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It is Time to be Change-Hardy with the new IPPS Proposed Rules

Be adaptable and ready for change if you are responsible for payer reimbursements in your healthcare organization. The Centers for Medicare & Medicaid Services (CMS) has announced a large number of changes to diagnosis-related groups DRGs for 2018, along with changes in ICD-10-CM and PCS. Here is a quick summary of the changes: 264 MS-DRGs […]

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Demystifying the Pathogenesis of Sepsis

I want to begin with a coding scenario: sepsis and pneumonia are documented, and the coder captures these conditions and assigns MS-DRG 871 and APR-DRG 720 with severity of illness (SOI) 2. Sepsis presents challenges for coders as well as clinicians. I want to provide insight into the complex molecular and cellular processes involved in […]

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CMS Tackles Opioid Prescribing

The Centers for Medicare & Medicaid Services (CMS) intends to align its Medicare plans, including Part D prescription plans, with the Centers for Disease Control and Prevention (CDC) opioid prescribing guidelines. On January 5, 2017, the agency released a statement justifying this action. Because of  “the growing body of evidence on the risks of misuse […]

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CMS Exempts Two Thirds of Clinicians From MIPS

The Centers for Medicare & Medicaid Services (CMS) has exempted about two thirds of physicians and other clinicians who provide care to Medicare beneficiaries from the Merit-based Incentive Payment System (MIPS), a pay-for-performance scheme that will determine part of physicians’ Medicare payments, starting in 2019. A CMS spokesman told Medscape Medical News, “CMS mailed approximately […]

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3 Best Practices for Hospital Claim Denials Management

Implementing claim denials management best practices is key to ensuring hospitals maximize claims reimbursement revenue and prevent denials. Healthcare cost control continued to top hospital priority lists in 2017. But hospital leaders may be leaving millions of dollars on the table because of inefficient claim denials management processes. Claim denial rates ranged between 0.54 percent […]

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Challenging the Six Year Lookback

The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently conducted an audit of Mount Sinai Hospital in New York City. After looking at a sample, the OIG found fault with about $1.4 million in claims, and projected that to an overpayment of just under $42 million. There are several […]

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ICD-10 Coding Questions Answered

Q: One of our physicians is getting conflicting information regarding the ICD-10 codes E66.01 and E66.9. We have been coding E66.9 for Body Mass Indexes (BMIs) between 30-34 and E66.01 for BMIs > 35. She has a laminated cheat sheet card that says E66.9 is for BMIs 30-39 and E66.01 is for BMIs >40. Can […]

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Computer Assisted Coding Anticipated To Grow To $2.5 Billion By 2023

Physician Computer Assisted Coding Market for Professionals Report 2017-2023 provide Industry shares, strategies, analysis and forecasted Computer Assisted Coding Market to reach $2.5 billion by 2023. Report also provides Research and Technology, Company Profile and Computer Assisted Coding for Large Physician Practices and Ambulatory Treatment Centers Market Description and Market Dynamics. The market for computer-assisted […]

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Feds Crack Down on Upcoding

By the time the late President Lyndon B. Johnson signed the law establishing Medicare and Medicaid in 1965, the health care community was already figuring out how to maximize its returns from these new programs designed to insure the elderly, poor, and disabled. Those proceeds, however, have been generated over the years in ways that […]

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Humana Refines Diabetes Risk Stratification Tool Using ICD-10

The ICD-10 transition provided Humana with the “perfect opportunity” to develop a more detailed diabetes risk stratification tool. In an effort to improve the delivery of targeted chronic disease management services to diabetes patients, Humana has revamped its Diabetes Complications Severity Index (DCSI) risk stratification tool to use ICD-10 codes, the payer detailed in a […]

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Why Medical Necessity Continues to Be a Top Priority

Medical necessity is an important issue. Just review the definition of medical necessity: “a legal doctrine, related to activities which may be justified as reasonable, necessary, and/or appropriate, based on evidence-based clinical standards of care.” So, what does that really mean? A few years ago, I was preparing to speak at a national conference with […]

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Healthcare Hotbed for Fraud Cases

While it might surprise some folks that five Modesto doctors are among those facing fraud charges in a $40 million medical billing and kickback case based in Southern California, it shouldn’t surprise anyone that there was yet another medical fraud case. Wherever there is money, you’ll find people or institutions are that ripe for defrauding, […]

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When Practices are Too Cautious about HIPAA

Many providers have the belief that HIPAA should be treated like well-regarded advice from your mom: It’s better to be safe than sorry. But that mentality is not always the way to go. Sometimes, practices can be too cautious with HIPAA. There’s a difference between ensuring protected health information (PHI) doesn’t fall in the wrong […]

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ICD-10 Diagnosis Codes That Identify Weeks Gestation of Pregnancy

ICD-10 Diagnosis Codes that identify weeks gestation of pregnancy and birth weight requirement when billing a delivery CPT Procedure Code Effective for Dates of Service beginning January 1, 2017, and thereafter, Medicaid required a Weeks Gestation of Pregnancy Diagnosis Code and a birth weight on delivery claims billed on an UB-04 or CMS 1500 Claim […]

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OB Coding: Delivering Accurate Coding Remains a Challenge

To quote Robert F. Kennedy, “There are those that look at things the way they are, and ask ‘why?’ I dream of things that never were, and ask ‘why not?’” Coders are experts at scanning provider documentation and assigning codes. My approach to chart review is to try to piece together what actually happened during […]

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CMS Told To Crack Down On Improper Medicaid Payments

The Centers for Medicare & Medicaid Services needs to step up its involvement in states’ Medicaid integrity programs in order to strengthen oversight and identify overpayments, according to a new federal watchdog report. CMS oversees how states run their Medicaid integrity programs and supports fraud-fighting efforts through reviews, training and hiring contractors to audit providers. […]

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