ACDIS advises members to ‘stay the course’ despite potential ICD-10 delay

ACDIS Advisory Board recommend facilities continue with ICD-10 preparations.

As I’m sure most of you are aware, The Department of Health and Human Services (HHS) has proposed a one-year delay of ICD-10-CM and ICD-10-PCS. You can read the complete release here http://www.gpo.gov/fdsys/pkg/FR-2012-04-17/pdf/2012-8718.pdf. The go-live date for which most of us were preparing—October 1, 2013—is now extended to October 1, 2014, barring any last-moment changes.

According to CMS, many provider groups had expressed serious concerns about their ability to meet the initial Oct. 1, 2013 compliance date. The proposed change in the compliance date for ICD-10 will give providers and other covered entities more time to prepare and fully test their systems to ensure a smooth and coordinated transition to these new code sets.

ACDIS would like to offer the following guidance for our members:

Stay the course with ICD-9 and ICD-10 documentation education. Hospitals continue to struggle with documentation and coding requirements under ICD-9; the best way to prepare for ICD-10 is to perform ICD-9 correctly and negotiate the differences between it and the new coding system. Regarding the best time to begin ICD-10 training: We’ve heard anecdotal evidence of hospitals moving out their ICD-10 training dates for their coding staff, which is understandable. However, an industry-wide recommended first step is ensuring that additional required physician documentation is in place for HIM/coding staff. Getting the additional specificity necessary under ICD-10 now is a good way to ensure a seamless transition to October 1, 2014. CDI specialists should use this time to improve their core competencies and knowledge base of ICD-10.

Provide commentary to CMS. Commentary on the proposed rule is open for 30 days starting on Tuesday, April 17. If you feel strongly that the one-year delay should not be implemented, or if you believe that the one-year delay will benefit your hospital, let CMS know by providing your comments at regulations.gov. CMS reviews all provider comments, and who better to hear from than CDI specialists, for whom the change to ICD-10 will be of the greatest impact. To comment on the proposed delay to ICD-10, click the following link to the Federal Register http://www.regulations.gov/#!documentDetail;D=CMS-2012-0043-0001 and click the “Submit a Comment” button. Comments are due on May 17, 2012 by 11:59 p.m. ET.

Brian Murphy, ACDIS Director, and the ACDIS Advisory Board

CMS issues IPPS proposed rule for FY 2013

CMS released the 2013 IPPS proposed rule Tuesday night.

by Michelle A. Leppert, CPC-A

Inpatient acute care hospitals could see a 2.3% increase in payment rates under the fiscal year (FY) 2013 Inpatient Prospective Payment System (IPPS) proposed rule, released April 24. The 2.3% is a net update after inflation, due to improvements in productivity, a statutory adjustment factor, and adjustments for hospital documentation and coding changes.

In addition, the IPPS proposed rule contains provisions to strengthen the Hospital Inpatient Quality Reporting (IQR) Program and proposes new policies and measures for the Hospital Value-Based Purchasing (VBP) Program.

“If the goal is to reward excellence, hospitals have to ensure that their coders are up to speed with appropriate identification of complications and with [present on admission] POA indicators as well as the over-documentation issues that could lead to financial penalties,” says Robert S. Gold, MD, CEO of DCBA, Inc., in Atlanta.

CMS also proposes a methodology to calculate the readmissions adjustment factor for inpatient hospitals that could result in a 0.3% decrease in overall payments to hospitals.

Coding changes
As expected, there were few changes to the ICD-9-CM code set. CMS previously indicated that it would limit such changes to allow providers time to prepare for ICD-10 implementation previously slated for October of 2013 but now potentially delayed until October of 2014.

“Since we are proposing to use ICD-9-CM until October 1, 2014, it potentially adds another year of limited updates,” says Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, director of HIM and coding for HCPro, Inc, in Danvers, Mass.

For FY 2013, CMS proposes to reassign cases with a principal diagnosis code 487.0 (influenza with pneumonia) and a one of a list of pneumonia codes listed as a secondary diagnosis codes from MS-DRGs 193, 194, and 195 to MS-DRGs 177, 178, and 179. CMS proposes to make three additional codes complications and comorbities (CCs) and change one major CC (MCC) to a CC for FY 2013. It does not plan to add any MCCs or delete any CCs.

CMS proposes adding these diagnoses to the CC list:

• 263.0, Malnutrition of moderate degree
• 263.1, Malnutrition of mild degree
• 440.4, Chronic total occlusion of artery of the extremities

It also is proposing to change the severity level of diagnosis code 584.8 (acute kidney failure with other specified pathological lesion in kidney) from an MCC to a CC.

“While I support many of their CC/MCC changes, such as making mild and moderate malnutrition a CC, I am saddened that CMS still refuses to make heart failure not otherwise specified a CC,” says James S. Kennedy, M.D., C.C.S., C.D.I.P., managing director at FTI Consulting in Brentwood, Tenn.

IQR proposed changes
The IQR program currently includes 72 quality measures. CMS has proposed reducing that number to 59 for the FY 2015 payment determination, and 60 for the FY 2016 payment determination.

Participation in the IQR program is optional, although those who choose not to participate receive a 2% reduction in the annual payment update. CMS proposes adding perinatal care and readmissions, including overall readmissions and readmissions relating to hip and knee replacement procedures to the IQR quality measures for FY 2013. In addition, CMS would also measure how well hospitals use a surgery checklist designed to reduce errors.

VBP proposed changes
Beginning in FY 2013 and continuing annually, CMS will adjust hospital payments based on how hospitals perform or improve their performance on a set of quality measures.

For the FY 2014 VBP Program, the proposed rule includes a new outcome measure that rewards hospitals for avoiding central line-associated bloodstream infections that can develop during inpatient hospital stays.

For the FY 2015 VBP Program, CMS proposes grouping and scoring measures in four domains—clinical process of care, patient experience of care, outcome, and efficiency. CMS also proposes adding a total of four new measures to the list.

Readmissions reduction program methodology
In the FY 2012 IPPS final rule, CMS began implementation of the Readmissions Reduction Program for three conditions:

1. acute myocardial infarction (i.e., heart attack)
2. heart failure
3. pneumonia

CMS also finalized its definition of readmission as:

“occurring when a patient is discharged from the applicable hospital and then is admitted to the same or another acute care hospital within a specified time period [30 days] from the time of discharge from the index hospitalization.”

CMS also addresses these areas related to the program:

• Adjustment factor (both the ratio and floor adjustment factor)
• Aggregate payments for excess readmissions and aggregate payments for all discharges
• Applicable hospital
• Limitations on review
• Reporting of hospital-specific information, including the process for hospitals to review and submit corrections

Additions to the HAC list
CMS proposes adding two conditions to the list of hospital acquired conditions (HACs) for 2013:

1. surgical site infection following cardiac implantable electronic device (CIED)
2. iatrogenic pneumothorax with venous catheterization

Inpatient facilities do not receive higher MS-DRG payments for patients with complications or major complications caused by the conditions on the HAC list. CMS plan to update the existing vascular catheter-associated infection HAC category by adding the following two codes:

1. 999.32 (bloodstream infection due to central catheter)
2. 999.33 (local infection due to central venous catheter)

CMS proposed adding pneumothorax associated with transbronchial biopsy several years ago, but it was not finalized, McCall says. This condition does seem to meet HAC the criteria of occurring commonly and can cause a significant increase in resource consumption in order to treat this condition, she says. It is also labeled as a complication and comorbidity. However, HACs must also be reasonably preventable, according to evidence-based research, and this has also kept other conditions, such as ventilator-associated pneumonia, off the list in the past.

The addition of the surgical site infections from CIEDs seems to follow along with the inclusion of other site infections already on the HAC list, especially given an increased focus on ensuring sterile environments to avoid contamination of a primary infection at the time of placement of such devices, McCall says.

Coding and documentation adjustment
CMS expects the FY 2013 proposed documentation and coding adjustment (DCA) to net an aggregate increase of 0.2%. The DCA was originally established at the time CMS implemented MS-DRGs. It was thought that due to the increased need for specificity, facilities would focus attention on improvements to documentation. The last two years, the DCA has resulted in a payment offset of -2.0% and -2.9%.

“In good news, the documentation and coding adjustment actually works in the provider’s favor this year, increasing reimbursement by 0.2%,” Kennedy says. “That’s a substantial increase from the previous years.”

Comment on the proposed rule
CMS will accept comments on the proposed rule until June 25 and will respond to all comments in a final rule to be issued by August 1, 2012. Facilities can download a display copy of the proposed rule here.

The proposed rule will appear in the May 11, 2012 Federal Register.

Editor’s Note: This article first appeared as a “Breaking News Alert” and was published on HCPro.com.

Conference Q&A: ‘The Art of Communication in CDI’

Colleen Stukenberg will present at the ACDIS Conference in San Diego.

Editor’s Note: Over the coming days and weeks, we will post a series of Q&As with presenters and participants from the 2012 ACDIS Conference in San Diego. The first in this series features Colleen Stukenberg, MSN, RN, CMSRN, CCDS, whose presentation “The Art of Communication in CDI and Beyond,” will take place on Thursday, May 10, 1:30-2:30 p.m.

Q: What core communication competencies should CDI professionals come to the role with?

A: While there are three main aspects I will address at the conference, I will add that professionalism, honesty, and respect for yourself and others are important traits for those working in the CDI role. These qualities will carry you far in life. If you do not have these in the CDI role, it can be difficult to communicate with others and earn their respect. You are working with other professionals with advanced education and they need to know that you are trustworthy and respectful. (You need to attend the session to hear my top three, though.)

Q: What communication talents can a CDI manager expect to be inherent and what elements can a manager help to instill in CDI team members?

Some characteristics are innate, meaning people are just born with certain talents. When interviewing a new CDI staff person, you only have a limited time to know whether this individual will be the right fit for the role. The person may act nervous in the interview but you should take note to observe how he/she interacts with you. Then have a team interview to see how he/she interacts with the team. You want someone that not only says he/she is a team player but also demonstrates it, as this is a team-player role. The CDI specialist will need to be able to interact clearly, honestly, and positively with various roles including physicians, nurses, and coders. Furthermore, the CDI specialist will need to be able to portray a professional positive attitude in meetings that may include administrative or board meetings.

Q: Can you name two or three common communication missteps that CDI professionals should be aware of?

A: Thinking too narrowly, thinking there is only one right answer, or thinking that the CDI specialist already “knows” the job. Education should never stop. We can learn from the expert and the novice. While we all have various roles, we ultimately are there to help improve patient care by promoting accurate documentation of the patient’s true clinical picture.

Q: What are you looking forward to most about this year’s ACDIS conference?

This is the first time I am speaking at the ACDIS conference and I am very excited. Attending the various sessions, activities, and networking with colleagues and the exhibitors are definitely on my agenda.  I am also looking forward to seeing all of the friends and acquaintances I have met over the past few years through ACDIS.

CMS offers ICD-10 Report on the State of the Union

A one-year delay in ICD-10-CM/PCS isn’t a slam dunk. “We’re recommending it, but it’s not [guaranteed],” said Denise Buenning, group director CMS Office of E-Health Standards and Services. Buenning delivered CMS ICD-10 Report on State of the Union at the AHIMA ICD-10 Summit on April 17 in Baltimore.

“The absolute worst thing you can do is stop working toward implementation,” Buenning added. “Follow our lead and stay the course.”

A series of events made CMS consider delaying ICD-10-CM/PCS implementation. One of the largest centered on problems providers and payers experienced when implementing HIPAA Version 5010. Many vendors did not have software updates in place in time to meet the January 1, 2012, implementation date. As a result, CMS has twice delayed the enforcement of HIPAA 5010.

Implementing HIPAA 5015 was supposed to be the easier transition, so CMS officials became concerned about potential problems with ICD-10-CM/PCS implementation.

HHS received many unsolicited comments regarding the delay with a number of different recommendations, Buenning said.

During the discussions about a possible delay, many wondered whether CMS might skip ICD-10-CM/PCS completely and move straight to ICD-11. That would result in huge economic losses and might not be feasible given the configuration of ICD-11, Buenning said.

CMS proposed the one-year delay after much consideration. A delay of longer than two years would be a waste of resources for those who have already spent a lot toward the implementation, Buenning said. A one-year delay balances the industry’s need to know when ICD-10-CM/PCS will be implemented, gives those who need it more time, but doesn’t penalize those who have already begun implementation.

“Use any additional time to your best advantage,” Buenning said, adding “I’m sure testing will be a big part of that conversation.”

CMS offered up a 30-day comment period “because we want to put out the final rule as soon as possible,” Buenning said. Normally, CMS provides a comment period of 60 days or more.

“We take feedback very seriously,” she said. “Positive and negative, we need all of it.”

Editor’s Note: This article first published on the ICD-10 Trainer Blog.

The 5th Annual ACDIS Conference won’t be all work

We have some of the fun events planned for San Diego! If you have any questions, don’t hesitate to contact ACDIS members services specialist Penny Richards.  We look forward to seeing you there!

Poster Session: Starting Thursday morning, check out the 2012 Poster Session in the Elizabeth Foyer outside the exhibit hall. Twenty-three of your colleagues prepared posters detailing CDI programs, improvement strategies, and on specific topics such as queries, mortality, and physician engagement. You’ll find a ballot in your conference bag to vote for your favorite poster.

THURSDAY

Wear purple and orange today. ACDIS staff Brian Murphy, Melissa Varnavas, and Penny Richards have a surprise for some special conference attendees.

Breakfast: Kick start your morning with a continental breakfast as guests of MedPartners CDI.

Lunch: Join us for the annual awards luncheon where we’ll introduce the 2012 CDI Professional of the Year and the two winners of the 2012 Recognition of CDI Professional Achievement awards. The buffet-style luncheon is sponsored by Maxim Health Information Services.

Join CDI Search Group for a San Diego harbor cruise.

Evening: Following the day’s conference activities, exhibitor CDI Search Group will host a San Diego harbor boat cruise and dinner. Tickets for this event will be limited to 250 guests. To reserve your tickets, visit www.cdisearchgroup.com.  On their home page you’ll find a link to a brief survey to complete in order to receive your boarding pass and two drink tickets. Boarding is from 6:30 – 7 p.m. The cruise is from 7:45  – 8:45 p.m.

Evening: If you are from California and decide not to go on the cruise, join members of the California ACDIS Chapter at the ‘Top of the Hyatt’ for cocktails and snacks. It’s right in the hotel so you don’t have too far to go. They will gather beginning at 6:15 p.m. Please email gallanjt@sutterhealth.org if you plan to attend (to give the group a headcount).

A number of other local chapters will also be hosting after hours events. If you’d like to find out more, visit the ACDIS Local Chapter page and email the leader for your region.

FRIDAY

Early Morning: Weather permitting, ACDIS Member Services Specialist Penny Richards is going to climb into her walking shoes and take a morning stroll. Her destination is the Kissing Statue at Tuna Harbor near the USS Midway Museum—about a two-mile round-trip trek. More details to come at the conference.

Regional Spirit: Wear your ACDIS local chapter gear or something special that celebrates your hometown or region. For example, New Englanders are invited to wear Patriot’s or Red Sox gear and the FL ACDIS Chapter has created its own T-shirts and encourages attendees to don their Florida apparel.

Lunch: Join our California ACDIS hosts at the Local Chapter lunch. Pick up your box lunch in the exhibit hall and bring it to the main hall for an ACDIS Bingo game. (If you prefer, you may enjoy lunch in the hall with exhibitors or outside on the hotel decks). Participants will be asked a number of trivia questions that relate to squares on the bingo cards. You’ll compete for prizes with colleagues from your state/area. Meta Health Technology is our luncheon sponsor.

Book Excerpt: Coding guidelines for diabetes under ICD-10

The age of a patient is not the sole determining factor for the type of diabetes, although most Type 1 diabetics develop the condition before reaching puberty. For this reason, Type 1 diabetes mellitus is also referred to as juvenile diabetes. If the physician does not document the type of diabetes mellitus in the medical record, the default category of codes is E11 (type 2 diabetes mellitus).

If the physician does not document the type of diabetes but does indicate that the patient uses insulin, assign a code from category E11; also report code Z79.4, long term (current use insulin to indicate that the patient uses insulin. Do not report code Z79.4 if a Type 2 patient is given insulin temporarily to bring  his or her blood sugar under control during an encounter. In situations where diabetes occurs during pregnancy and for cases of gestational diabetes, refer to the ICD-10 Official Guidelines for Coding and Reporting Section I.C.15, Diabetes mellitus in pregnancy and gestational (pregnancy-induced) diabetes.

The codes under category E08 (diabetes mellitus due to underlying condition) and E09 (drug or chemical induced diabetes mellitus) identify complications/manifestations associated with secondary diabetes mellitus. Secondary diabetes is always caused by another condition of event (e.g., cystic fibrosis, malignant neoplasm of pancreas, pancreatectomy, adverse effect of drugs, poisoning.)

The sequencing of the secondary diabetes codes in relation to codes for the cause of the diabetes is based on the tabular instructions for categories E08 and E09. For category E08, first code the underlying condition. For category E09 first code the drug or chemical (T36-T65). For a patient with diabetes ketoacidosis without coma due to cirrhosis of pancreas, report K86.8 (cirrhosis of pancreas) and E08.10 (diabetes mellitus due to underlying condition with ketoacidosis without coma).

Editor’s Note: This post is an excerpt from The Clinical Documentation Improvement Specialist’s Guide to ICD-10.

Diagnose first, admit second

Consider CDI collaboration with case management to target documentation concerns in the emergency department.

Among other tidbits in my background, I’m a recovering case manager.  It’s a hard, often thankless job, and it never ends.  I don’t think I could do it again, and I give lots of credit to those who still work in this field.  Nevertheless, I have had many occasions to interact with case managers in my previous role as a CDI specialist, and now, a CDI consultant.

As a recovering case manager, I often shied away from dealing with the CM department, but I’ve come to realize that not developing collaborative processes can be a huge mistake. When we avoid case management, we avoid the opportunity to build an ally. We both want medical records that reflect the optimum patient acuity, and that will survive RAC and other audits. And this process starts at the hospital’s front door.

Case managers review patients in the emergency department for admission criteria. If they know that chest pain and syncope and abdominal pain are RAC targets, and that documentation of diagnoses instead of symptoms may move the DRG out of the RAC crosshairs, they can communicate this to the physicians. I like to think of it this way: when the physician writes nothing of consequence, the CDI specialist looks for clinical findings and asks for the diagnosis, while the case manager asks for clinical findings and the treatment plan that support the medical necessity for the admission and strengthen the diagnosis that we just got.

It’s a symbiotic relationship.

I’ve had occasion to work with the case management team at a client hospital, and we decided to put our collective heads together to see how we could educate ED physicians not to admit patients who didn’t meet criteria. We chose as our slogan:  “Diagnose first, admit second!”

We created one page flyers to be posted in the ED and distributed to the ED physicians on popular topics such as chest pain and syncope.  In the flyers, we briefly gave suggestions of alternative diagnoses, defined what is needed to meet admission criteria, and encouraged physicians to consult with case management before writing that admit order.

At the same time, I’ve been presenting a weekly series of lectures to the case management department, very similar to what I would use to teach a new CDI specialist, but adding a little twist that ties clinical documentation improvement to case management.  It’s been a big hit.  They are eager to help teach physicians not to write “CHF” or “urosepsis,” and they want to learn more.  I’m going to give them all they can handle, including helping them read their PEPPER and use it to their best advantage.

Never assume that because someone doesn’t understand what you do, that they don’t want to understand what you do.  It’s like working with physicians and nurses; when you show them how your job relates to them and how it benefits everyone, you get more cooperation.  And as we used to say, cooperate and graduate.

The clash of clinical vs. coverage/payment concerns

by Trey La Charité, MD

Auditors are increasingly looking at medical necessity denials but shouldn't the physician make the decision about whether the patient needs to be admitted?

In the aggressive post-discharge auditing environment where I now find myself practicing medicine, I and my colleagues are subject to heavy scrutiny by CMS and private insurers. Observation versus inpatient status review is the new focus of these non-clinician auditors and has become the reason for the vast majority of my facility’s denials. This new auditing pressure we all face stems from the completely noble idea that reductions in fraud, abuse, and improper payments will preserve resources for those who truly need medical care. Sadly, as with many commendable aspirations, the execution is poor and often produces a dismal result.

As the physician advisor for CDI, I have been diligently educating every physician at my institution about ensuring the medical necessity of our inpatient admissions. But while CMS asserts that the admitting physician is solely responsible for status selection (i.e., inpatient, outpatient, or observation status), admission status for the physician has no clinical  relevance. Physicians do not recognize “conditional” or “partial” admissions, which observation status implies. As far as physicians are concerned, their patients either medically need something or they don’t.

The rules concerning inpatient versus observation status selection are not newly created; CMS’ vague guidelines for
appropriate status selection have been around for years. The difference is that CMS and other payers suddenly discovered that they can extend their existing financial resources by “enforcing” those rules. Payers and their related auditing agents have traditionally avoided the question of whether a patient actually needed the medical care that was provided. Instead, they simply point to inappropriate status selection and deny the associated claim. The issue is whether physicians should be contemplating a patient’s admission status at all.

Editor’s Note: This article is an excerpt from the quarterly publication for ACDIS members the CDI Journal. La Charité is a hospitalist and physician advisor for CDI and coding at the University of Tennessee at Knoxville, and an ACDIS Advisory Board member. Contact him at Clachari@UTMCK.EDU.

Examine guidelines for medical necessity documentation needs

Because most CMS local and national coverage determinations governing medical necessity and limitations of coverage

Looking for ways to improve your CDI program consider examining records for medical necessity.

center around outpatient procedures (e.g., lesion removals, cataract surgeries, and blepharoplasty repairs), typically physicians’ clinical judgment and medical decision-making alone have qualified as sufficient support for the need for inpatient procedures.

To meet medical necessity for commonly performed inpatient procedures (e.g., hip and knee replacements and spinal fusions), medical necessity for performing the procedure in and of itself is predicated upon supporting documentation in the physician’s office notes. Unfortunately, oftentimes this documentation is sparse, clinically nonspecific, and without sufficient detail to meet the stringent medical necessity requirements by Medicare and other third-party payers. The end result is medical necessity denials for these inpatient procedures for both the hospital and the surgeon. This makes for a tangled web from all aspects of the collection of health information.

Examine guidelines for reporting diagnoses and procedures

The Medicare Program Integrity Manual, chapter six, section 6.5.2, “Medical Review of Acute Inpatient Prospective Payment System (IPPS) Hospital,” and section 6.5.4, “Review of Procedures Affecting the DRG,” contains language on diagnosis and procedure code assignment:

“The contractor shall determine whether the performance of any procedure that affects, or has the potential to affect, the DRG was reasonable and medically necessary. If the admission and the procedure were medically necessary, but the procedure could have been performed on an outpatient basis if the beneficiary had not already been in the hospital, do not deny the procedure or the admission. “

Section 6.5.4 offers guidelines for the MAC when a procedure wasn’t medically necessary:

• “If the admission was for the sole purpose of the performance of the non-covered procedure, and the beneficiary never developed the need for a covered level of service, deny the admission;
• If the admission was appropriate, and not for the sole purpose of performing the procedure, deny the procedure (i.e., remove from the DRG calculation), but approve the admission.

In other words, if the clinical documentation does not clearly and unequivocally support the medical necessity for a procedure, the Medicare contractor will deny the entire stay for both the hospital and the physician. This congruent Part A and Part B denial for medical necessity is becoming more common from a MAC standpoint, as the following information published by MAC Trailblazer Health illustrates:

“Prepay service-specific edits are in place to review services billed with the following DRGs:

• 243, Permanent cardiac pacemaker implant with complications
• 246, Percutaneous cardiovascular procedure with drug-eluting stent with major complications or 4+ vessels/stents
• 247, Percutaneous cardiovascular procedure with drug-eluting stent without major complications
• 460, Spinal fusion except cervical without major complications
• 470, Major joint replacement or reattachment of lower extremity without major complication”

“To increase consistency in Medicare reimbursement, effective November 1, 2011, TrailBlazer began cross-claim review of these services. The related Part B services (i.e., procedure and evaluation and management services) reported to Medicare will be evaluated for reimbursement on a postpayment basis. Overpayments will be requested for services related to the inpatient stay that are found to be paid in error.”

Trailblazer outlines documentation requirements for DRG 470

Trailblazer Health has outlined and defined specific joint replacement (DRG 470) documentation for both hospitals and physicians to follow in support of medical necessity.

Clinical documentation from both the physician’s office as well as the hospital must support medical necessity for joint replacement procedures. Coders cannot directly control the quality and completeness of documentation in the record, but they can certainly familiarize themselves with the guidelines of clinical documentation necessary for joint replacements and apply this knowledge when reviewing these records.

Coders can collaborate with case managers and utilization review staff to identify documentation deficiencies, which place both the hospital and the physician at financial risk for recoupment due to a lack of medical necessity. To this end, consider developing a training program for physicians and other clinical staff that covers principles of documentation to establish medical necessity.

For example, physicians need to be aware that for a knee replacement, they need to document:

• Pain in the knee (e.g., level of pain and whether it has worsened)
• Pain increasing with activity (e.g., whether the pain increases with weight-bearing and daily activities)
• Passive or limited range of motion or swelling of the joints
• X-rays that support any of these findings:
• Subchondral cysts
• Subchondral sclerosis
• Periarticular osteophytes
• Joint subluxation
• Joint space narrowing
• The use of medication that was unsuccessful in providing pain relief

This is quite a bit of information that the physician needs to document to support medical necessity, but without the proper diligence of various parties (e.g., utilization review, physicians, and coders), and without this supporting detail, it could lead to costly denials.

Editor’s Note: This article was originally published on JustCoding.com.

Ideas for fun in San Diego

Planning on going to San Diego to attend the fifth annual ACDIS conference (May 10-11)? There’s plenty to do in the city and if you can build some personal time into your trip, I’ve got a few suggestions for you.

The Gaslamp  District
The Gaslamp Quarter National Historic District is eight blocks long (from Broadway to Harbor Drive) by a little more than two blocks wide (4th, 5th, and 6th Avenues) for a total of 16 and one half blocks of shopping, dining, entertainment, and Victorian architecture excellence. It’s an easy walk from the conference hotel. Visit the web site, click on the link for coupons and enjoy discounts from some of the area merchants.

The Kissing Statue in San Diego is just one of the fun sights to see.

The Kissing Statue
The 25-foot tall, 6,000-pound sculpture is a rendition of the famous photo of the sailor kissing the nurse in Times Square in New York City at the end of World War II. It’s on loan to the city of San Diego and due to be replaced with a permanent painted bronze statue. At this writing, we’re not sure when the statue will be moved or when the new one will be installed, but look for it. And if your honey is with you, you can mimic the pose at the foot of the statue for your own photo to remember! It’s located at the foot of G Street and adjacent to the USS Midwest Aircraft Carrier Museum.

USS Midway Aircraft Carrier Museum
The USS Midway Museum is an unforgettable experience.  It’s an actual naval aircraft carrier that served in the United States Navy for 47 years.  Explore the exhibits, see restored aircraft on the flight deck, and take a self-guided audio tour that’s narrated by Midway sailors. Chat with docents who will share their stories about serving on board. Located on the harbor in downtown San Diego.

Old Town
Step back in time and visit beautiful Old Town San Diego, the birthplace of California. It’s right in the city and accessible by the Metropolitan Transit System. You’ll find historic sites and parks, wonderful shops and restaurants. This is a “don’t miss” for history buffs.

The San Diego Zoo
Travel from the savannah to the arctic at the San Diego Zoo. The zoo features animals from A (armadillos) to Z (zebras), including pandas, koalas, jaguars, wallaby, and wild dogs. View five species of eagles (including the bald eagle), as well as gila monsters, komodo dragons, and Panamanian golden frogs. Wear your walking shoes or take the in-park trolley. The zoo is located inside Balboa Park and you can access from the Metropolitan Transit System.

Balboa Park
A beautiful park with gardens and walking trails, museums  (including Air & Space Museum, Auto Museum and the Natural History Museum),and the San Diego Zoo. You can access the park from the Metropolitan Transit System

Hotel del Coranado
The Del is the most magnificent and elegant place I’ve ever visited. When I was there a few years ago, I watched a fashion photography shoot on the beach. Built more than 120 years ago, The Del has been visited by princes, Presidents, and Hollywood elite, and has served as the backdrop for movies and books (such as Some Like It Hot, which starred Marilyn Monroe, Jack Lemmon, and Tony Curtis; The Stunt Man, which starred Peter O’Toole; Wicked, Wicked, which was completely filmed on location there, and the 1990 version of My Blue Heaven, with Steve Martin and Rick Moranis). I’m going to visit The Del and I’d love to have you come along! We’ll take the ferry across the bay and then hop a bus to our destination. Oh, I almost forgot to mention: The Del is rumored to be haunted.

The San Diego Padres at Petco Park
The Padres will be in town on Monday-Wednesday May 7-9, playing the Colorado Rockies. Monday’s and Tuesday’s games begin at 7:05 p.m.; Wednesday’s game has a 12:35 p.m. first pitch.

Public transportation
San Diego has a great public transportation system to help you get around the city and enjoy the sights.

Need more ideas?
Talk to a San Diego local. Ask the front desk staff at the hotel for their suggestions about places to visit, where to shop, and where to get a great meal. You know that business web sites tout theirs as “The Best in the City”. The locals really know where to go to find the hidden jewels that will make your visit to San Diego one to remember.

You can also visit the region’s official travel resource at www.sandiego.org/nav/Visitors.

I’m looking forward to not only a great conference but visiting all the sights and sounds of San Diego and I hope you enjoy them as well!