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


ACDIS Director Brian Murphy

Part 4 (click here to view part 1, click here to view part 2, and click here to view part 3)

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 looked at the regulations and commentary regarding claims submission to Medicare Advantage and the ramifications for CDI. Part 4, discusses recent developments of the case.

Since I wrote my initial three parts of the developing case of UnitedHealth Group, Inc. vs. the United States of America there has been a huge development on the legal front. Round 1 of the case of UnitedHealth Group, Inc. vs. the Unites States of America is over, and the decisive winner (at least in the matter of one complaint filed by the DOJ) is United. [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]

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


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]

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.