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Note from the Instructor: Your 2018 IPPS Final Rule questions, answered

Allen Frady

Allen Frady, RN-BSN, CCDS, CCS, CRC

By Allen Frady, RN-BSN, CCDS, CCS, CRC

Yesterday, 845+ codes took effect thanks to the fiscal year 2018 IPPS Final Rule, which was released at the beginning of August. As you review the updates, additions, and deletions in this year’s rule, I wanted to answer some of your burning questions to help guide you through this transition.

1.) Is it true that chronic obstructive pulmonary disease (COPD) does not have to be sequenced before pneumonia?

The Index for 2017 had the language “use additional code to identify infection.” This was misinterpreted as applying to conditions such as pneumonia by both coders using the index and the AHA’s Coding Clinic. “Use additional code” means that a subsequent diagnosis must be sequenced as a secondary code. However, “use additional code to identify infection,” usually means to assign an additional organism code from the organism code category of B95 to B97. [more]

News: CMS holds call for appeals settlement

CMS will hold a MLN Connects® National Provider Call on Monday, December 12, 1:30-3 p.m., Eastern, regarding the 2016 hospital appeals settlement update, which became available to providers with outstanding claims denials as of December 1.

On November 3, 2016, CMS provided details on the process to allow eligible providers to settle their inpatient status claims currently under appeal using the Hospital Appeals Settlement process. Details on the settlement process are posted on the Hospital Appeals Settlement Process 2016 website.

To register or for more information, visit MLN Connects Event Registration. Space may be limited, register early.

Q&A: Unsigned notes

Open dialogue is the most valuable tool we have to grow the CDI profession.

Have a question? Comment below!

Q: Is there guidance on reviewing a record, such as an operative (OP) note, that has not been signed by a physician? I am at a facility that allows coding from unsigned transcriptions. I was always told that the information needs to be confirmed by a signature as valid before including that information in the review worksheet. Do you have any recommendations for this?

A: I would not advocate assigning codes based on unsigned OP notes. I believe that several organizations do allow this, so as not to hold up billing waiting for a signature, but I would want a method to assure the notes are signed.

The Centers for Medicare & Medicaid Services (CMS) requires that any Medicare service provided or ordered must be authenticated by the author — the one who provided or ordered that service. Authentication may be accomplished through the provision of a hand-written or an electronic signature; however, stamp signatures are unacceptable, with the exception of a physical disability.

The information you need from the OP note may also be found on other areas of the record, including the pre-op and post-op progress notes.

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, and CDI Education Specialist at HCPro in Danvers, Massachusetts, answered this question. Contact her at For information regarding CDI Boot Camps visit

News: CMS’ first round of end-to-end testing a success

news blocksAdd another nail in the “delay ICD-10 because the industry isn’t ready” coffin.

CMS declared its end-to-end testing week from January 26 through February 3 a success. A total of 661 volunteers submitted 14,929 test claims, with CMS accepting 81% (12,149 claims).

CMS rejected 13% of the claims for reasons not related to ICD-10, such as:

  • Incorrect National Provider Identifier
  • Dates of service outside the range valid for testing
  • Invalid HCPCS codes
  • Invalid place of service

Three percent of claims contained an invalid ICD-10-CM and 3% had an invalid ICD-10-PCS codes, leading CMS to reject the claims.

More than half (56%) of the claims fell under professional services and 38% were institutional claims. Suppliers submitted 6% of the claims.

CMS identified zero issues related to professional and supplier claims and stated that none of the claims were rejected because of front-end submission problems.

CMS did find one system issue related to institutional claims, but it affected fewer than 10 total claims. It will fix the problem before the next end-to-end testing week April 26-May 1.

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

Guest Post: Expanding CDI focus beyond MS-DRG capture

ICD-10 testing process in play

CMS puts additional emphasis on quality of care for payment purposes in recent address.

The recent ACDIS Radio titled “Resolving Coder and CDI Clashes” presented on February 4 was another thought provocative discussion on an important area for most CDI programs.

Allow me to share my own personal thoughts and comments on the concept of MS-DRG congruence tracking in the hopes of provoking beginning a dialogue on the value even incorporating the MS-DRG tracking into a CDI program. Let’s start by defining the core elements of an effective CDI program.

An effective CDI program strives to demonstrate, collaborate, promote, and continually improve clinical documentation. Its purpose is to ensure that medical record documentation is effective, efficient, concise, coherent, complete, and accurate, and that it supports good patient care and captures quality outcomes.

An integral part of CDI specialists’ day-to-day duties and responsibilities is working closely with physicians and other allied health professionals to make a compelling case for best practice strategies of clinical documentation; documentation which clearly captures the physicians’ effective care choices through their:

  • clinical judgment
  • medical decision making
  • thought processes
  • analytical skills
  • problem solving ability

These elements serve as the fundamental basis for Medicare’s recently reinforced commitment to transitioning away from volume-based, fee-for-service, healthcare reimbursement to one which embraces the “triple aim.” The “triple aim” is a framework developed by the Institute of Healthcare Improvement which calls for simultaneously improving an individual’s experience of care, improving the health of populations, and reducing the per capita costs of the care provided.

Medicare’s goal in this value-based, cost-effective, quality-focus approach to the delivery and payment was summarized best in a January 26, 2015 release titled “Better Care, Smarter Spending, Healthier People: Improving Our Health Care Delivery System.”

Consider the following statements from this fact sheet:

  • Improving the quality and affordability of care received by Americans is, alongside increasing access to it, a core pillar of the Affordable Care Act. The Administration is working to ensure that:
    • Americans receive better care
    • Our health care dollars are spent more wisely
    • We have healthier communities, a healthier economy, and ultimately, a healthier country
  • This means finding better ways to:
    • Deliver care
    • Pay providers
    • Share and utilize information
  • The Affordable Care Act offers many tools to improve the way providers are paid to:
    • Reward quality and value instead of quantity
    • Strengthen care delivery by better integrating and coordinating care for patients
    • Make information more readily available to consumers and providers
  • Doing so will improve:
    • The coordination and integration of healthcare
    • Integration of patients in decision-making
    • The health of patients – with a priority on prevention and wellness

Effective clinical documentation, that is, documentation which best explains the reason for a patient’s care is fundamental to the promotion and achievement of smart effective care choices demanded by all third party payers as well as healthcare care consumers. This means that physicians need to provide (and CDI specialists need to seek out and support):

  • an accurate account of the patient acuity and severity
  • clinical rationale for intensity of services ordered and/or performed
  • medical need for inpatient hospitalization
  • evidence-based medical decision making
  • adherence to and justification for deviating from practice guidelines

In light of the above discussion, I pose the question of whether tracking MS-DRG congruency between the coder and the CDI specialists is realistic, practical, or of any material benefit to true effective clinical documentation improvement programs.

That may be a controversial thought considering how many CDI programs begin and the ongoing focus of many on simple CC/MCC capture rates and MS-DRG optimization, but I think that’s where we, as an industry need to be. What are your thoughts and ideas?

News: Study reveals overspending on U.S. billing and insurance paperwork

CMS says new date for ICD-10-CM/PCS implementation set for 2015.

Billing paperwork costs billions

Healthcare organizations spent approximately $471 billion on paperwork related to billing and insurance in 2012, with 80% of that potentially wasted, according to the study “Billing and insurance-related administrative costs in United States’ health care: synthesis of micro-costing evidence,” published in BMC Health Services Research.

Using a standard definition of “billing and insurance-related costs” (BIR), researchers found that physician practices spent approximately $70 billion, hospitals spent roughly $74 billion, and other institutions (e.g., nursing homes, home health care agencies, prescription drug, and medical supply companies) spent approximately $94 billion. Private insurers spent approximately $198 billion on BIR compared to $35 billion spent by government-sponsored health insurance programs.

Adopting a simplified, single-payer insurance system similar to Medicare could save the U.S. approximately $375 billion annually or more than $1 trillion in three years.

Editor’s Note: This article originally published in the HIM-HIPAA Insider.

News: CMS sets ICD-10 testing process in place

ICD-10 testing process in play

ICD-10 testing process in play

The new ICD-10 implementation date is less than a year away, and CMS is gearing up its end-to-end testing process in preparation.

CMS will select submissions from approximately 2,550 volunteers for three separate testing opportunities in January, April, and July 2015, and will make an effort to choose participants that represent a variety of provider, claim, and submitter types. MLN Matters SE1409 Revised states that the goal of the testing is to demonstrate the following:

  • Providers or submitters are able to successfully submit claims containing ICD-10 codes to the Medicare fee-for-service claims systems
  • CMS software changes made to support ICD-10 result in appropriately adjudicated claims (based on the pricing data used for testing purposes)
  • Accurate remittance advice is produced

Take action as early as possible regardless of whether your organization opts to test with CMS or another payer, says Barbara Hinkle-Azzara, RHIA, vice president of HIM operations at HRS Coding in Baltimore. Throughout the transition to ICD-10, organizations have made the mistake of assuming they will be able to test with payers only to find themselves left out because payers are only testing with a limited number of providers, she says.

Continue reading “ICD-10 countdown: Testing may offer a glimpse into the future” on the HCPro website.

Medicare Compliance Review provides new blueprint for CDI efforts

Glenn Krauss

Glenn Krauss

If you haven’t seen the OIG report “Medicare Compliance Review of University of Cincinnati Medical Center [UCMC] for Calendar Years 2010 and 2011,” take a look here at the Office of the Inspector General’s (OIG) website.

What you will see is eye-opening: The OIG reviewed a sample of claims that it deemed were improperly billed by the 695-bed hospital, and, by extrapolating the error rate, determined that UCMC owes more than $9.8 million in improper payments.

The next thing you should consider as a CDI specialist is: How can I prevent my hospital from such a similar (potential) catastrophic review by the OIG? By focusing on affecting positive change in clinical documentation that represents “true” documentation improvement vs. a narrowly defined CDI focus on the capture of CCs/MCCs, says Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI, a manager with Accretive Health in Chicago.

CDI specialists tend to look only at solidifying individual diagnoses in the chart, but often ignore equally important supporting information like clinical indicators to support admission to the facility.

“Do we have good solid documentation of the patient’s DRG, or do we have diagnoses with little clinical support? Are we just sending automatic queries?” he asks. “Often we’re not focused on getting a solid, effective, and encompassing history and physical [H&P] that accurately captures the patient’s history of present illness [HPI] reflective of the patient’s severity of illness, signs and symptoms.”

Physicians tend to elaborate on a patient’s past illnesses vs. a patient’s present illness. A sound HPI consists of a chronological description of the development of the patient’s present illness from the first sign and/or symptom to the present, Krauss notes. “There is often inconsistent or lack of clinical context for the reason for the admission. Doctors need this context for their billing, and [hospitals] need it for quality,” he says.


News: CMS presents free ICD-10 readiness webinar today

CMS will host a 90-minute special event from 12:00-1:30 p.m., Eastern Thursday, February 20, focused on ICD-10 readiness. The agenda for this WEBINAR ONLY event is provided below for your reference.

12:00-12:15PM Welcome Remarks  

Robert Tagalicod

Director, Office of E-Health Standards and Services

Centers for Medicare & Medicaid Services


12:15-1:15PM CMS ICD-10 ReadinessCMS representatives will discuss their ICD-10 plans for the rigorous testing CMS has conducted to date.


Moderator: Denesecia Green, Senior Health Insurance Specialist

Office of E-Health Standards and Services

Centers for Medicare & Medicaid Services


John Evangelist, Acting Director

Business Applications Management Group

Office of Information Services

Centers for Medicare & Medicaid Services


Diane Kovach, Director

Provider Billing Group, Center for Medicare

Centers for Medicare & Medicaid Services


Stacey Shagena, Health Insurance Specialist

Division of Change and Operations Management, Medicare Contractor Management Group, Center for Medicare

Centers for Medicare & Medicaid Service


Carol Messick, Deputy Director

Medicare Contractor Management Group, Center for Medicare

Centers for Medicare & Medicaid Services

Brian Pabst, Technical Advisor

Division of Medicare Secondary Payer Operations, Financial Services Group, Office of Financial Management

Centers for Medicare & Medicaid Services


Shana Olshan, Acting Deputy Director

Provider Communications Group, Center for Medicare

Centers for Medicare & Medicaid Services


Jessica Kahn, Director Division of State Systems

Data and Systems Group, Center for Medicaid and CHIP Services

Centers for Medicare & Medicaid Services


CAPT Godwin Odia, State Medicaid Program ICD-10 Implementation Lead

Division of State Systems, Data and Systems Group, Center for Medicaid and CHIP Services

Centers for Medicare & Medicaid Services


1:15-1:30PM Online Q&A  

Understand how HCC changes relate to physician quality scores, reimbursement

Tips for ICD-10 queries.

Tips for ICD-10 queries.

By James S. Kennedy, MD, CCS, CDIP

Although most physicians have heard of DRGs with inpatient admissions, only those invested in accountable care organizations and independent practice associations are likely familiar with hierarchical conditions classifications (HCCs). Based on ICD-9-CM codes submitted by physicians or hospitals in a calendar year for documented diagnoses requiring assessment, management, or treatment, HCCs will significantly change in 2014 with additions and deletions as well as relative weight changes.

Physicians documentation will need to improve related to HCCs because one of the goals of the Patient Protection and Affordable Care Act (PPACA) is to encourage provider efficiency, defined by CMS as a ratio of observed to expected costs and outcomes for selected populations. And, to this end, CMS is developing efficiency measurement metrics that will influence reimbursement and may be reported on its Physician Compare website ( mnq89rh). These include:

  • CMS Episode Grouper for Medicare. Part of CMS’ Quality and Resource Use Reports, currently focused on cardiac conditions and pneumonia. Learn more at
  • CMS Physician Value-Based Payment Modifier. Applicable to groups of 100 or more providers in calendar year (CY) 2015, potentially groups of 10 or more providers in CY2016, and all others in CY2017, its calculation involves the total per capita cost measure for Medicare fee-for-service and the Medicare spending per beneficiary models using CMS’ HCCs. Read more in the CY2014 CMS Proposed Physician Fee Schedule, available at 2013-07-19/pdf/2013-16547.pdf

Editor’s note: This article is an excerpt from the Featured Article on the ACDIS homepage and was originally published in the December 2013 edition of Medical Records Briefings. James S. Kennedy, MD, CCS, CDIP, is president of A past ACDIS Advisory Board member, Kennedy is a general internist and certified coder, specializing in clinical effectiveness, medical informatics, and clinical documentation and coding improvement strategies. Contact him at 615-479-7021 or at