierarchical condition categories related to the MACRA.

Coding must be based on provider documentation, not what is entered on a superbill or computer software. ICD-10-CM code assignment is based solely on a provider’s documentation in the legal medical record, according to the 2017 ICD-10-CM Official Guidelines and Coding Clinic, Fourth Quarter, 2016, pp. 147–149. The problem is that many physicians document one way in their notes and then pick an ICD-10-CM code in their billing software or superbill that would not be assigned if one applies ICD-10-CM coding conventions based on the provider’s documentation.  [more]

Guest post: Time to learn about HCCs

James S. Kennedy, MD, CCS, CDIP

James S. Kennedy, MD, CCS, CDIP

by James S. Kennedy, MD, CCS, CDIP

Now that you’ve finally mastered coding compliance with DRGs and quality measures, now it is time to learn the new risk-adjustment method, Hierarchical Condition Categories (HCC).

HCCs are to physicians what DRGs are to hospitals and, as such, are subject to government and Recovery Auditor scrutiny. In fact, a whistleblower accused United Healthcare of “upcoding” ICD-10-CM diagnosis codes affecting HCC-derived risk-adjustment factor scores, mentioning that CMS overpaid insurers by $14.1 billion in 2013 alone, according to an article in the New York Times in May. [more]

Guest post: Keep up with coding compliance for physicians facing MACRA changes

James S. Kennedy, MD, CCS, CDIP

James S. Kennedy, MD, CCS, CDIP

by James S. Kennedy, MD, CCS, CDIP

What’s a physician’s favorite radio station? When it comes to coding compliance and revenue cycle management of their practices, WII-FM, What’s In It For Me, is what physicians listen to.

Physician salaries have traditionally been based on CPT-driven relative value units in a fee-for-service environment, meaning the more that the physician did, the more he or she got paid. As a result, many physicians diminished their understanding or application of ICD-10-CM diagnosis coding because, most of the time, these don’t affect physician reimbursement unless it is to determine medical necessity for a procedure they want to perform. [more]

Guest Post: New ICD-10-CM/PCS codes up the ante in coding compliance, part 3: Right heart failure

James S. Kennedy, MD, CCS, CDIP

by James S. Kennedy, MD, CCS, CDIP

Editor’s note: With the fiscal year 2018 ICD-10-CM/PCS codes released, Kennedy unpacked some of the compliance pitfalls and opportunities awaiting CDI and coding professionals when these new codes are implemented on October 1. Some of these issues may be addressed in the 2018 ICD-10-CM Official Guidelines for Coding and Reporting or the American Hospital Association’s Coding Clinic, Fourth Quarter, 2017, so be sure to compare Kennedy’s opinions with these documents. This article is part three in a three-part series. Click here to read parts one and two!

Right Heart Failure

Notice that we now have new codes for acute, chronic, and acute-on-chronic right heart failure. Remember also that Coding Clinic, Third Quarter, 2013, p. 33, states that the documented term of “decompensated” indicates that there has been a flare-up (acute phase) of a chronic condition. [more]

Guest Post: New ICD-10-CM/PCS codes up the ante in coding compliance, part 2: Pediatric Glasgow coma scales

James S. Kennedy, MD, CCS, CDIP

by James S. Kennedy, MD, CCS, CDIP

Editor’s note: With the fiscal year 2018 ICD-10-CM/PCS codes released, Kennedy unpacked some of the compliance pitfalls and opportunities awaiting CDI and coding professionals when these new codes are implemented on October 1. Some of these issues may be addressed in the 2018 ICD-10-CM Official Guidelines for Coding and Reporting or the American Hospital Association’s Coding Clinic, Fourth Quarter, 2017, so be sure to compare Kennedy’s opinions with these documents. This article is part two in a three-part series. Click here to read part one. Return to the blog next week to read part three!

Pediatric Glasgow coma scales

In what should have been a welcome change, the National Center for Health Statistics amended the ICD-10-CM Alphabetic Index to allow for reporting of the clinical descriptors of the pediatric Glasgow coma scale. Notice that in the best motor response section, “flexion to pain” gets three points in the clinical scale whereas “withdrawal from pain” gets four points. Now notice how ICD-10-CM manages these conditions in 2018: [more]

Guest Post: Using coding, CDI to transform hospitals’ revenue integrity, part 1

Want to write for ACDIS? Send us your ideas!

Want to write for ACDIS? Send us your ideas!

by Amber Sterling, RN, BSN, CCDS, and Jana Armstrong, RHIA, CPC

Most healthcare systems already have a proven process in place to monitor revenue integrity and ensure correct reimbursement. More than 60% of hospital executives believe revenue integrity is essential to their organization’s financial stability and sustainability, according to a survey by Craneware, Inc.

But does revenue integrity extend beyond charge masters and billing? Kalispell Regional Medical Center (KRMC), one of the “100 Great Community Hospital” according to Becker’s Hospital review, says yes.

For KRMC, revenue integrity focuses on three operational pillars: clinical coding, CDI, and physician education. At KRMC and many other health systems, revenue integrity is a three-legged stool: [more]

Guest Post: New ICD-10-CM/PCS codes up the ante in coding compliance, part 1: Myocardial infarction

James S. Kennedy, MD, CCS, CDIP

by James S. Kennedy, MD, CCS, CDIP

Editor’s note: With the fiscal year 2018 ICD-10-CM/PCS codes released, Kennedy unpacked some of the compliance pitfalls and opportunities awaiting CDI and coding professionals when these new codes are implemented on October 1. Some of these issues may be addressed in the 2018 ICD-10-CM Official Guidelines for Coding and Reporting or the American Hospital Association’s Coding Clinic, Fourth Quarter, 2017, so be sure to compare Kennedy’s opinions with these documents. This article is part one in a three-part series. Return to the blog next week for the next installment! [more]

UnitedHealth Group, Inc. vs. the United States of America: The case for CDI, part 2

Brian-Murphy

ACDIS Director Brian Murphy

By Brian D. Murphy

In Part 1 of this series I introduced the developing story of UnitedHealth Group, Inc. vs. the United States of America, and my intent to write a series of articles on this civil fraud action. Why? Because I find this to be an incredibly interesting case with broad ramifications for CDI and coding departments.

So let’s review the basic at the facts of the case, starting with the who and when. [more]