All Entries in the "Payment matters" Category

Coding changes offered in IPPS proposed rule

CMS offers IPPS proposal.

Editor’s Note: CMS released the Inpatient Prospective Payment System fiscal year (FY) 2014 proposed rule on Friday, April 26. ACDIS members received a full-length synopsis of the proposal via email earlier this week.

As usual, CMS plans to implement a Documentation and Coding Adjustment (DCA) this time of 0.8%, with hopes to continue adjustments through FY 2017 in order to recoup $11 billion as mandated in the American Taxpayer Relief Act of 2012. However, hospitals may see an overall net increase in payments of the same amount.

As always, some MS-DRG weights increased, while others decreased. Facilities should review the relative-weight change tables included in the proposed rule.

CC/MCC changes include adding diagnosis code 575.0 (acute cholecystitis) to the CC Exclusion List when reported as a secondary with principal diagnosis code 574.00 (calculus of gallbladder with acute cholecystitis without mention of obstruction).

CMS also proposes removing the following diagnosis codes from the CC Exclusion List for diagnosis code 440.4 (chronic total occlusion of artery of the extremities):

• Atherosclerosis codes 440.20-440.32, 443.22, and 443.29
• Aneurysm codes 441.00-441.03, 441.1-441.7, 441.9, 442.0, 442.2, 442.3, 442.9

The proposed rule does not include any revisions to the CC/MCC Exclusion List based on ICD-9-CM code changes.

CMS proposes moving stroke cases with ICD-9-CM code V45.88 (status post administration of tPA [rtPA] in a different facility within the last 24 hours prior to admission to current facility) as a secondary diagnosis from MS-DRG 066 to MS-DRG 065. CMS would change the title of MS-DRG 065 to Intracranial Hemorrhage or Cerebral Infarction with CC or tPA in 24 hours. Hospitals who receive patients undergoing a stroke-in-evolution who had tPA given at an outside facility demonstrated higher costs and lengths of stay in all stroke MS-DRGs without tPA (MS-DRG 64-66), particularly if there was a MCC.

“I am grateful that CMS proposes to allow hospitals accepting patients with stroke-in-evolution who receive tPA at an outside facility to have code V45.88, in essence to count as a CC if a CC is not otherwise documented,” says James S. Kennedy, MD, CCS, CDIP, managing director of FTI Healthcare in Brentwood, Tenn.

CMS proposes reassigning the following diagnosis codes from MS-DRG 794 to MS-DRG 795:

• V64.00, vaccination not carried out, unspecified reason
• V64.01, vaccination not carried out because of acute illness
• V64.02,vaccination not carried out because of chronic illness or condition
• V64.04, vaccination not carried out because of allergy to vaccine or component
• V64.06, vaccination not carried out because of patient refusal

In addition, all of the diagnosis codes currently assigned to MS-DRG 794 would be added to the “only secondary diagnosis” list for MS-DRG 795.

To read the complete article, visit HCPro.com.

Calculating the worth of CDI staff

Here is a “what if” scenario to help illustrate CDI specialists’ return on investment.

By Mark N. Dominesey, RN, BSN, MBA, CCDS, CDIP

What follows below is applicable to a program or organizational perspective, not all who read the ACDIS Blog are interested in this type of program management discussion.

Hospitals that base CDI pay on nursing or HIM pay scales may not be taking into account the value of CDI to the bottom line. We, as CDI professionals, have to continually advocate for the value we bring to the organization.  CDI Staff are “value-add,” not “net-loss” employees.  It is understandable for a hospital to offer a lower salary for a person new to CDI, but within 1-2 years, that employee becomes very valuable in the CDI world.

Let’s make this easy for the accountants and the chief financial officers in our hospitals to understand (let’s talk quality afterwards, the numbers guys and gals want “hard financial numbers” to justify their investment in CDI).

Think about it this way….  The Advisory Board Company (a Washington, D.C., based global research company) states that a high performing CDI specialist (someone with roughly 2 years’ experience) brings about $1.4 million in revenue to a 250-bed hospital.  An “average” CDI specialist brings about $700,000 in revenue, according to a 2012 webinar titled “Creating Top Tier CDI Capabilities.”

Let’s do some math.  (All salary numbers are assumptions, not based on mine or any other numbers.)

Costs: Let’s assume 30% overhead on salary for benefits, space, utilities, education costs etc. and build this in to the salary equation. Let’s assume three employees working at a given facility all earn the same salary and the manager earn about 20% more in additional salary. It appears that the national “going rate” (advertised salaries) for a CDI specialist is $75,000; and roughly $90,000 for a CDI manager.  (For additional rates review the ACDIS “2012 CDI specialist Salary Survey,” published in the CDI Journal.) So far, for costs we have:

• $315,000 for personnel
• $94,500 for overhead
• $60,000 for software/hardware
• $40,000 for part-time physician advisor salary (This assumes a hospitalist who makes roughly $200,000-$250,000 salary would be paid about a 1/4^th or 1/5th of their time).
• $509,500

Revenue: Again these are assumptions, but let’s say that a high performing team (which includes our staff of three and their manager) can earn the facility roughly $1.4 million each with the manager who reviews records part-time earning roughly $700,000 for a total of about $4.9 million. If we consider this in reference to the previous mentioned webinar and within context of anecdotal earning from consulting firms, this looks about right (other organizations say a 250-bed hospital can make as much as $5 million/year with a great CDI program). Let’s say that an average performing team of the same make up earns about $2.45 million.

Return on investment (ROI): Let’s calculate the return-on-investment using the following equation: ROI equals payback after investment divided by that investment or ROI=(payback – investment/investment). So for our high-performing team in the above example the equation would be ($4.9M-$509.5k)/$509.5k=8.62

Some financial people like to see and present ROI in percentages.  So multiply the number by 100 and add the percent unit, or 862%, and be described this way: “The potential return on investment for a high performing CDI team is 862%.”

Assuming we have an average performing team ROI = 3.8.  In percentage form: 380%

So, don’t you think we easily justify our existence from a financial standpoint? A CDI team represents at minimum a 4 to 1 ROI with the potential being much greater!

Let’s give our staff members’ raises of about 10% to make our team have better standing in competitiveness and retention.

Costs: Specialists $83k x 3 + Manager $100k = $349k + 30% (overhead) = $454k; add $60k (software) + $40k (adviser) = $554k. ROI=  7.84 or 784% for a high-performing staff and 3.42 or 342% for an average performing staff.

How many other departments in the hospital show an ROI as good as this?

The main point of this exercise is to show that most of us CDI practitioners have advanced training and we are in a very competitive and fast-growing career field.  Thus, by presenting the value we bring in financial terms, we should be able to justify to administration our higher pay in relation to our nurse and HIM colleagues.

Editor’s Note: Mark N. Dominesey, RN, BSN, MBA, CCDS, CDIP, is the manager of Clinical Documentation Excellence at Sibley Memorial Hospital in Washington, D.C., and a frequent contributor to CDI Talk, where this post originated. Contact him at mdomine2@jhmi.edu.

Revenue Cycle Institute releases 2013 Recovery Auditor Benchmarking Report

Debbie Mackaman

by Debbie Mackaman, RHIA, CHCO

We’ve been on quite a ride since the start of the Recovery Auditor (RA) efforts. In 2012, RAs continued to expand. This report examines how providers have adjusted their approach in the past year, and it looks forward to some new initiatives and proposals that could alter the state of RAs as a whole.

The Revenue Cycle Institute’s 2013 Recovery Auditor Benchmarking Survey had 325 respondents, representing both small and large hospitals, from all four RA regions. These respondents represented a number of different departments, including compliance, HIM, PFS, case management, and clinical documentation improvement.

The main theme of this year’s survey is the growing state of the RAs, and the fact that they only seem to be gaining speed.

The percentage of providers that have had recoupments from automated reviews rose by 14% this year. In addition, the amount of providers that have seen record requests for complex or semi-automated reviews has increased from 82% to 91%. This may not be shocking, as CMS continues to approve more issues and the scope of the RAs continues to expand, but it highlights the fact that the audits are ever-changing and will force providers to stay on their toes.

Another item providers need to pay attention to is the arrival of the prepayment RA reviews. As of right now, only two issues have been approved—MS-DRGs 312 and 069—with short inpatient hospital stays looming, and only 11 states are in the prepayment demonstration, but that does not mean that providers are unfamiliar with the prepayment review process. According to our survey, 74% of respondents have seen a prepayment review either from their MAC (52%), their RA (6%), or both (16%). A total of 52% said that they are not specifically changing any internal processes related to prepayment concerns but 33% said they’ve heightened awareness in departments affected by RAs. However, almost half of the respondents have felt the need to revise internal processes to meet auditor scrutiny, which appears to be increasing from year to year. As the RA program expands, providers need to be flexible to adjust to current issues and anticipate upcoming reviews.

Another RA-related demonstration project is the Part A to Part B rebilling demonstration. While only 380 hospitals are participating in this demonstration, 28 responded to the survey. Of these, the majority (62%) have been able to rebill and get reimbursed. Only 14% have not rebilled anything yet, but were planning on doing so in the future. This demonstration project will last three years, and although it could assist facilities in recouping some of their costs for inpatient stays that were deemed not medically necessary, it is certainly not an answer to resolving the daily operational issues facilities face.

The third recent development is the complaint filed by the American Hospital Association (AHA) against RAs. As you all probably know, the AHA, along with several other hospitals, issued a lawsuit against the RAs for unfair Medicare practices. Based on this bold move, I was curious what respondents thought about the initial action. Sixty percent think that something will happen as a result of the complaint, but 43% of those think that it will only involve very minor changes. On the other side, 17% think that nothing will happen, while 25% are just happy to see the RAs being called out on their current practices. This will be an interesting topic to follow and may set a precedent for other audit processes. Although respondents appear to be pessimistic regarding the potential outcome of the lawsuit, the fact that RAs are being challenged should give providers hope for changes going forward.

Editor’s Note: Debbie Mackaman, RHIA, CHCO, is a Regulatory Specialist with HCPro, Inc., and teaches its Medicare Boot Camps. This post is an excerpt from the benchmark report. To read the entire report, visit The Revenue Cycle Institute.

Guest Blog Part 2: Why CDI efforts should matter to patients and physicians

Melinda Tully

by Melinda Tully, MSN, CCDS, CDIP

My last blog post focused on physician profiling. Time and time again, I’ve seen that once physicians understand how clinical documentation impacts their pay, profiling, medical/legal risk and severity of illness reporting, they realize it is in their best interest to learn the key elements of clinical documentation improvement (CDI), and how that applies to ICD-10.

As we all know, it’s not just physicians getting a grade. Whether it’s Healthgrades, Hospital Compare or Consumer Reports’ Hospital Ratings feature, it is easier than ever to search and find scores for hospital performance. Finding a quality physician or hospital has become as easy and simplified as searching for a favorite restaurant online.

Hospitals and health systems need to make sure their ‘grade’ online is a true reflection of performance. And since that grade is derived from coded data and abstracted from quality measures, CDI has yet another role to play in setting the record straight.

Perhaps the most significant transition facing hospitals is value-based purchasing (VBP). Required by the Patient Protection/Affordable Care Act, VBP shifts payment models so that hospitals will receive value-based incentive payments which start in October 2013 based on performance or improvement on a set of clinical and patient experience-of-care quality measures. It is now more important than ever to document carefully. Hospital reimbursement will not only be based on severity of illness (case mix) but also on the quality of care delivered and patient outcomes.

What’s at stake for hospitals?

• Hospitals face an expected $270 million in readmission penalties
• Stakes increase each year, as these programs increase the percentage of reimbursement at risk across several years

Hospitals face two choices:  Make sure revenue stays at least neutral during this transition; or, leverage this focus on accurate documentation for payment to improve its overall case mix index – and turn VPB into a strategic advantage. With ICD-10, hospitals have the opportunity to increase specificity by shifting the Medicare Severity Diagnostic Related Group coding system (MS-DRG), explaining resource consumption patterns, and reporting severity of illness, or risk of mortality.

If a hospital is ready to look at VBP as a strategic advantage, then top-level administrators should ask themselves the following:

• Do you have a CDI program in place now—or plan to ASAP?
• Are you actively monitoring your CDI program?
• Are you benchmarking yourself to your peers with a CDI program?
• Have you set goals for targeted improvements?
• Are you reviewing all payment schemes that base payment on coded data?
• Are you prepared to manage the CDI opportunities afforded by both ICD-10-CM and ICD-10-PCS?
• Have you determined if your CDI program is adequate for both ICD-9 and ICD-10 success?

If a hospital answers ‘no’ to any of the above questions, they are leaving opportunities at the door.

Editor’s Note: Melinda Tully, MSN, CCDS, CDIP, vice president of clinical services and education, joined the Nuance team in October 2012 as part of the J. A. Thomas & Associates acquisition. This post originally published on the Nuance blog “For the Health of IT.” Contact her at mel.tully@nuance.com.

News: Medical necessity battle continues; AHA says lawsuit requires urgent attention

The AHA is suing CMS for inappropriately denying claims.

The fight over medical necessity continued last week as the American Hospital Association and its four co-plaintiffs asks courts to “expedite” a lawsuit against U.S. Department of Health and Human Services (HHS) for unfair Medicare practices pertaining to the Recovery Auditor program.

According to a motion filed in Washington, D.C., December 13, the crux of the issue is this: Recovery Auditors second guessing physicians’ right to make decisions regarding where to best provide patient care. It suggests that Recovery Auditors “examine cold paper records and determine—at an alarming rate—that the physicians were wrong and patients should not have been admitted to [the] hospital,” the motion states.

Recovery Auditors collected $2.29 billion in overpayments in fiscal year (FY) 2012, according to CMS’ November report. The top concern listed for three of the four Recovery Auditors was medical necessity for cardiovascular procedures. The fourth was for medical necessity related to admissions for minor surgery. The latest recoupments represent a staggering increase of nearly three-times more than FY 2011, according to an article in Fierce HealthCare. (A November 27 report from the Office of the Inspector General indicated it expected some $6.9 billion in total fraud and related HHS recoupments.)

Determining where to best provide care and understanding Medicare’s rules and regulations surrounding payment for that placement continues to be difficult issue for many facilities. A recent 60 Minutes investigation “Hospitals: The Cost of Admission”, focused on admission practices of the 70-hospital for-profit Health Management Associates Inc. The news report alleged the chain pressured physicians to admit a set quota of patients in order to receive increased reimbursement for the services provided. Despite the company’s denial of the allegations its stocks fell sharply following the report.

Nevertheless, the AHA states that CMS is illegally withholding funds. Its motion “seek(s) an expeditious resolution … because … the nation’s hospitals, are being harmed on an ongoing basis by an arbitrary government policy: [CMS] has refused, and is still refusing, to pay the nation’s hospitals for hundreds of millions of dollars’ worth of medically necessary care that they provide to Medicare beneficiaries,” the report states.

Editor’s Note: This article was originally published in the December 20, 2012 edition of CDI Strategies.

Guest Blog: Why CDI efforts should matter to patients and physicians

by Melinda Tully, MSN, CCDS
For providers, the days of earning full Medicare payment by simply submitting complete and accurate information are drawing to a close.  In 2013, Medicare will begin paying healthcare providers and facilities based on the quality of care provided, not just the quantity of services.

Then, starting in 2014, base payments will depend on the outcomes of the care documented.

So how do we shape up before we face even bigger federal cuts?  Simple. Clinical Documentation Improvement. CDI. It’s an acronym that everyone in the healthcare industry should become familiar with.

I sometimes like to think of CDI as investigative reporting for healthcare. CDI helps make sure the patient record is telling the true clinical patient story, including what care the physician provided and why, to ensure the record is coded and billed appropriately.  For healthcare facilities and physician practices to thrive through these changes they need to understand the value of CDI and its direct impact on both patients and physicians.

Patients a Priority
Regardless of the rule or regulation, physicians will not change what they do until they see what’s in it for patients. While it’s easy to see how better clinical documentation can help patients, it’s hard to make that a reality in a typical healthcare setting where clinicians are juggling tight schedules and hectic patient workloads.

The most successful CDI programs work with clinicians to enhance the core training they learned in medical school, teaching them how to document a patient’s true  clinical story during their workflow to best represent the complexity of a patient’s case and decisions made along the way.  This helps keep patients safe, improves communication between clinicians and protects providers from lost revenue.

Quality scores are becoming more transparent to the public every day and high mortality rates and medical errors make headlines. While many CDI programs are led by finance departments, clinical documentation is not an issue reserved for HIM departments. Clinical leaders from many areas including chief medical officers and quality officers need to be involved in CDI to keep the patient’s best interests in mind.

For the last several years I have worked with physician leaders at a large academic medical center to identify and implement CDI efforts focused on improving quality. These efforts have transformed the organization’s performance metrics, improving mortality indexes so they more accurately reflect the severity of illness of their patient population.  These quality indicators are important because decisions are made based on these types of quality metrics – whether it’s by patients seeking treatments or payers evaluating providers.  The best part about this customer’s success is they have improved their documentation  and now their clinical information is so good that when physicians look ahead to pay-for- performance, Accountable Care Organization implementation and bundled payments, they know they are in good shape for the future. [more]

CDI growth depends on record review expansion

In a recent CDI Talk conversation the discussion centered around whether CDI professionals are working with case management staff on the documentation of medical necessity. The overall consensus was that the establishment of medical necessity for inpatient admission rests with the case management (CM) and utilization review (UR) staff of the hospital.

In my opinion, failing to work collaborative with CM/UR teams fails to do justice to our profession—that is strengthening clinical documentation throughout the patient’s continuum of care as an integral part of the hospital’s effective revenue cycle process. Everyone involved—from the admitting physician to the CM/UR staff, from the CDI specialists to the HIM team—has a strong incentive in avoiding medical necessity denials in the name of the fiscal health and integrity of their institution.

Let’s not kid ourselves, despite the fact that CDI efforts can also improve severity of illness (SOI) and risk of mortality (ROM) scores, the major thrust of CDI programs in most facilities is to enhance facility reimbursement and to boost the hospital case mix index (CMI).

Granted, a CDI program must be self-sustaining to justify its existence. Increasingly, however, high-quality, low-cost care is being demanded not only by government initiatives but increasingly by third-party payers. These concerns are driving reimbursement models from strict Fee-for-Service models to Pay-for-Performance, Value-Based Purchasing, and bundled payment efforts. To meet the business challenges associated with these models facilities need to develop CDI practices which ensure succinct and complete clinical documentation throughout the hospital stay. That includes clinical documentation that supports medical necessity and evidence-based medical decision making (MDM) from the time the decision is made to admit the patient through to plans for post-acute care discharge.

Our focus as CDI specialists has been (until now) primarily on obtaining “buzz words” related to selecting principal and secondary diagnoses. While in-arguably important, this focus fails to capitalize on the role we can certainly play in solidifying the medical necessity for inpatient admission. After all, what good does it do to capture documentation of diagnoses if auditors later refute the medical necessity of the admission and deny the claim?

The mindset that solidifying diagnoses which impact reimbursement may be referred to as the “silo” approach to CDI.  This approach overlooks the clinical context of admission. It overlooks the explicit capture of other factors contributing to the physician’s sometimes difficult MDM about whether to admit a patient for inpatient versus outpatient services.

Medical necessity, according to the American Medical Association (AMA), is defined as:

“Health care services or products that a prudent physician would provide to a patient for the purpose of preventing, diagnosing, or treating an illness, injury, disease or its symptoms in a manner that is: (a) in accordance with generally accepted standards of medical practice; (b) clinically appropriate in terms of type, frequency, extent, site and duration; and (c) not primarily for the convenience of the patient, physician, or other health care provider.”

To summarize in a few short words, medical necessity is the clear demonstration of a patient’s unavoidable requirement for a specific health service born from his/her medical condition.

Above, the AMA makes direct reference to “disease or its symptoms.” Factors such as comorbidities, surgical history, current medical needs (including medications), abnormal vital signs, presenting or persistent symptoms, availability of diagnostic procedures, and the safety of the patient should all be taken into consideration and explicitly documented during the provider’s MDM period. Documentation of this sort can be accomplished with a short, two- or three-line notation in the medical record with the admission order, within the physician progress note, or the admitting history and physical.

Short-term focus on improving clinical documentation, episodically, one record at a time, without including record reviews for medical necessity as an integral part of CDI efforts, is a pointed lesson in futility. Consider the number of potential cases in a given month where the Recovery Auditors (formerly Recovery Audit Contractors [RAC]) and other Medicare contractors eventually come to the conclusion that the patient stay “should have been observation” due to lack of established medical necessity, this despite the fact CDI efforts resulted in a shift of the principal diagnosis of chest pain to “GERD” or altered mental status to “drug induced delirium.” (For example, read about the recent Whistleblower settlement regarding Tampa-based BayCare Health System.)

In conclusion, I would like to reference a few points made in a NHIC Medicare contractor forum held in February of 2011, titled “Medical Necessity and Level of Care.” Among these, is the fact that establishing medical necessity requires:

• Care coordination
• Physician involvement
• Utilization review efforts
• Financial/billing/coding involvement

I also want to explore some perspectives shared during that session which highlights those traditional thought patterns against broader realities such as:

Traditional thought: Only billing office and coder activities affect payment

Reality: Payment and coverage is driven by clinical staff and physician documentation

Traditional thought: Clinical staff does not need to understand the financial aspect of healthcare business

Reality: The healthcare business will crumble if clinicians do not understand the documentation requirements and payment implications

Traditional thought: Doctors provide the patient care and the office staff takes care of everything else

Reality: Physicians play just as large a role in coding/claims submission as facility staff

Traditional thought: Only office staff needs to know regulations that affect compliance

Reality: Coverage and payment determinations are based on medical necessity and only clinicians can determine “medical necessity”

Unequivocally, CDI specialists have a duty to work collaboratively with physicians, clinicians, and case managers to change ineffective patterns of documentation. Record reviews should also look for documentation which reflects the need for either inpatient care or observation serves. If the CDI specialist role is truly to ensure quality documentation that accurately reflect patient acuity, SOI, and the intensity of service consistently throughout the record, reviews for medical necessity must be included.

I rest my case that the present role of CDI in principal diagnosis and CC/MCC capture will ultimately become a self-defeating proposition, a role that will fail to eventually stand the test of time as healthcare reimbursement models evolve.

The CDI version of the body politic

When you think of “politics” in terms of who gets what piece of the pie, the CDI profession may take on a larger role in the healthcare vision.

It may surprise some people to learn that my undergraduate major was political science.  (On a whim, I applied to nursing school six years after finishing my bachelor’s and three years after my master’s.)  So when I tell you that C-Span is a great cable channel, that I found watching the Senate Watergate hearings as a teenager unbelievably fun, and that one of my favorite movies is Eddie Murphy’s Congressional satire The Distinguished Gentleman, my background makes more sense.  I even know that the Constitution sets Election Day as the first Tuesday after the first Monday in November, and I can recite the Preamble by heart.

But what does any of this have to do with us as CDI professionals?

The very first thing I learned in my poli-sci class was the definition of politics.  It isn’t about elections, it isn’t about how a bill is passed, and it isn’t even about Democrats versus Republicans.  It’s the process of who gets what, why, and how.  It’s the way we decide to divide the pie.  Although the majority of nurses I’ve met in my career have avoided politics like the proverbial plague, I can’t think of a domain more in need of understanding “politics” than healthcare.

When I watch C-Span or the Sunday morning news shows or the political pundits talking over each other, I always look at the process.  What stake does that person have in this game?  What’s driving their viewpoint and how effective are they in furthering their goals?  I don’t find many true idealogues, people whose ideals are pure and without self-interest.  I do find that most people have something they want to get, and if I understand what that person’s “get” is, I have a better understanding of what they’re willing to do to get their “get.”

Two other terms I learned as a poli-sci major were “zero-sum game” and “Hobson’s choice.”

Zero sum game is incredibly important to understand when you talk about healthcare dollar allocation.  Zero sum game means the pie is fixed.  If you give something to one person/entity/organization, then an equal amount must be taken away from someone else.  In an era of budget deficits and battles over the federal debt ceiling, with ferocious arguments in Washington about raising or lowering taxes, we can’t assume there will always be more money to pay for more programs for more people—regardless of how worthy or valuable those programs may be.

If you have a fixed amount of dollars available and consumers want more services, or more consumers want services, where does the money come from?  Competition for healthcare dollars is fierce.  When you see Medicare reimbursement cut as part of value-based purchasing (VBP) with the possibility of re-earning some of that money back through performance,  do you see your glass half-full or half-empty? A challenge or a punishment? Why do you suppose VBP came about? What was the process? If the pie were infinitely expandable, there would be no need for Recovery Auditors.

Hobson’s choice means you have the free will to choose anything you want…but there’s only one choice on the menu.  Old timers may remember Henry Ford’s maxim that the customer could have a Model T in any color he wanted, as long as it was black.  Some of us may also remember when we had many choices in selecting our healthcare plans, or even which hospital we frequented.  Most people now seem to be locked into a single insurer choice, if they have insurance at all, and a single hospital or hospital system.

We as hospitals are also given Hobson’s choices. We have to take the DRG assignment or nothing.  We have to take the case-rate payment or nothing. We have to take the RAC decision—oh, wait.

Time to remember who gets what, why, and how. We in CDI, by protecting and perfecting that medical record, can influence the who, the what, the why, and the how. We can also protect our self-interest (yes, we aren’t pure, either) by staying aware and involved.

In this election year, prove your value to your hospital, and prove your hospital’s value to the world.  Whether you vote Democratic or Republican, make sure your voice is heard. And don’t be afraid of the word politics.

IPPS Final Rule includes some CDI related code changes

CMS chose not to include code 428.0 (congestive heart failure, unspecified) as a CC. That disappoints ACDIS Advisory Board member James S. Kennedy, MD, CCS, CDIP, managing director at FTI Consulting in Atlanta, because in some instances of acute heart failure, no systolic or diastolic heart muscle disease is present, such as in acute aortic or mitral insufficiency.

In other cases the treating physician or surgeon simply did not want to incur unnecessary healthcare spending to get an echocardiogram needed to determine whether the heart failure is currently systolic or diastolic.

“I estimate that 20% of concurrent CDI work is to clarify this very issue which, if classifying 428.0 as a CC was approved as requested, would have reduced the work and hassle involved in clarifying systolic or diastolic heart failure and improve hospital efficiency and cost which, in turn, could be passed along to the government,” Kennedy says.

CMS also finalized the move of code 584.8 (acute renal failure with a specified pathological lesion) from an MCC to a CC based on their analysis of MedPAR data. Although this move is a disappointment, it may result in official follow-up on the advice provided in the AHA’s Coding Clinic, 3rd Quarter, 2011, in which coders were instructed to report acute renal failure due to specified pathological lesions, such as lupus nephritis, to code 584.9 (acute renal failure, unspecified), instead of code 584.8 Kennedy says.

“Perhaps the Cooperating Parties will now revisit this advice and provide official follow-up that allows coders to use 584.8 when a physician links acute renal failure to a specified pathological lesion, such as lupus nephritis, acute glomerulonephritis, interstitial nephritis, or another renal pathology not covered in [codes] 584.5, 584.6, or 584.7, since 584.8 is no longer a MCC,” Kennedy says.

Kennedy is pleased that CMS included mild and moderate malnutrition as CCs. He would like to see ICD-10 embrace the recently published American Dietetic Association / American Society for Parenteral and Enteral Nutrition consensus statement on malnutrition that classifies this entity as “non-severe” and “severe” instead of “mild,” “moderate,” and “severe.”  View this reference at http://pen.sagepub.com/content/36/3/275.full.

CMS did not add any MCCs or delete any CCs.

CMS finalized a proposal to reassign cases with a principal diagnosis code 487.0 (influenza with pneumonia) and an additional secondary diagnosis code of certain pneumonia codes listed as a secondary diagnosis codes from MS-DRGs 193, 194, and 195 to MS-DRGs 177, 178, and 179.

Editor’s Note: This article was written by Michelle A. Leppert, CPC for HCPro Inc. Breaking News

IPPS final rule released

Editor’s Note: The following excerpt is from a CMS release published on August 1 regarding the Inpatient Prospective Payment System final rule.

On August 1, CMS issued a final rule that updates fiscal year (FY) 2013 Medicare payment policies and rates for inpatient stays at general acute care and long-term care hospitals (LTCHs). The final rule also implements key elements of the Affordable Care Act’s hospital value-based purchasing and hospital readmissions reduction programs.

Under the final rule, payment rates to general acute care hospitals will increase by 2.8 percent in FY 2013. CMS projects that total Medicare spending on inpatient hospital services will increase by about $2 billion in FY 2013 relative to FY 2012.

Hospital Readmissions Reduction Program that will reduce payments beginning in FY 2013 (for discharges on or after October 1, 2012) to certain hospitals that have excess readmissions for three selected conditions:  heart attack, heart failure and pneumonia. Today’s rule finalizes a methodology and the payment adjustment factors to account for excess readmissions for these three conditions.

The final rule strengthens the Hospital Value-Based Purchasing Program (VBP program) includes a new outcome measure to reduce central line-associated bloodstream infections.

ACDIS members will receive complete analysis of the IPPS Final Rule via email soon.