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Note from the ACDIS Editor: CDI Journal focuses on reimbursement concerns

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ACDIS Editor Linnea Archibald

By Linnea Archibald

Though any CDI specialist will tell you this profession isn’t about money, a facility’s reimbursement can certainly be affected by CDI professionals’ work. Because of this undeniable fact, we’ve dedicated the November/December edition of the CDI Journal to the multi-faceted world of reimbursement.

Within the newest edition’s pages, you’ll find valuable information covering reimbursement topics such as using PEPPER data for denial defense and tracking CMI metrics. You’ll also get a glimpse into the non-reimbursement fueled world of PPS-exempt cancer centers. [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]

Note from the ACDIS Director: Saying thanks to some key individuals and influences

Birthday cupcake

Thanks for celebrating ACDIS’ 10th birthday with us!

Ten years have passed since we founded the Association of Clinical Documentation Improvement Specialists, and to say I have met some good people along the way is a gross understatement. I have met some GREAT people over the last decade, without whom ACDIS would not be where it is today.

Here are just a few: [more]

Q&A: Acceptable documentation for HCCs

Have CDI questions?

Have CDI questions?

Q: What clinical documentation is acceptable to pull Hierarchical Condition Category (HCC) information from for reporting purposes? Would you code from history of present illness, past medical history, active problem list, or the assessment?

A: Follow the coding guidelines when reporting diagnosis codes for HCC purposes. The coding guidelines don’t change with HCCs. As long as the documentation meets the MEAT (monitored, evaluated, assessed, treated) criteria, it can be reported from anywhere in the note. [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]

Note from the Associate Editorial Director: What’s so special about ACDIS?

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Associate Editorial Director Melissa Varnavas

By Melissa Varnavas

In short, the membership. There are more than 5,500 ACDIS members now as we celebrate our 10th anniversary. That’s the size of a city. Sure, it’s not a large city but it’s definitely a community. It’s a community that’s chosen to live together and work together and ensure that its neighbors succeed. And that’s an amazing and special thing to be a part of in this day and age.

But it’s been that way since the start of the organization. Back then everyone was scrambling to figure out the best way to do this job. Back then everyone was looking for the best clinical indicators to help win their physicians over. Back then everyone was struggling to find their niche within the hospital hierarchy of department reporting structure. So everyone shared. Everyone shared just about everything they possibly could. [more]

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

Brian-Murphy

ACDIS Director Brian D. Murphy

Part 3 (to read part 1, click here. To read part 2, click here.)

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. In part 2, I detailed the facts of the case. Part 3 looks at the regulations and commentary regarding claims submission to Medicare Advantage and the ramifications for CDI.

Section III of the complaint United States of American ex rel. Benjamin Poehling, explains the payment methodology which UnitedHealth Group, Inc. allegedly manipulated for financial gain. The Medicare program pays Medicare Advantage (MA) organizations a pre-determined monthly amount for each Medicare beneficiary in the plan. The payment amount for each beneficiary is based on their particular risk adjustment factor (RAF) score, which among other factors including the beneficiary’s demographics is impacted by assigned Hierarchical Condition Categories (HCC). [more]

Outpatient CDI Workshop: Join us for five weeks of education and networking

outpatient CDI workshop

Join us tomorrow as we kick-off the Outpatient CDI Workshop!

Due to the overwhelming success of our first ever ACDIS Symposium: Outpatient CDI, ACDIS has responded with a one-of-a-kind multimedia platform to keep the education, networking, and development going—right from your home office.

The Outpatient CDI Workshop features a broad sampling of the presentations delivered at the ACDIS Symposium in an easy-to-access online format. Participants in the Workshop will also enjoy facilitated collaboration with their peers and event presenters.

Take part in an ideas lightning round with the ability to send questions to presenters, enjoy conversation with your fellow attendees through an email discussion group, and participate in a live networking and problem-solving call with workshop participants and moderators. Get your outpatient CDI program off the ground with help from your peers and the experts at ACDIS! [more]

Note from the instructor: Reminiscing over 10 years in CDI

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Sharme Brodie, RN, CCDS

By Sharme Brodie, RN, CCDS

One of the wonderful things that time allows us is the ability to look back with an experienced eye and either learn from the past or at the very least have some fun with it.

I remember my first weeks as a CDI specialist as if it just happened. It was a  grueling hiring process and I was thrilled to have gotten the job. Looking back, I have no idea why I thought this would be a good step in my career. None of us knew at that time what we were doing and we had no idea what to expect from this new profession. [more]

Q&A: Coding mixed cardiogenic and septic shock

Have CDI questions?

Have CDI questions?

Q: If the attending documented, “likely mixed cardiogenic and septic shock,” can I assign codes R57.0 and R65.21?

A: Refer to the documentation within the code book. If you open the book to the R57 code grouping (Shock not elsewhere classified) listed below there is an Excludes1 note. Remember, Excludes 1 notes instruct us that we cannot use codes from this grouping with those listed within the Excludes 1 note. Cardiogenic shock (R57.2) falls within this grouping. Also listed is R65.2 septic shock. Purely relying on the coding conventions, I would conclude that we cannot code septic shock with cardiogenic shock. See the image below. [more]