Attending the 2016 AHIMA Annual Convention and Exhibit in Baltimore, MD had its pros and cons.
The pros: unbeatable networking opportunities and the chance to hear astronaut Captain Mark Kelly and former US Congresswoman Gabby Giffords deliver their inspiring message.
The cons: jetlag and responding to the avalanche of work e-mails upon arrival back in the office.
The good news is that if you weren’t able to travel to Baltimore, the Journal has you covered—and you time to spare since you’re caught up on your e-mails. The convention closed a little over a week ago, which has given AHIMA’s top subject matter experts—presenters and organizers of many of the convention’s events—time to reflect on all that they learned during the action-packed week. We’ve broken down convention takeaways by HIM domain.
This year marked the 10-year anniversary of AHIMA’s Privacy and Security Institute, which attendees helped celebrate with cake, champagne, and a slate of top-tier speakers, according to Angela Rose, MHA, RHIA, CHPA, FAHIMA, a director of HIM practice excellence at AHIMA. The Institute is held on the Saturday and Sunday prior to the formal kickoff of the convention.
Baltimore’s proximity to Washington, DC, and federal agencies such as the Department of Health and Human Services’ Office for Civil Rights (OCR) and the Office of the National Coordinator for Health IT (ONC) helped Rose recruit speakers such as Deven McGraw, Esq., OCR’s deputy director of health information and privacy. Rose says Institute attendees were hanging on to McGraw’s every last word “because she makes all the decisions about their privacy and security programs,” Rose said.
McGraw also touched on recurrent compliance issues, business associate agreements, risk analysis, and failure to manage identified risk, as well as insufficient data backup and contingency planning, among other privacy and security topics.
Click here for the AHIMA Today article on McGraw’s presentation.
While attendees of the 2015 AHIMA convention were literally counting down to the October 1, 2015 go-live of ICD-10-CM-PCS, this year coding-focused convention goers were more concerned with ICD-10 updates for 2017 and with how the recently finalized MACRA final rule would impact providers.
In addition to coding and clinical documentation improvement (CDI) sessions held throughout convention, AHIMA also convened the Clinical Coding Meeting held on the Saturday and Sunday prior to the convention’s official launch.
“We had a great crowd for both days of the Clinical Coding Meeting,” said Donna Rugg, RHIT, CCS, CDIP, a director of HIM practice excellence at AHIMA. “We also had more registrants listening via live streaming than last year… Attendees were anxious to hear about ICD-10 post-implementation and CDI—both of these tracks were well attended and we had good Q&A sessions with presenters and the attendees.”
Tammy Combs, MSN, RN, CCS, CCDS, CDIP, a director of HIM practice excellence at AHIMA, said it was exciting to see so much interest in outpatient CDI from those who attended the coding meeting.
“It was exciting to see how interested CDI specialists are in outpatient CDI and expanding CDI into specialty areas such as skilled nursing facilities, pediatrics, home health, and critical access hospitals,” Combs said. “The outpatient CDI workshop had a great response. We had several people come up afterwards making comments about how they enjoyed it and they would like to have more outpatient information from AHIMA.”
Information governance (IG) had a high profile at this year’s convention, with events including the Information Governance Leadership Forum, which was held on the Sunday of convention, as well as the “Building the Case for Information Governance—IG Roundtable,” which took place that Monday.
Ann Meehan, RHIA, director of information governance at AHIMA, felt that attendees were interested and engaged in learning more about IG, and that IG knowledge among convention goers ranged from people who weren’t familiar with the term “information governance” to individuals that are actively implementing IG programs.
“It’s always a learning experience to hear from others who are on the IG journey and to learn new ways that people are going at it. The IG Roundtable and the IG Leadership Forum on Sunday, allowed attendees to interact and share their experiences,” Meehan said.
Meehan said that throughout the convention a theme she kept hearing is that the role of the HIM professional—whether a coder, a CDI manager, or other—is evolving.
“We must all step up and prepare ourselves to evolve with it. We don’t want to become the next ‘Blockbuster Video’ as Lynn [Thomas Gordon] said. That was absolutely the pervasive theme throughout the convention… and IG is part of that,” Meehan added.
Click here for more Journal coverage on IG at convention.
The mission of AHIMA’s standards team at this year’s convention was to was to raise awareness about AHIMA’s role in standardization of HIM practices and guiding the development of Health IT standards for interoperable health information systems, according to Anna Orlova, PhD, senior director of standards at AHIMA.
Orlova and her team were thrilled to find that attendees at standards-related sessions were engaged and interested in learning about the concepts, processes, and entities of standards development activities. Additionally, Orlova received several inquiries from individuals who were interested in joining AHIMA’s Standards Task Force.
“There is growing interest in participating on the AHIMA Standards Task Force. Those who already participate in the Task Force strongly advocated for continuation of AHIMA involvement in standardization efforts both nationally and globally,” said Orlova.
At the session “Data on the Go: Keeping up with mHealth,” presenters shared success stories about improving patient engagement with people with chronic illnesses via mobile devices.
The question Orlova and her team heard the most often was “How can I get involved?” and “How would I use standards in my organization?”
Accountable care units can help streamline communication and reduce length of stay
At the completion of this educational activity, the learner will be able to:
Opening the lines of communication between clinicians and specialists to make care more efficient can be a sizable challenge.
At many facilities, hospitalists shuttle from floor to floor to see patients, each time trying to track down the nurse and other professionals working on each case. Information is typically transferred through an inefficient system of pages and phone calls?sometimes taking hours at a time to deliver crucial pieces of information.
Enter the accountable care unit?a new way of configuring care systems that can help to uncoil tangled communication wires between clinicians and support staff to provide care that is more efficient and streamlined.
In this model, hospitalists work with patients in a specified geographical area of the hospital in conjunction with interdisciplinary teams.
Having patients in one area helps make care more efficient, and as one hospital system in New Mexico learned, can also reduce length of stay and increase cost-efficiency.
A push toward regionalization
Regionalization of hospitalist patients is becoming more common today, because of the benefits it’s been shown to bring, says Stefani Daniels, RN, MSNA, ACM, CMAC, founder and managing partner of Phoenix Medical Management in Pompano Beach, Florida. Those benefits include:
"I’m pushing accountable care units at all my hospital clients," says Daniels. But while the will is there in many cases to make the change, it’s not always an easy conversion.
Sometimes these initiatives face pushback from physicians concerned about personnel or scheduling issues.
Other challenges include:
Despite the challenges these initiatives can face, Presbyterian Medical Group in Albuquerque, New Mexico successfully implemented a unit-based model with multidisciplinary rounds about six years ago, says David J. Yu, MD, MBA, FACP, SFHM, medical director of adult inpatient medicine service for Presbyterian Healthcare Services.
The initiative was prompted by a desire to improve inefficiencies and streamline care. "We basically needed to improve patient flow and communication," says Yu. "But we also realized it was a very large process because it involved almost every department, including case managers, physical therapy, nursing, and ancillary services."
To overcome that daunting multi-departmental challenge, officials enlisted the hospital’s Lean Six Sigma group to help coordinate the project.
Presbyterian sought to trade its outmoded care model for something more efficient; one that would improve communication and eliminate delays related to breakdowns in this area.
The changes began as a unit-based project with multidisciplinary whiteboard rounds, a daily meeting that included the hospitalist, nursing staff, care coordination, physical therapy, and other specialists. They discuss the treatment plan and the goals related to the patient care both for that day and the hospitalization for each patient, he says.
The success of that pilot program led officials to implement the same unit-based model in eight of the medical floors at the hospital.
The payoff for the organization has not only been a huge boost in the efficiency of communication, but reduced length of stay for patients. "We’ve seen significant improvements in the average length of stay. This is not because we’ve reduced therapeutic time, but because we’ve reduced inefficiencies," says Yu. Lag time created by communication gaps has been tightened up, allowing patients to move through the system more quickly and efficiently.
To ensure that these new efficiencies weren’t resulting in quality reductions, Yu says the organization also tracked readmissions, which remained steady, confirming that faster discharges weren’t compromising patient care.
Presbyterian has managed to overcome many hurdles that can make this model a challenge. Although these changes have been successful, they have not necessarily been quick.
"I think in many cases people are just interested in a quick fix," says Yu. This process has been anything but. More than half a decade in, Yu says the program is still a work in progress and the team is continually looking to make improvements.
The initiative took time because it addressed the underlying structure of the organization and didn’t just make surface changes that can’t be sustained.
"I like to use the analogy of painting a wall. The painting is the easiest part. What takes time is all the prep work getting the surface ready," he says.
Most organizations just want the paint on the wall?they aren’t willing to address work needed to fix the underlying structure. "This really is a foundational project that takes months and years to develop and mature," he says.
This project not only solved many communication problems at the organization, but it also helped to ready the facility for the new era in healthcare ahead?one where revenue is driven by quality, not volume.
Organizations that want to thrive in this new model will need to rethink antiquated processes and systems going forward, he says. Those that don’t may not survive in this model.
Steps to success
For an initiative like this one to be successful, it has to be well designed and have support?both in commitment and in terms of dollars?from upper management.
"A lack of resources is another reason why a lot of these projects fail," says Yu. "The hospital doesn’t want to fund it. If only one department is very excited about the project, it won’t work."
The model involves a major change that requires support from multiple disciplines. "Without the support of leadership it’s not going to succeed," he says.
You also have to give hospital staff members a reason to support it, which may be the biggest challenge.
"It has to successfully answer the question, ‘What’s in it for me?’ " says Yu.
If the changes are onerous and provide little benefit to the people they affect, there’s little incentive for anyone to support it.
"Understand your worker and your project," he says. And overcoming barriers may involve system and even contract changes, he says.
If you can get that support, you can make changes that will improve communication and consequently care at your organization?and help ready it for the changing healthcare landscape of the future.
Commonwealth Fund study shows insurance gaps remain
At the completion of this educational activity, the learner will be able to:
While some 26 million Americans have gained insurance since the Affordable Care Act (ACA) became effective in 2010, another 24 million U.S. adults are still living without coverage, according to a new report by the Commonwealth Fund, a private, nonprofit organization that supports health policy research and reform.
This is a concern because not only are uninsured adults likely to skip needed health services due to the cost, but a lack of insurance is also a risk factor for preventable hospitalizations and health declines due to chronic diseases, according to the Henry J. Kaiser Family Foundation (http://ow.ly/Bs3a304bJR7).
So who are these uninsured Americans? According to The Commonwealth Fund survey (http://ow.ly/I8uZ304cB2b), 88% are Latinos under the age of 35 who earn less than $ 16,243 and/or work for a small business. "Half (51%) of the remaining uninsured live in one of the 20 states that had not yet expanded Medicaid at the time of the survey," states a press release issued by the Commonwealth Fund (http://ow.ly/gqsB304bJZk).
Case managers should take note of the survey findings.
"The Commonwealth Fund analysis is beneficial to all case managers, because the uninsured population compromises our most at high-risk groups of patients," says June Stark, RN, BSN, Med, director of care coordination at St. Elizabeth’s Medical Center in Boston. "Most hospitals today seem to be the primary source of healthcare provision to the patients in their communities. Expanding the case manager’s understanding of this population can contribute to the development of successful strategies for managing this group."
About the study
The study, called The Commonwealth Fund Affordable Care Act Tracking Survey, consisted of 15-minute telephone interviews. Interviewers conducted the interviews in two languages, either English or Spanish, between February and April 2016. The data was collected by calling a random, nationally representative sample of nearly 5,000 adults ages 19?64.
Since the ACA went into effect, the uninsured population shifted from mostly white adults to Latinos, according to the Commonwealth Fund press release. Results also show that renewed efforts to help uninsured individuals gain coverage might also be in order.
"The ACA held promise for many, especially those with incomes that could bear new market sticker prices, and as can be seen from the study, diverse populations benefitted from targeted reform marketing efforts," says Shawna Grossman Kates, MSW, MBA, LSW, CMA, the director of case management and bed management for RWJBarnabas Health in Toms River, New Jersey. "Yet it is very apparent that while there has been success with some at-risk populations, those with the lowest incomes who do not qualify for Medicaid are still struggling."
This study, she says, shows it may be time for a revival of the initial efforts to enroll Americans in health plans, which have become less prominent over time. There may also be a role for case managers and social workers to help guide uninsured patients they encounter in the hospital to seek coverage.
"The case manager has an active role in helping patients acquire insurance coverage," says Stark. "A mainstay of the traditional case manager role is, during the admission assessment, to determine if the patient has insurance and if so, to validate if it is correct and active. This is accomplished by interviewing the patient, viewing their insurance card, and checking further with the help of the hospital’s financial counselors."
If a patient is uninsured, case managers should refer him or her to financial counselors to determine the patient’s eligibility and to help him or her secure insurance during the hospital stay, she adds.
"The case manager’s efforts to secure insurance is essential, as the specific insurance benefits drive what discharge options are available for the patient, and therefore, helps secure a safe discharge plan," says Stark.
Social workers, too, play a role.
"It is often the social work partner in a case management relationship who provides the under-insured and uninsured the counseling, available tools and resources, and sometimes the hands-on, step-by-step training to explore with patients and families their income/assets/spending and eligibility for entitlement programs or market products," says Kates. "It is a continuous conversation that has been rooted in a long history of patient intervention by social work. Possessing expert knowledge in federal and state eligibility requirements, financial/social access limits, and having strong relationships with county and state providers, the social worker will connect services with patients."
In their role as patient advocates, case managers and social workers can help to break down cultural and social barriers, such as language and access based on geography, she adds.
Action points from the Commonwealth Fund
The Commonwealth Fund study authors agree with Kates that enhancing efforts to reach the uninsured and help them enroll in health plans should be a goal based on these findings. Only 62% of people without insurance said they knew about insurance marketplaces.
They also recommend a number of other steps that they say could help more of these uninsured individuals gain coverage. Their recommendations are as follows:
Ultimately, using a combination of local and federal interventions can help the U.S. move closer to its goal of helping get coverage for all its citizens.
Is the 2-midnight rule going away and when will short-stay audits resume?
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Every couple months, it seems questions arise about the 2-midnight rule and there are rumors that it may be going away. Below are some questions with answers from our expert Ronald Hirsch, MD, FACP, CHCQM, vice president of the Regulations and Education Group at Accretive Health in Chicago, to clarify where things stand today with regard to the 2-midnight rule.
Q: I heard the 2-midnight rule is now gone based on changes to Medicare payment rates under the 2017 inpatient prospective payment system (IPPS) final rule. Is this true, and if not, what changed?
A: No, this is not the case. The 2-midnight rule is still alive and kicking. What the FY 2017 IPPS final rule did is finalize two adjustments in addition to updating the annual rate for inpatient hospital payments.
"First, CMS is finalizing the last year of recoupment adjustments required by the American Taxpayer Relief Act of 2012 (ATRA). Section 631 of ATRA requires CMS to recover $ 11 billion by FY 2017 to fully recoup documentation and coding overpayments related to the transition to the MS-DRGs that began in FY 2008," states the CMS Fact Sheet. "For FYs 2014, 2015, and 2016, CMS implemented a series of cumulative -0.8 percent adjustments. For FY 2017, CMS calculates that $ 5.05 billion of the $ 11 billion requirement remains to be addressed. Therefore, CMS is finalizing a -1.5 percent adjustment to complete the statutorily specified recoupment."
And the second part of the change, which seems to be causing the confusion, is CMS took action on a -0.2 percent adjustment it implemented in the FY 2014 IPPS final rule.
This adjustment was initially made to account for an estimated increase in Medicare spending due to the 2-midnight policy. "Specifically, in the FY 2014 IPPS final rule, CMS estimated that this policy would increase expenditures and accordingly made an adjustment of -0.2% to the payment rates," states the fact sheet.
While CMS thought this adjustment was reasonable at the time, a recent review led CMS to permanently remove this adjustment, "and its effects for FYs 2014, 2015, and 2016 by adjusting the 2017 payment rates. This will increase FY 2017 payments by approximately 0.8%," stated CMS.
Hirsch says this move is "purely about money." "They are leaving the 2-midnight rule itself completely intact," he says.
The bottom line: Pay attention to 2-midnight compliance and ensure your organization has good systems in place to support it.
Q: When are Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIO) short-stay reviews going to resume?
A: Back in May, CMS put a hold on short-stay inpatient audits related to the 2-midnight rule. That hold was lifted effective September 12, 2016, according to a FAQ published by CMS (http://ow.ly/DQxW304bCa6).
According to the FAQ, CMS decided to lift this temporary suspension for five reasons, which are as follows:
It appears that based on the five points, the temporary audit suspension accomplished its goal of helping BFCC-QIOs sort out the challenges they faced during the initial round of audits.
Prior to the suspension, hospitals complained about inconsistencies in the review process, which triggered the suspension. The BFCC-QIO audits began in October 2015, and hospitals reported a number of surprises including:
These problems made it difficult for hospitals to hit filing deadlines, and they were consequently reporting problems because they missed the window to appeal denied claims. Hospitals also didn’t have a chance to get education to understand what they were doing wrong to fix the problem.
There were also rumored problems related to benchmark admissions. Hospitals reported that BFCC-QIOs were routinely and in some cases inappropriately denying inpatient admissions when the patient spent one night as an outpatient in the emergency department or in observation services before he or she was admitted?even when the patient spent a second night in the hospital as an inpatient.
To prevent future problems, CMS said in its FAQ that it will continue to provide oversight for BFCC-QIO efforts by:
CMS also said that BFCC-QIOs will continue tofollow the guidance called, "Reviewing Short-Stay Hospital Claims for Patient Status." To see a copy ofthe guidance, go to www.cms.gov/research-statistics- data-and-systems/monitoring-programs/medicare-ffs- compliance-programs/medical-review/inpatienthospitalreviews.html.
The BFCC-QIOs will also be charged with providing provider education going forward. "The BFCC-QIOs were directed to use comprehensive outreach and communication approaches (i.e., website, newsletter, one-on-one training, and town hall type events) to continue to educate providers on when payment under Medicare Part A is appropriate under the 2-midnight policy," states the FAQ. "BFCC-QIOs are required to educate providers using quality improvement core principles that facilitate continuous learning and promote greater provider understanding of the appropriate application of the 2-midnight policy in accordance with the revisions in the CY 2016 OPPS Final Rule (CMS-1633-FC): www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices-Items/CMS-1633-FC.html."
Now that audits have resumed, organizations should maintain a focus on 2-midnight compliance. Below are some tips Hirsch has recommended in the past, including:
Navigating the 2017 pressure ulcer coding changes in newly released guidelines
By Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP
As if coders and clinical documentation improvement specialists aren’t under enough pressure as it is, the advent of the 2017 Official Guidelines for Coding and Reporting brings to the table new documentation requirements for pressure ulcer coding. The guidelines can be viewed here: www.cdc.gov/nchs/data/icd/10cmguidelines_2017_final.pdf.
Considering that these conditions impact length of stay, require additional monitoring and nursing care, and ultimately affect reimbursement for facilities, it’s no wonder coding for these conditions is under increased scrutiny. However, with a solid understanding of these types of ulcers, taking the time to read and understand the coding requirements can alleviate the "pressure" of ulcer codes.
In April, the National Pressure Ulcer Advisory Panel (NPUAP) revised the pressure injury staging system, which can be found here: www.npuap.org/national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-injury. Since then, the NPUAP has received positive feedback regarding the system, and in August, The Joint Commission adopted the new terminology.
The definitions for each type of pressure injury are now:
The new staging system identifies the stages of pressure ulcers as 1 through 4 as well as an unstageable ulcer. These are similar to the codes from the L89 category in ICD-10-CM, however, the system introduces new terms in an attempt to more accurately describe the stages and descriptions of such injuries.
The NPUAP no longer uses the term "pressure ulcer," and has replaced it with "pressure injury," since stage 1 and deep tissue injuries describe intact skin, not open ulcers. The system also introduced the new term DTPI with this update.
Incorporating these changes in ICD-10
CMS has been in discussion with the NPUAP to in-corporate the new terminology, however, these terms are not used in the 2017 ICD-10-CM/PCS code update. The incorporation of the pressure ulcer terminology will be directed by both CMS and The Joint Commission, and NPUAP is currently working to introduce the changes to the code definitions.
According to the NPUAP:
Some documentation requirements for pressure ulcer coding, such as using non-physician documentation for identifying pressure ulcer stages, hasn’t changed from 2016 to 2017. What has changed for 2017 is the requirements for coding the progression of stages.
For ulcers that were present on admission (POA) but healed at the time of discharge, assign the code for the site and stage of the pressure ulcer at the time of admission. Furthermore, if a patient is admitted with a pressure ulcer at one stage and it progresses to a higher stage, two separate codes should be assigned: one code for the site and stage of the ulcer on admission and a second code for the same ulcer site and the highest stage reported during the stay.
These new coding requirements differ greatly from 2016 guidance which required only the highest stage of the pressure ulcer to be reported for pressure ulcers that evolve into a higher stage during the admission.
These new requirements could have an impact on hospital-acquired condition (HAC) reporting, considering stage 3 and stage 4 pressure ulcers with POA indicators of either a N- No or U-Documentation is insufficient are considered to be HACs, and also are classified as major complications or comorbidities.
American Hospital Association Coding Clinic guidance from First Quarter 2009 stated that the National Quality Forum excludes progression of pressure ulcers that were present on admission as a serious reportable event (SRE), also called a "never event." The intent was not to penalize facilities for progression of a pressure ulcer that was POA, as these are difficult conditions and even with the best preventive measures in effect, ulcers may evolve to a higher degree. The revised guidance for 2017, which is necessitating that two codes be used to identify the different stages of a site, feels as if it’s changing the standpoint of whether the pressure ulcer evolution is now an SRE.
The latest Coding Clinic, Third Quarter 2016, has updated guidance for pressure injury terminology. They acknowledge the changes in definition by the NPUAP from pressure ulcer to injury and advise:
For a DTPI, there is an entry in the Alphabetic Index under "injury, deep tissue," with further guidance which states: "meaning pressure ulcer ? see ulcer, pressure, unstageable, by site." Therefore, per Coding Clinic, code a DTPI as an unstageable pressure ulcer by site.
What is in the future for coders?
Can coders expect to see changes in pressure ulcer terminology soon? The most recent Coding Clinic did not give a time frame for updates, thus the potential impact on hospital reimbursement is something we can only speculate on at this point. If a pressure ulcer evolves from a stage 1, 2, 3, or 4 during an inpatient admission, these ulcers could be identified as an HAC and therefore impact the diagnosis-related group.
Commeree is a coding regulatory specialist at HCPro, a division of BLR, in Middleton, Massachusetts. She has many years of experience in the healthcare industry involving coding, auditing, training, and compliance expertise. This article originally appeared on JustCoding, and opinions expressed are that of the author and do not represent HCPro or ACDIS. For questions, contact editor Amanda Tyler at email@example.com.
A new sepsis definition: Finding coding compliance at a crossroads
This article is part two of a two-part series on the definition changes for sepsis. Reread part one in the October issue of BCCS.
In my October Clinically Speaking column, we discussed the evolution of the definition of sepsis and its implications in clinical care (Sepsis-1, Sepsis-2, and Sepsis-3), quality measurement (CMS’ SEP-1 core measure), and ICD-10-CM coding compliance.
We emphasized that the February 2016 definition of sepsis (Sepsis-3) as a "life-threatening organ dysfunction caused by a dysregulated host response to infection," differed from the terminology of sepsis and severe sepsis that has been embraced by many clinicians, CMS, and ICD-10-CM. We also discussed how provider documentation using the Sepsis-3 terminology eliminates the term "severe sepsis," and discussed that the definition change impacted ICD-10-CM code assignment and compliance.
Definitions and clinical indicators in Sepsis-2 are available at http://tinyurl.com/SepsisTwo, and definitions for Sepsis-3 are available at www.jamasepsis.com. CMS’ definition of sepsis and severe sepsis for the SEP-1 core measure is available at http://tinyurl.com/2017SEP1.
Coding Clinic update
Effective September 23, the American Hospital Association (AHA) Coding Clinic for ICD-10-CM/PCS published advice concerning the documentation and coding of sepsis in light of Sepsis-3. In Coding Clinic, Third Quarter 2016, p. 8, they stated "coders should never assign a code for sepsis based on clinical definition or criteria or clinical signs alone. Code assignment should be based strictly on physician documentation (regardless of the clinical criteria the physician used to arrive at that diagnosis)."
Coding Clinic went on to write (emphasis mine):
In my opinion, this means that Coding Clinic is saying ICD-10-CM still embraces the coding of infections without sepsis, with sepsis but without organ dysfunction, and with sepsis resulting in organ dysfunctions (otherwise known as severe sepsis), if the diagnosis is incorporated by the documenting physician. The AHA further stated that if a physician arrives at a diagnosis of sepsis or severe sepsis using whatever criteria he or she wishes, and then documents these terms in the medical record, the coder is to code it, period, end of story.
Alternatively, while Sepsis-3 states that the word "sepsis" requires the presence of acute organ dysfunction, Coding Clinic states that ICD-10-CM does not recognize this clinical concept. Unless the provider documents "severe sepsis" or associates an acute organ dysfunction to sepsis, a code reflecting this concept, R65.20 (severe sepsis), cannot be assigned. Furthermore, if a provider wishes to diagnose and document the term "sepsis" (without organ dysfunction) using Sepsis-2 or other reasonable criteria, the coder is obligated to code it as such in ICD-10-CM.
Coding Clinic, Fourth Quarter 2016
As we discussed last month, the fiscal year 2017 ICD-10-CM Official Guidelines were amended to state (emphasis mine):
In explaining this new guideline, Coding Clinic, Fourth Quarter 2016, pp. 147?149 stated (emphasis mine):
Coding Clinic went on to highlight that this concept applies only to coding, not the clinical validation that occurs prior to coding. Coding Clinic emphasized that clinical validation is a separate function from the coding process and the clinical skill embraced by CMS and cited in the AHIMA practice brief Clinical Validation: The Next Level of CDI. Access these at http://tinyurl.com/2016AHIMAclinicalvalidation and www.hcpro.com/content/327466.pdf.
Coding Clinic then went on to say that (emphasis mine) "a facility or a payer may require that a physician use a particular clinical definition or set of criteria when establishing a diagnosis, but that is a clinical issue outside the coding system."
While I agree that facilities should standardize clinical definitions for clinical and coding validation purposes, note how Coding Clinic gave tremendous power to a payer to define any clinical term any way they want to. This may differ from that of a duly-licensed physician charged with direct face-to-face patient care responsibilities using the definitions of clinical terms he or she learned in medical school or read in the literature.
As such, while our facilities may implement clinical validation prior to ICD-10-CM code assignment, a payer that is not licensed to practice medicine and has no responsibilities for direct patient care can require a provider or facility to use a completely different clinical definition that serves only one purpose in my mind, and that is to reduce or eliminate payment for care that was properly rendered, diagnosed, documented, and coded. I’m sure that legal battles will ensue, given this caveat written by Coding Clinic.
Solving the problem
In developing a sepsis strategy in light of these Coding Clinics, allow me to remind all of you that there are three environments by which we must consider disease terminology and supporting criteria. One cannot talk about sepsis, severe sepsis, or septic shock unless he or she states what environment they are in. These are:
Therefore, allow me to suggest the following strategy to ensure a balance of compliance with all three of these environments:
1.Standardize the definition and documentation of severe sepsis first. I believe that the Recovery Auditors (RA) are looking for records with sepsis codes that do not have R65.20 or R65.21 (septic shock) as a secondary diagnosis as to deny these codes and their resultant DRGs. In so doing, I believe that the definition of severe sepsis should be negotiated with and standardized by the medical staff, which could incorporate any or all of the following three criteria:
No matter what criteria is used, be sure to coordinate its development and deployment with your quality, clinical documentation integrity, and coding staff so that if a physician documents severe sepsis or septic shock, the SEP-1 algorithm can be implemented.
Also, be sure that physicians explicitly link organ dysfunctions to sepsis, or preferably, use the term "severe sepsis" so that R65.20 is not inadvertently missed by the coders. If a clinical documentation specialist or coder obtains a record supporting R65.20, be sure to notify the SEP-1 manager to determine if it qualifies for the SEP-1 core measure.
2.Develop a facilitywide definition for sepsis without organ dysfunction. As noted last month, many physicians do not believe that organ dysfunction is required to diagnose sepsis. Given that RAs are likely to use Sepsis-3 as a foundation for denying claims, we must have the statements of your internal medicine, critical care, and other physician committees as to what the definition of sepsis is for clinical and coding validation purposes. When it is documented by a provider without evidence of acute organ dysfunction, this statement can be used to rebut the RA’s denials. These will be handy if we are appealing beyond the first level.
3.Remind the RA that the ICD-10-CM guidelines are part of HIPAA and that coding is based on provider documentation. I’m sure that all of our contracts with private payers state that we will comply with federal laws, such as HIPAA. Given that the 2017 ICD-10-CM Official Guidelines state that we are to assign codes based on provider documentation, and not so much on what the RA thinks, and that Coding Clinic, First Quarter 2014, pp. 16?17, states that "the official guidelines are part of the HIPAA code set standards," we don’t want the RAs to violate HIPAA or our contracts with payers. This may require that our hospital attorneys or compliance officers weigh in, given that RAs have been known to deny codes based on provider documentation and want us to do the same.
Please recognize that this topic is very controversial and that the opinions expressed here are solely my own. I encourage all of us to discuss Sepsis-2, Sepsis-3, SEP-1, the 2017 Official ICD-10-CM Guidelines, and these Coding Clinics with our compliance officers and/or attorneys so that we can best support policies and procedures ensuring complete, precise, and compliant coding of sepsis in light of Sepsis-3. If you have success stories, please share them with me and the editor here at BCCS.
This article was part two of a two-part series. You can read part one in BCCS’ October issue. Dr. 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 firstname.lastname@example.org. Advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions. For any other questions, contact editor Amanda Tyler at email@example.com. Opinions expressed are that of the author and do not necessarily represent HCPro, ACDIS, or any of its subsidiaries.
Has your CDI program shifted its focus for optimal PSI 15 performance?
by Shannon Newell, RHIA, CCS, and AHIMA-approved ICD-10-CM/PCS trainer
The recent adoption of a refined version of the Patient Safety Indicator (PSI) 90 composite by the Agency forHealthcare Research and Quality (AHRQ) has a significant impact on what discharges are included in PSI 15 (Unrecognized Abdominopelvic Accidental Puncture Laceration Rate).
Your clinical documentation improvement (CDI) program has likely focused on this measure due to the well-established challenges associated with accurate reporting of procedure-related accidental puncture/lacerations. Given the changes to PSI 15, should your CDI team shift its focus to promote and support accurate data integrity for this measure? Let’s take a look.
A fundamental understanding of patient safety indicator measures
Optimal data integrity for PSIs requires that we have the appropriate clinical documentation and reported ICD-10 codes to accurately reflect the following:
The inputs above?numerator, denominator, risk adjustment?are used to calculate our observed over expected performance. CMS compares our performance to that reported by other hospitals, and our reimbursement may be then impacted if we do not appear to manage patients well.
For example, in the Hospital Acquired Condition Reduction program, if our performance for PSI 90 does not meet established thresholds, then our Medicare fee-for-service reimbursement is reduced by 1% the next CMS fiscal year (October 1?September 30) for every claim we submit.
The new PSI 15?what counts?
The revised measure specifications for PSI 15 have altered the numerator (outcome of interest). The denominator, or cohort?which represents the population at risk?has also undergone a noteworthy change).
The revised numerator and denominator greatly narrow the pool of discharges screened for accidental punctures or lacerations as well as those flagged with outcomes of interest.
From a CDI perspective, the likelihood of incorrectly reporting accidental puncture or laceration for the discharges included in the newly defined measure is greatly diminished.
PSI 15: Are you focused on risk adjustment?
Given that our performance for PSI 15 is assessed using our observed over expected rate of procedure related accidental puncture or lacerations, the CDI team’s focus may be better spent on strengthening the capture of comorbidities relevant to risk adjustment.
The AHRQ risk adjustment methodology looks for multiple comorbidities to calculate the predicted likelihood of accidental punctures/lacerations for each discharge.
The revision to the discharges included in the narrowed cohort has also impacted which comorbidities affect risk adjustment. This makes sense given that these comorbidities must be clinically relevant to the numerator and denominator. The number of comorbid categories has been reduced from 13 to 11. Some of the categories remain the same, some have been deleted, and new ones have been added.
Keeping abreast of revisions to claims-based measures is an expanded responsibility for today’s CDI program. These measures impact both reimbursement and quality profiles. Positioned with this information, the CDI program can then shift efforts to promote and support clinical documentation capture and accurate reporting of codes associated with areas of the greatest vulnerability and impact.
Newell is the director of CDI quality initiatives for Enjoin. She has extensive operational and consulting expertise in coding and clinical documentation improvement, performance improvement, case management, and health information management. You can reach Newell at (704) 931-8537 or firstname.lastname@example.org. Opinions expressed are that of the author and do not represent HCPro or ACDIS.
New clinical criteria definitions in 2017 Official Guidelines up the ante for coders
by Laura Legg, RHIT, CCS, CDIP, and AHIMA-approved ICD-10-CM/PCS trainer
The new guideline for code assignment and clinical criteria in the 2017 ICD-10-CM Official Guidelines for Coding and Reporting does not mean clinical documentation improvement is going away; instead it just upped the ante for continued improvement.
Up the ante means to increase the costs, risks, or considerations involved in taking an action or reaching a conclusion. With the new coding guideline for clinical validation that went into effect October 1, the stakes remain high for the diagnoses documented by the physician to be clearly and consistently demonstrated in the clinical documentation.
It is not that the information was not there before, but now the issue is finally getting attention. When clinical documentation is absent, coders are instructed to query the provider for clarification that the condition was present. But what are we to do if the clinical indicators are not clearly documented? For HIM professionals who deal with payer denials, this has been a haunting issue for a very long time.
The ICD-10-CM Official Guidelines for Coding and Reporting are the foundation from which coders assign codes. Coders need to review the new guidelines in detail to understand the changes and implications for their facilities.
The Centers for Disease Control and Prevention published these new guidelines which can be read in their entirety here: www.cdc.gov/nchs/data/icd/10cmguidelines_2017_final.pdf.
Taking a closer look
The coding guideline for section A.19 (code assignment and clinical criteria) has been labeled as controversial and, at this point, we have more questions than answers. Denials issued by payers due to the absence, or perceived absence, of clinical indicators by which the payer lowers the DRG is now being called DRG downgrading and it’s getting attention.
The code assignment and clinical criteria states:
Physicians and other providers document a patient’s condition based on past experience and what the clinician learned in medical school, which often differs from clinician to clinician. When you put a patient in front of a group of clinicians you will most likely get differing documentation. So how do we fix that?
The diagnosis of sepsis is a good example. There does not appear to be a universally accepted and consistently applied definition for the condition of sepsis.
In a patient record with the principal diagnosis code of sepsis, followed by the code for the localized infection, pneumonia, a payer denial could occur.
Payer denials often deny the sepsis diagnosis code stating that "the diagnosis of sepsis was not supported by the clinical evidence. Therefore, as a result of this review, the diagnosis code A41.9 [sepsis, unspecified organism] has been removed and the principal diagnosis re-sequenced to code J18.9 [pneumonia, unspecified organism] for pneumonia and to the lower paying DRG 193." This is now being referred to as a DRG downgrade. DRG downgrades can occur for different reasons including both DRG coding changes and clinical validation downgrades.
What is a coder to do?
What is a coder to do when a physician documents a diagnosis that may not be supported by the clinical circumstances reflected in the patient’s chart? Facilities and coding teams should develop guidance and be sure they fully understand the content and the impact of this coding guideline to coding practices.
Remember the section that reads: "the assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient."
This represents a catch-22. If the diagnosis is not clinically validated, both recovery auditors (RA), as well as commercial insurance auditors, are going to deny the claim. On the other hand, if coders or the facility decide not to report the diagnosis, they are in violation of the coding guidelines, which is also a major problem.
AHIMA’s 2016 Clinical Documentation Toolkit offers this advice:
The toolkit is available here: http://bok.ahima.org/PdfView?oid=301829.
Increasing clinical documentation
As the healthcare industry experiences an increased number of external audits, both federal and private, the need to up the ante on clinical documentation has become essential. The answer is not to let this guidance prompt lazy documentation, which has far reaching consequences, but to use it as a catalyst for improvement.
The goal of any clinical documentation improvement (CDI) program is to ensure a complete and accurate patient record, and this cannot be done without the presence of documentation supporting the clinical indicators and clear and consistent documentation regarding the condition. The provider’s documentation of their full thought process will accomplish this. If medical staff can come together and agree upon a definition for a certain condition, they can begin the process of being consistent with how the description is presented in the patient record.
CDI specialists and coders should not use the new guideline as an excuse not to query. Coders are not clinicians and, therefore, should not be expected to evaluate clinical criteria. Coding and CDI were separate functions, but, as audits from outside organizations expand, there is more emphasis on correct coding, DRG assignment, and the use of clinical criteria to support the reported codes, which means these entities need to work together.
The American Hospital Association’s Coding Clinic for ICD-10 instructs coders not to use background clinical information contained in their responses for code assignment. This information is only provided so the coders can make a judgment to query where there is incomplete documentation. Coders and CDI staff should review all chart documentation and data, and query when necessary to clarify inconsistencies in physician documentation.
Query the provi
UHC has just started denying the old codes and I am sending corrected claims on them, but my supervisor is telling me to bill for 4 units on G0480 because that’s the number of drugs tested for, I explained my thoughts on it but she is not seeing it that way.
Please tell me your thought!! And if I am wrong then why 4 different codes for different amounts of drug classes???
Please give me opinions, I would greatly appreciate them!!!
By Dari Bonner, RMC, CCP, CHCA, and Dr. Karen M. Fancher, MD, RMC, CPC, CANPC, CFPC . Originally published in AHIMA.
Inpatient clinical documentation improvement (CDI) has thrived since the implementation of MS-DRGs. More recently, it has grown in popularity commensurate with the implementation of ICD-10-CM/PCS. In some cases, organizations took a holistic approach to ICD-10, deliberately embedding CDI specialists within their owned or affiliated physician practices to ensure a smooth transition—thereby expanding CDI efforts into outpatient and ambulatory settings.
With the proliferation of accountable care organizations (ACOs) and the rise in healthcare mergers and acquisitions, many hospitals and health systems are looking for ways to continue the ICD-10 educational momentum and expand CDI efforts into outpatient, ambulatory, and physician practice settings. Beyond these hospital-led initiatives, many independent practices and private physicians are also quickly recognizing the importance of documentation quality—and how coded data translates to reportable outcomes. This article takes a deeper dive into implementing effective CDI programs within physician practices.
In today’s healthcare environment, documentation is paramount, being used for medical coding and reimbursement. It’s also increasingly used to gauge the quality of care provided. When physicians accurately and thoroughly capture the true clinical picture of a patient’s condition or problem, not only do they justify medical necessity, they may also avoid third-party audit scrutiny and denials. This has a direct positive effect on cash flow and the overall successful operation of the business—for both hospitals and physicians.
Regulatory changes have also forced physicians to take a closer look at clinical documentation. ACOs and bundled payments, for example, incentivize efficient and effective care, requiring physicians to document as specifically and completely as possible. Public outcomes data has also forced physicians to question the efficacy of their coded data, which almost always leads back to a discussion about documentation. In addition, the Physician Quality Reporting System (PQRS) and “meaningful use” Electronic Health Record (EHR) Incentive Program are pushing the need for better physician documentation.
In the years ahead, the Centers for Medicare and Medicaid Services’ (CMS’) new Merit-Based Incentive Payment System (MIPS) will become a significant regulatory driver behind physician practice CDI. This program, which consolidates the PQRS, value-based payment modifier (VBPM), and meaningful use incentive program, uses data collected during 2017 to determine potential payment adjustments in 2019. Payment adjustments are determined based on a MIPS composite score that is partially driven by the coding of hierarchical condition categories (HCC), making HCC capture vital in the practice setting.
Negative payment adjustments will be distributed as follows, depending on whether a provider’s composite score falls below a particular performance threshold: four percent in 2018, five percent in 2019, seven percent in 2020, and nine percent in 2021 through 2023. Above-par performance could earn a physician a bonus as high as 12 percent in 2018 and 27 percent by 2021.
Because of this potential negative impact on finances due to lax clinical documentation, CDI programs in physician practices will certainly become the norm. The question today is: How can HIM professionals help support them?
Unlike hospitals that have more operational and personnel resources for CDI, physician practices must often rely on a certified coding professional or office manager to perform the task. In addition to overseeing CDI efforts, these individuals may also be responsible for checking patients in and out, obtaining insurance authorizations, responding to audits, coding, billing, performing accounts receivable follow-up, contracting, and much more.
Given the plethora of responsibilities, CDI must therefore be extremely targeted and thoughtful in the practice setting. Those charged with CDI must audit documentation frequently so they can pinpoint educational opportunities for each individual provider—physicians, nurses, medical assistants, and scribes.
Another challenge is that CDI in a physician practice is often retrospective. Practices typically receive a denial and then perform physician or staff education based on the reason for the denial. Unfortunately, by the time the education occurs most physicians don’t remember making the documentation error or omission, and don’t recall the specifics of the case. Retrospective CDI also permits subsequent errors to snowball, causing a cascade of denials before a correction is provided.
To be truly effective, practices need a “front-to-back” approach—proactive education and concurrent CDI on the front end of the process. This may require a more dedicated CDI resource within the practice as well as close collaboration with the practice’s EHR vendor to remediate documentation vulnerabilities, tweak templates, and update documentation alerts and prompts.
To identify documentation vulnerabilities, one needn’t look further than the “FY 2016 Office of Inspector General (OIG) Work Plan” in which the OIG identifies trends and patterns of compliance risk and fraud. Some of these include non-covered chiropractic and anesthesia services as well as unreasonable use of prolonged services, high use of outpatient physical therapy services, and non-compliant referrals/orders for certain Medicare services, supplies, and durable medical equipment. But there are many other areas ripe for CDI. Consider the following five areas.
This occurs when nurses or other providers copy and paste information from a previous visit into the current visit without verifying the accuracy of that information. In many cases, details are completely inaccurate or omitted entirely. There’s also often a mismatch between the chief complaint/history of present illness and the assessment. For example, a patient complains of neck pain but the entire assessment addresses the patient’s lower back pain. This incongruence can certainly benefit from a CDI specialist’s analytical eye.
Physicians sometimes don’t understand that medical necessity isn’t synonymous with medical decision making. The specific ICD-10 diagnosis codes that the physician chooses can either make or break a payer’s decision to deem services medically necessary for the patient. Many physicians don’t even realize that local coverage determinations (LCDs) exist, requiring certain diagnoses as a prerequisite for payment. As payers continue to update these LCDs in light of ICD-10, someone focused on CDI can monitor changes and ensure that documentation is updated accordingly.
Certain specialties, such as orthopedics, OB/GYN, internal medicine, and cardiology, saw many more code expansions in ICD-10-CM than others. These specialties could benefit from CDI that prompts greater specificity related to laterality, disease manifestation, anatomical location, and more. An individual trained in CDI can help explain ICD-10 terminology to physicians and create ICD-10 favorite lists and shortcuts to alleviate the burden of sifting through diagnosis codes listed in the EHR—ultimately increasing productivity.
Unspecified codes may prove to be particularly problematic in practices. That’s because CPT codes—not diagnosis codes—drive reimbursement in the practice setting, leaving little incentive for physicians to pay attention to diagnoses. In addition, the American Medical Association/CMS joint announcement made last July indicates that contractors conducting medical reviews (i.e., Medicare administrative contractors, recovery auditors, zone program integrity contractors, and the supplemental medical review contractor) during the 12-month period following ICD-10’s implementation on October 1, 2015 could not deny claims solely for the specificity of the ICD-10 code. This is as long as the code is in the correct family of codes (i.e., the correct ICD-10 three-character category) and there is no evidence of potential fraud. This flexibility applies to both automated and complex medical reviews.
Many physicians don’t understand that this flexibility pertains only to Medicare and only to retrospective audits. Some have misinterpreted the announcement to mean that they have complete flexibility with all payers for ICD-10 reporting on the front end. Someone well-versed in CDI can ensure compliant coding that won’t subsequently jeopardize reimbursement once the Medicare flexibility has expired.
Due to fear of denials and audits, physicians frequently down-code their evaluation and management (E/M) levels (i.e., code a lower-level, lesser paying E/M code). In some cases, a higher level might be justified if the individual trained in CDI can identify opportunities where documentation is lacking—and then query for clarification. In other cases, a CDI specialist can identify patterns of over-coding that could trigger an audit or raise a payer’s red flag. An example is when a physician provides a follow-up office visit or subsequent hospital visit and then bills using a higher level E/M code as though a comprehensive new patient office visit or an initial hospital visit had been provided.
CDI specialists can help physicians identify when it’s appropriate to use a modifier and when a particular procedure or service is inherent in a more extensive procedure or service performed at the same time.
In this age of documentation scrutiny, physician practices can’t afford to wait for an OIG or CMS audit to reveal noncompliance. Doing so could put a practice out of business. It’s also in the practice’s best interest to improve documentation if it’s part of an ACO, shared-savings initiative, or larger health system. Consider these three strategies:
Documentation quality begins in the outpatient setting. Physicians who document well in their practices help establish a baseline for patient severity and justify medical necessity for inpatient services. Quality documentation enhances outcomes and ensures accurate revenue. Now is the time to evaluate needs, build partnerships, and begin the important task of improving physician practice documentation.
Healthcare is rapidly changing. Stay in the game by taking a proactive approach to clinical documentation.
Online Clinical Documentation Improvement Course: Click Here