Resource ICD-10 Monitor Articles

Great article on Acute Pulmonary Insufficiency following Surgery and educating providers on linking respiratory failure to an alternate medical condition.

Acute Pulmonary Insufficiency following Surgery​

Acute Pulmonary Insufficiency following Surgery – MedLearn Publishing

It’s not a valvular problem, but a definitional one. I recently received an email from a clinical documentation integrity (CDI) friend from my previous life as a physician advisor, asking my opinion on acute pulmonary insufficiency. She pointed out that the Association of Clinical Documentation...

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[Lori]

The “Other” Vaccinations
The CDC recommends healthcare workers get one dose of influenza vaccine annually.

The Centers for Disease Control and Prevention (CDC) has many more vaccines it recommends than just the COVID-19 vaccine. The list includes the following:

Hepatitis B
Flu (Influenza)
MMR (Measles, Mumps, & Rubella)
Varicella (Chickenpox)
Tdap (Tetanus, Diphtheria, Pertussis)
Meningococcal

The “Other” Vaccinations – MedLearn Publishing

The CDC recommends healthcare workers get one dose of influenza vaccine annually. The Centers for Disease Control and Prevention (CDC) has many more vaccines it recommends than just the COVID-19 vaccine. The list includes the following: Hepatitis B Flu (Influenza) MMR (Measles, Mumps, & Rubella)...

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[Lori]

Use of Stigmatizing Language in Patient Medical Records by Healthcare Providers​

Use of Stigmatizing Language in Patient Medical Records by Healthcare Providers – MedLearn Publishing

Stigmatizing language should be avoided whenever possible. I read an article in the Journal of the American Medical Association (JAMA) a few weeks ago that intrigued me; it was titled Physician Use of Stigmatizing Language in Patient Medical Records. When I teach my documentation course to...

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[Lori]

Coordination and Maintenance Meeting Starts Today​

Coordination and Maintenance Meeting Starts Today - ICD10monitor

Coordination and Maintenance committee meeting remains virtual.

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Coordination and Maintenance Committee Holds Marathon Meeting​

Coordination and Maintenance Committee Holds Marathon Meeting – MedLearn Publishing

Comments on the PCS proposals may be emailed to ICDProcedureCodeRequest@cms.hhs.gov by Oct. 15 for codes considered for implementation on April 1, 2022. The Coordination and Maintenance Committee met virtually Sept. 14 and 15, starting with the procedure proposals. There were two ICD-10-PCS...

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[Lori]

Finalized finally.

New COVID add-on treatments.

CMS is predicting inpatient covid cases will continue to be treated beyond the expiration date of the Public Health Emergency.

CMS Finalizes One-year Extension of New Technology Add-on Payments – MedLearn Publishing

Various approvals, exceptions, and new PCS codes that may potentially lead to additional payments. The Centers for Medicare & Medicaid Services (CMS) desires to use the best data available when rate setting for the upcoming fiscal year. Because COVID-19 unsettled the playing field within the...

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[Lori]

TPE audits were suspended by CMS during the public health emergency.

Tells you the who, why, what, & common mistakes.

This can help you prepare for this type of audit.

Important News: TPE Audits Resume – MedLearn Publishing

CMS resumes its targeted, probe and educate program. The Centers for Medicare and Medicaid Services (CMS) announced that Targeted Probe and Educate (TPE) audits would resume on Sept. 1, 2021. TPE audits had been suspended by CMS during the public health emergency (PHE). Unlike recovery audits...

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[Lori]

Outpatient HCC capture

2 Categories Hierarchy (determines payment) & Condition

A patient can have multiple HCC categories assigned to them but within an HCC category only the most highest & most severe hierarchy is assigned.

But what is a RAF score?

Read to learn more:

Outpatient CDI: Risk Adjustment and HCC Capture – MedLearn Publishing

The CMS-HCC model has two components, the hierarchy, and the condition category. EDITOR’S NOTE: Colleen Deighan will be conducting a Talk Ten Tuesdays Listener Survey on CDI today. Hierarchical Condition Categories or HCCs have been used by the Center for Medicare and Medicaid Services (CMS)...

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[Lori]

CMS releases the Final Rule Fee schedule.

3 priorities were increased leverage for telehealth for behavioral care, diabetes prevention & mitigation, & enhanced payment for vaccine administration.

CMS took steps to bolster its medicare diabetes prevention program (MDPP) expanded model it time for diabetes awareness month of November.

CMS Releases Physician Fee Schedule Final Rule – MedLearn Publishing

CMS says it the goal is to support health equity while focusing on high-quality person-centered care. Increased leverage of telehealth for behavioral care, diabetes prevention and mitigation, and enhanced payment for vaccine administration were three out of many priorities cited by federal...

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[Lori]

Reducing the number of cesareans can lower the mortality rates for Inductions of labor (IOL).

The various methods used to induce labor include cervical ripening, Pitocin administration, cervical dilation, and artificial rupture of membranes (AROM).

ACOG STANDARD LABOR DEFINITIONS (2014)

LABOR

Uterine contractions resulting in cervical change (dilation and/or effacement)

Phases:

· Latent phase – from the onset of labor to the onset of the active phase

· Active phase – accelerated cervical dilation typically beginning at 6cm

The Impact of Coding on Maternal Outcomes: Part III – MedLearn Publishing

Severe maternal morbidity often intersects with cesarean deliveries. Reducing the number of cesarean deliveries can lower the maternal mortality rate, and one of the drivers of cesarean rates is thought to be induction of labor (IOL). In 2014, the American College of Obstetricians and...

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[Lori]

Flu time.

This year's vaccine protects against 4 distinct strains of flu.

They include A (H1N1 or H3N2) and B (Victoria or Yamagata) strains.

Flu Season is Here – MedLearn Publishing

This year’s flu vaccine was designed to protect against four distinct strains of the virus. Flu season has arrived! The best time to get vaccinated is September or October. The timing is a bit difficult to predict this year, because of the lack of flu virus activity since March 2020. Flu vaccine...

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[Lori]

Severe Maternal Morbidity: Part 4​

Sepsis is one of the top five causes of maternal deaths so being familiar with the coding guidelines associated for reporting sepsis, which are found in sections I.C.1. (infectious and parasitic disease) and I.C.15 (pregnancy), can be extremely helpful.

The author my friend Kristi Pollard is a member of The California Maternal Quality Care Collaborative (CMQCC) which developed a sepsis toolkit, which will soon be adopted by the Centers for Medicare & Medicaid Services (CMS) and incorporated into the SEP-1 core measure.

Get the CMQCC Sepsis Toolkit here:

https://www.cmqcc.org/resources-toolkits/toolkits/improving-diagnosis-and-treatment-maternal-sepsis

Severe Maternal Morbidity: Part 4 – MedLearn Publishing

Sepsis is one of the top five causes of maternal deaths. EDITOR’S NOTE: This article by Kristi Pollard concludes an exclusive four-part series focusing on maternal and morbidity and mortality, a vitally important and timely topic. Pollard, Director of Coding Quality and Education for Haugen...

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[Lori]

Reducing Revenue Leakage: An Important Role for Outpatient CDI
Steps include mapping out the revenue cycle workflows and finding the causes of the denials so that effective solutions can be implemented. It’s answering three basic questions:

What’s the problem?
Why did it happen?
What can be done to prevent it from happening again?

Reducing Revenue Leakage: An Important Role for Outpatient CDI – MedLearn Publishing

One category of denials where outpatient CDI can help is medical necessity denials. EDITOR’S NOTE: Colleen Deighan will conduct the Talk Ten Tuesdays Listener Survey on CDI today as she concludes her series on outpatient CDI. Developing a successful and effective outpatient clinical...

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[Lori]

On Oct. 21, MLN Matters provided updates to the Medicare Code Editor (MCE), which includes a new edit, R11059CP, for unspecified codes. This edit will directly impact inpatient discharges occurring as of April 1, 2022.

Codes used to report Complications or Comorbidities (CCs) or Major Complications or Comorbidities (MCCs) are the targets of the new edit.

Potential Impacts of new Edit 20 for Inpatient Claims

Potential Impacts of new Edit 20 for Inpatient Claims – MedLearn Publishing

The list of unspecified diagnosis codes subject to the new edit will require targeted training for your billing staff to avoid reimbursement issues and provide a platform for improving CDI. It is essential to perform a pulse check on the number of unspecified codes currently used in your...

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[Lori]

COVID Guidelines for Omicron, Masking, Vaccination, and the Shifting CDC Guidance.​

With 2 household members being confirmed as positive this week I know I was confused as to what exactly to do.

Do you still find CDC guidelines confusing?

The most recent data on COVID-19 and the omicron variant (which constitutes 95 percent of COVID-19 cases, currently) is that the majority of viral transmission occurs in the 1-2 days prior to symptom onset and 2-3 days after. If you can transmit the virus before you know you have it, THAT is why routine mask-wearing is/was recommended. Once you test positive, the recommendation is to isolate for five days, and then if you are asymptomatic or improving, you can go out with a mask on for the next five days.

Omicron, Masking, Vaccination, and the Shifting CDC Guidance – MedLearn Publishing

Are you confused about the Centers for Disease Control and Prevention’s (CDC’s) ever-changing guidance on COVID-19?

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[Lori]

Invest the time and effort necessary toward educating your providers.

Payer denials are traced back to insufficient and/or poor documentation often times causing a denial.

A CDI should take an active role in reviewing payer denials to learn where the gaps are for future improvements.

IMPROVE YOUR CDI IN 3 STEPS:

Step One:
Stop relying primarily upon querying, and start educating. Take the time to uncover what the physicians and other providers really desire in a physician-driven CDI program. Learn what the physicians are requesting in a program that is meant to document and communicate patient care effectively and efficiently, allowing them to work smarter, not harder. Providers as a whole wish to document accurately the first time around, with fewer time-consuming interruptions from CDI and other ancillary care staff, particularly with the pandemic at hand.

Step Two:
The CDI must become more knowledgeable in what represents “clinical documentation integrity.” This means becoming knowledgeable of the standards and best-practice principles of clinical documentation. What are the critical elements of a history & physical, progress notes, and discharge summaries? What are acceptable practices in copying and pasting, also known as carry-forward, with rampant practices seen today that contribute to “note bloat” and inconsistencies in documentation that payers use to their advantage in denials?

Step Three:
Lastly, CDI must be committed to incorporating an approach that embraces the concept of proactive denials avoidance as the fundamental mission. Processes of CDI that support this mission will engage physicians, benefit the patient and all other healthcare stakeholders, and equally as important, align with a high-performing revenue cycle with optimal reimbursement and less second-guessing from third-party payers.

Three Steps to Improve CDI for Good – MedLearn Publishing

There is a three-step process for improving the CDI process, bringing it closer to true clinical documentation integrity. -Medlearn Media NPOS Non-patient outcome spending

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[Lori]

Medicare rules do not make sense from a compliance or best-practices perspective at times.

Medicare has a reputation of putting out policy that many feel is so confusing causing more questions than answers.

In 2022, evaluation and management (E&M) services may be billed as shared or split services when provided in a facility setting.

Conflicting Medicare & CPT rules are at the center of some the confusion involving E/M.

In 2022, evaluation and management (E&M) services may be billed as shared or split services when provided in a facility setting, according to Medicare Claims Transmittal 11146, rev. 11181, Medicare Processing Manual 30.6.18.

In 2021, CPT® added “shared visits” language into the new 2021 office visit documentation guidelines, when leveling a visit based on time, but in 2022, CMS is no longer allowing shared services in an office setting (30.6.18 B 1), although incident-to services in the office setting are still allowed.

Read more here on what was Medicare thinking:

What was Medicare Thinking? – MedLearn Publishing

Often, the rules do not make sense from a compliance or best-practices perspective. -Medlearn Media NPOS Non-patient outcome spending

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[Lori]

Is the joint infected?

A prosthetic joint is a foreign body, and its presence alone is a significant risk factor for infection.

Does the term ‘hematogenous’ mean the prosthetic joint infection is due to the presence of the prosthesis, or instead is seeded from concurrent infection elsewhere?

“Hematogenous” doesn’t mean it originated in the blood, although it does mean “spread by way of the bloodstream from a distant source during bacteremia.”

So how is this coded?

Read more here:

Hematogenous Means Bloodborne, not that the Prosthetic Joint isn’t Infected

A prosthetic joint is a foreign body, and its presence alone is a significant risk factor for infection. I am changing gears today, and I am sure you are

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[Lori]

To avoid reporting J18.9 perhaps a query is in order for pneumonia specificity ?

PEPPER (PEPPER is an electronic report that provides provider-specific Medicare data statistics for discharges/services vulnerable to improper payments) data allows clinical documentation integrity (CDI) departments to compare the volume of cases involving simple pneumonia to those involving respiratory infections.

In addition to comorbidities, the causative organism or etiology affects the severity of pneumonia.

With an inability to accurately identify the causative organism, providers often classify pneumonia as community-acquired pneumonia (CAP) or hospital/healthcare-associated pneumonia (HAP/HCAP).

HAP is defined by the American Thoracic Society as a lung infection that begins in a non-intubated patient within 48 hours of admission, but it has more commonly been used interchangeably with HCAP to describe pneumonia associated with organisms that result from exposure to healthcare (e.g., nursing homes, dialysis, etc.) These are broad terms that allow the provider to differentiate a simple pneumonia, CAP, from a complex pneumonia (HAP/HCAP, e.g., one associated with a more virulent pathogen), but ICD-10-CM does not index using these terms, so they both default to J18.9, pneumonia, unspecified organism.

The Merck Manual, states the most common pathogens associated with CAP are streptococcus pneumoniae, haemophilus influenzae, atypical bacteria (i.e., chlamydia pneumoniae, mycoplasma pneumoniae, legionella species), and viruses.

Updated guidelines have clinically eliminated HCAP as a pneumonia classification tool, instead focusing on the severity of pneumonia.
Some CDI departments only query for pneumonia specificity if HAP/HCAP is documented, since it can result in a DRG shift, but not when CAP is documented.

It is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures.

Read more here:

PEPPER Tip: Monitor Pneumonia Specificity – MedLearn Publishing

A best practice is to always query for pneumonia specificity to avoid reporting J18.9. -Medlearn Media NPOS Non-patient outcome spending

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[Lori]

What are the continuous challenges associated with attaining timely payment.

Where can key improvements be made?

AI is a red flag but what else?

Payer Strategies and the Long Road to Payment – MedLearn Publishing

The average cost of debunking a denial is $25 per claim, not to mention the continuous challenges associated with attaining timely payment. Reviewing denial management strategies on a regular basis may prove a more efficient payment journey. -Medlearn Media NPOS Non-patient outcome spending

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[Lori]

The final rule for Medicare Advantage (MA) and Part D prescription drug programs.
Includes making dually eligible beneficiaries easier, & provide enhanced transparency.
This rule improves the healthcare experience and affordability for millions of people with MA and Part D coverage.

CMS Issues Final Rule for MA and Part D Drug Programs – MedLearn Publishing

The announcement aligns with the Biden Administration’s push to emphasize health equity through policy. -Medlearn Media NPOS Non-patient outcome spending

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[Lori]

IPPS Rule delayed for another year implementation a comprehensive CC/MCC restructuring that the agency had proposed four years ago.
The proposed rule from the Centers for Medicare & Medicaid Services (CMS) includes rates for both Short-Term Acute Care Hospitals (STACHs) and the Long Term (Acute) Care Hospitals (LTACHs). Updates for Medicare-Severity DRGs (MS-DRGs) reimbursement, but also advocates for the President’s executive orders that address health quality, inequities, and outcomes.

Proposed IPPS Rule Likely a Sand Trap for Coders – MedLearn Publishing

The proposed rule delays for another year its implementing a comprehensive CC/MCC restructuring that the agency had proposed four years ago. -Medlearn Media NPOS Non-patient outcome spending

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FY 2023 IPPS Proposed Rule Home Page | CMS

This is the home page for the FY 2023 Hospital Inpatient PPS proposed rule. The list below centralizes any IPPS file(s) related to the proposed rule. The list contains the proposed rule (display version or published Federal Register version) and a subsequent published correction notices (if...

www.cms.gov