All Entries Tagged With: "Compliance"
Few IPPS changes final rule could cause CDIs trouble
There are a few changes in the IPPS final rule that may prove problematic for clinical documentation improvement specialists, according to Robert S. Gold, MD, CEO of DCBA, Inc., Atlanta.
Hypoxic ischemic encephalopathy (HIE), for example, has its roots in the pediatric population. So it will be important to recognize that the code for an adult with HIE is 348.1— anoxic brain damage. “And we need to be specific about the causes of encephalopathy in the neonate,” says Gold, “they’re not all HIE.”
The 285.3 code for anemia due to anti neoplastic treatment is different from anemia due to neoplastic disease and different from aplastic anemia from chemotherapy. The CDI specialists has to know what cell lines are missing and determine the true cause of the anemia in order to frame the question to the physician properly.
Gold also suggested that CDIs require better specificity of location of blood clots currently under treatment with Coumadin in order to assign the right code for deep vein thrombosis. He also suggested that physicians need to document whether the condition is new during the patient’s current hospital stay or whether it had been under treatment from a previous hospitalization.
Finally, Gold urged healthcare professionals to “work to preserve” the terms acute renal failure and acute kidney injury and to totally downplay the new definition of acute kidney failure. “This is a misunderstanding currently under discussion. You don’t want to promote the use of a term that might not last long. You don’t want to have to re-teach,” he says.
Alphabet soup: Five CMS acronyms every CDI should know
Okay, I know there are ton of other acronyms that clinical documentation improvement specialists
Tasty!
need to know, not the least of which include CC, MCC, DRG, POA, HAC, CHF, CKD, ARF, (don’t forget about the biggy—CMS!) and so on. . .
On the tail of my last post regarding recovery audit contractors I noticed a number of other data collection government groups associated with CMS that clinical documentation folks may or may not be aware of. I thought maybe you’d find a quick rundown of these acronyms helpful. A note of caution, however, I pulled the definitions from various helpful public Web sites so consider these more like Grandma’s recipes than the combination to the safe that hides the list of well-guarded Campbell’s ingredients.
- Quality Improvement Organizations (QIO): The mission of the QIO is to improve the effectiveness, efficiency, economy, and quality of services delivered to Medicare beneficiaries. In August 2008, work began on the QIO Program’s 9th Statement of Work, which extends through July 31, 2011.
- Comprehensive Error Rate Testing (CERT): One of two CMS programs to monitor and report Medicare payment inaccuracies. CERT measures the error rate for claims submitted to Carriers, Durable Medical Equipment Regional Carriers (DMERCs), and Fiscal Intermediaries (FIs).
- Hospital Payment Monitoring Program (HPMP): The second of two CMS programs to monitor and report Medicare payment inaccuracies.The HPMP measures the error rate for the Quality Improvement Organizations (QIOs).
- Program for Evaluating Payment Patterns Electronic Report (PEPPER): An electronic data report containing hospital-specific data for a number of target areas specific Diagnosis Related Groups (DRGs) and discharges that have been identified as at high risk for payment errors.
- Recovery Audit Contractors (RACs): The Recovery Audit Contractor (RAC) program was created through the Medicare Modernization Act of 2003 to identify and recover improper Medicare payments paid to healthcare providers and will become permanent for all states by January 1, 2010.
You should be ready to take the CMS quiz now. . . either that or you’re longing for the days when such ABC mashups meant merely another bowl of soup. Nevertheless, this Scrabble-esque snap shot illustrates just how many ways the government uses data to monitor healthcare services from both a quality perspective and a financial perspective. Where data meets documentation. . . that’s where CDI comes in.
Knock, knock: Picking a principal diagnosis is no joke
There was some controversy on CDI Talk this week concerning the correct way to code a case where the patient had shortness of breath, Pneumothorax, DVT, and hypoxia. The debate centered around which diagnosis was the principal: Emboli or DVT. There were many opinions, mine included, and as the talk ensued, it made me chuckle. There did not seem to be a clear-cut answer.
We all seemed to reach separate conclusions while all doing the same jobs. We all agreed with which sequence pays the most-DVT with Pneumothorax as the MCC. And we all know which diagnosis is the most resource intensive-Pneumothorax with DVT as CC. But nevertheless, we couldn’t agree about how to properly code this. It reminded me of an old knock, knock joke I heard as a kid.
It went something like this:
Anyone got this answer?
Knock.
Knock.
Who’s there?
Who’s where?
The Coding Guidelines state:
“When there are two or more interrelated conditions potentially meeting the definition of principal diagnoses, either condition may be sequenced first, unless the circumstances of the admission, the therapy provided, the Tabular List, or the Alphabetic Index indicate otherwise.”
When sequencing fractures in the trauma setting, the most significant should be sequenced as the principal. Does this rule only apply to bones? An emboli is certainly more life threatening than a DVT.
Knock.
Knock.
Who’s there?
Who’s where?
Who’s right?
Code sequencing is no knock knock joke. It’s a real compliance trick. CDI specialists, coders, help us out on this one. . .
Compliance eyes CDI concerns
When brought to court under a False Claims Act whistleblower suit, a miscommunication regarding leading physician queries no longer seems like a misdemeanor. One potential suit is rumored (it has not been publicly released yet) to have its roots in CDI, according to a January 26 article in the Report on Medicare Compliance.
The article outlines a few emerging compliance concerns and quotes our own ACDIS board member Robert Gold, MD, who reiterated for the compliance crowd that the goal of a CDI program is improved documentation.
Furthermore, the goal of improved documentation should be consistent across payers and disease-type, he says. The goal shouldn’t be improved documentation-but only for Medicare patients. It shouldn’t be improved documentation-only for acute respiratory failure patients. Or only for any other special situation. Where consistency lags, the risk for fraud excels.
In CDI Strategies on January 22, we explored a few ways you can work with your compliance officer to locate risk areas and develop compliance policies and procedures. A first step, of course, is to reach out to your facility’s compliance officer and tell him or her about your CDI program. If you do not have a compliance program at your facility, consider reaching out to other facilities in your area. Ask an experienced compliance professional to help you scrutinize your program’s practices, policies, and procedures to ensure you don’t run afoul of the law.
Look for additional tips and the latest information in the upcoming quarterly CDI Journal. In the meantime, please let us know if you are currently working with your compliance officer and what tools or tips you might have developed that you wouldn’t mind sharing with others.