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Optimizing the Monitoring of ICD-10 Coding Productivity

With the help of hindsight and data, we can now more accurately predict coding productivity and staffing needs. The run-up to ICD-10 had most of us very concerned, expecting to experience a decline in productivity of as much as 40 percent or more. Early productivity reports, based on perceptions and/or small sample sizes, confirmed that […]

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Final ICD-10-CM Codes for 2018 Contain Some Surprises

Revisions include 322 more changes than CMS proposed in April The final updated ICD-10-CM codes for 2018, posted on the Centers for Medicare and Medicaid Services’ (CMS) website, contain 360 new, 142 deleted, and 226 revised diagnosis codes, according to a report from HealthLeaders Media. The revisions include 322 more changes than what was proposed […]

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Combining Data Analytics with Expertise to Optimize Claims Performance Management

There’s a smart trend we’re starting to see that starts with a simple equation: E + D = O Where E=expertise, D=data, and O=optimization. Carriers are starting to discover that without professional expertise to turn disparate data into actionable optimization and measurable intelligence, data is powerless. With property and casualty being a dynamic and constantly […]

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Outpatient CDI: Is “Outpatient” Out? Part I

There is a great push within the healthcare industry to move clinical documentation integrity (CDI) into the outpatient arena. People refer to this as “outpatient CDI,” but I think this is a misnomer. If you plan on stationing CDI specialists (CDISs) in physician offices, that could be construed as “outpatient CDI,” but I believe the […]

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Medicare Compliance: The Basics for Injury Settlement Recipients

Medicare is a government-provided health insurance program designed to assist certain people with hospital care, medical costs, and other expenses. Qualifying beneficiaries are people who are 65 or older, those younger than age 65 with certain disabilities, and people of all ages with permanent kidney failure. How to keep medicare eligibility If you were injured […]

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Succeeding in an ICD-10 World: A Peek Inside the New Issue of the AHIMA Journal

In the ICD-9 era, there were universally accepted benchmarks to measure coding professionals’ productivity. Now, more than 18 months after the ICD-10 implementation date, the challenge is to do the same for the new coding system. The article, “Coding Checkup,” in the June issue of the Journal of AHIMA, addresses this issue and provides direct […]

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OIG Investigates Payments for Ambulance Transports of SNF Patients

Medicare’s Office of Inspector General (OIG) has issued a sixteen-question survey to many ambulance service suppliers. The survey is focused on SNF patients, and specifically why the ambulance service has billed Medicare Part B for transports while patients were in a Part A stay. During Part A stays, the nursing home receives Medicare payments that […]

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Understanding the Basics of Bundled Payments in Healthcare

How do bundled payments fit into the growing value-based reimbursement ecosystem? The shift to value-based care has driven public and private payers to redesign reimbursement models that stress accountability for care quality and healthcare costs. As the fee-for-service environment fades away, alternative payment models like bundled payments are helping to define the future of revenue […]

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Medicare Cardiac, Ortho Bundled Payments Delayed Until 2018

CMS pushed back the implementation of compulsory Medicare cardiac and orthopedic bundled payment models and the Cardiac Rehabilitation Incentive Payment program until 2018. CMS recently delayed the launch date of three mandatory Medicare cardiac and orthopedic bundled payment models and the Cardiac Rehabilitation Incentive Payment program from May 20, 2017, to Jan. 1, 2018. The […]

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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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