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Guest post: Compliance risks abound in HCCs

James Kennedy, MD, CCS, CDIP

James Kennedy, MD, CCS, CDIP

by James S. Kennedy, MD, CCS, CDIP

Let’s discuss the compliance risks CDI and coding professionals need to address related with hierarchical condition categories related to the MACRA.

Coding must be based on provider documentation, not what is entered on a superbill or computer software. ICD-10-CM code assignment is based solely on a provider’s documentation in the legal medical record, according to the 2017 ICD-10-CM Official Guidelines and Coding Clinic, Fourth Quarter, 2016, pp. 147–149. The problem is that many physicians document one way in their notes and then pick an ICD-10-CM code in their billing software or superbill that would not be assigned if one applies ICD-10-CM coding conventions based on the provider’s documentation.  [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]

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]

Guest Post: New ICD-10-CM/PCS codes up the ante in coding compliance, part 3: Right heart failure

James S. Kennedy, MD, CCS, CDIP

by James S. Kennedy, MD, CCS, CDIP

Editor’s note: With the fiscal year 2018 ICD-10-CM/PCS codes released, Kennedy unpacked some of the compliance pitfalls and opportunities awaiting CDI and coding professionals when these new codes are implemented on October 1. Some of these issues may be addressed in the 2018 ICD-10-CM Official Guidelines for Coding and Reporting or the American Hospital Association’s Coding Clinic, Fourth Quarter, 2017, so be sure to compare Kennedy’s opinions with these documents. This article is part three in a three-part series. Click here to read parts one and two!

Right Heart Failure

Notice that we now have new codes for acute, chronic, and acute-on-chronic right heart failure. Remember also that Coding Clinic, Third Quarter, 2013, p. 33, states that the documented term of “decompensated” indicates that there has been a flare-up (acute phase) of a chronic condition. [more]

Guest Post: New ICD-10-CM/PCS codes up the ante in coding compliance, part 2: Pediatric Glasgow coma scales

James S. Kennedy, MD, CCS, CDIP

by James S. Kennedy, MD, CCS, CDIP

Editor’s note: With the fiscal year 2018 ICD-10-CM/PCS codes released, Kennedy unpacked some of the compliance pitfalls and opportunities awaiting CDI and coding professionals when these new codes are implemented on October 1. Some of these issues may be addressed in the 2018 ICD-10-CM Official Guidelines for Coding and Reporting or the American Hospital Association’s Coding Clinic, Fourth Quarter, 2017, so be sure to compare Kennedy’s opinions with these documents. This article is part two in a three-part series. Click here to read part one. Return to the blog next week to read part three!

Pediatric Glasgow coma scales

In what should have been a welcome change, the National Center for Health Statistics amended the ICD-10-CM Alphabetic Index to allow for reporting of the clinical descriptors of the pediatric Glasgow coma scale. Notice that in the best motor response section, “flexion to pain” gets three points in the clinical scale whereas “withdrawal from pain” gets four points. Now notice how ICD-10-CM manages these conditions in 2018: [more]

Guest Post: Using coding, CDI to transform hospitals’ revenue integrity, part 2

Want to write for ACDIS? Send us your ideas!

Want to write for ACDIS? Send us your ideas!

by Amber Sterling, RN, BSN, CCDS, and Jana Armstrong, RHIA, CPC

Seven lessons learned in physician education

The following lessons were learned at KRMC and proved to be instrumental in improving communication between physicians, CDI staff, and coders: [more]

Guest Post: Using coding, CDI to transform hospitals’ revenue integrity, part 1

Want to write for ACDIS? Send us your ideas!

Want to write for ACDIS? Send us your ideas!

by Amber Sterling, RN, BSN, CCDS, and Jana Armstrong, RHIA, CPC

Most healthcare systems already have a proven process in place to monitor revenue integrity and ensure correct reimbursement. More than 60% of hospital executives believe revenue integrity is essential to their organization’s financial stability and sustainability, according to a survey by Craneware, Inc.

But does revenue integrity extend beyond charge masters and billing? Kalispell Regional Medical Center (KRMC), one of the “100 Great Community Hospital” according to Becker’s Hospital review, says yes.

For KRMC, revenue integrity focuses on three operational pillars: clinical coding, CDI, and physician education. At KRMC and many other health systems, revenue integrity is a three-legged stool: [more]

Guest Post: New ICD-10-CM/PCS codes up the ante in coding compliance, part 1: Myocardial infarction

James S. Kennedy, MD, CCS, CDIP

by James S. Kennedy, MD, CCS, CDIP

Editor’s note: With the fiscal year 2018 ICD-10-CM/PCS codes released, Kennedy unpacked some of the compliance pitfalls and opportunities awaiting CDI and coding professionals when these new codes are implemented on October 1. Some of these issues may be addressed in the 2018 ICD-10-CM Official Guidelines for Coding and Reporting or the American Hospital Association’s Coding Clinic, Fourth Quarter, 2017, so be sure to compare Kennedy’s opinions with these documents. This article is part one in a three-part series. Return to the blog next week for the next installment! [more]

Guest Post: Communication eases challenges of fiscal year 2018 code changes

coding changes

On October 1, over 800 code changes take effect!

by Crystal Stalter, CDIP, CCS-P, CPC

It’s that time of year again—time to wonder just how the 2018 IPPS final rule will affect CDI and coding efforts.

The 2018 IPPS final rule includes more than 800 ICD-10-PCS changes. Previously recognized operating room codes have become non-operating room codes, affecting DRG assignment, changing surgical DRGs to medical DRGs, and thus affecting reimbursement. Some diagnoses are gaining new definitions and explanations that will result in new ICD-10-CM code assignments and shift DRGs as well.

[more]

Guest Post: Altered mental status remains a challenge in ICD-10-CM – part 2

James Kennedy, MD, CCS, CDIP

James Kennedy, MD, CCS, CDIP

By James Kennedy, MD, CCS, CDIP

Determine the underlying cause of the altered mental status

Remember that the various forms of altered mental states have underlying causes, which, if defined, diagnosed, and documented, accurately represent the patient’s condition for risk-adjustment purposes. Options include:

  • Neurodegenerative disorders. To the extent that it’s possible to state what the underlying degenerative brain disease is, please do so. Options include Alzheimer’s disease, Lewy-body dementia, late effects of multiple strokes, normal pressure hydrocephalus, some cases of Parkinson’s disease, and a host of others. Note: The term “multi-infarct dementia” requires additional documentation that it is the late effect of multiple strokes. Consider the word “encephalopathy” as well (see the next item) when documenting these underlying causes.

[more]