HIMagine That! Inter-Rater Reliability

Donna: Sue, have you heard people using the buzz word inter-rater reliability in the context of ICD-10?

Sue: Isn’t that a statistical formula used to determine agreement or consensus between two raters or judges?

Donna: Yes, but HIM professionals are using the term, not the formula, to compare the agreement rate between two or more coders coding a case in ICD-10. Continue reading

Critical Care Coding

How many of us have worked for providers who, regardless of showing them the descriptor in the CPT book, insist upon charging critical care time for a patient in the ICU? For coders, the directions are clear: Regardless of the location of the patient, if the provider treated a critically ill or critically injured patient for 30 or more minutes, it is appropriate to report that service with a critical care code. So, when we see those magic words within the provider’s note, we submit the appropriate code(s). But, some coders don’t see the record. Some are just given a charge slip with the patient’s identifying information, procedure and diagnosis information. What is the right thing to do in this case? Because the critical care reimbursement is much higher than other E&M codes, some clinics review documentation for all critical care codes before submitting. Each group must decide how to handle the coding of these services. Continue reading

Achieving Semantic Interoperability: Point-to-Point Versus Centralized Mapping

Our philosophy at 3M is to approach terminology mapping and semantic interoperability using a centralized terminology server. With a centralized source of terminology management and maintenance, each data source needs to be mapped only once. Once this single mapping occurs, all the other systems that are mapped to the centralized server can leverage the mappings so data can be translated and exchanged without losing meaning. Therefore, for n systems that need to be mapped, only n mappings need to be performed.

On the other hand, in a point-to-point mapping approach, each system is mapped directly to every other system. While this is a feasible approach when dealing with a few systems, it becomes unwieldy as the number of systems increases. For example, given three systems to map, the total number of mappings that need to be created is three. However, if we increase the number of systems to five, the point-to-point mappings increase to 10. This is illustrated in Figure 1. Continue reading

What Consumers Think about Healthcare Costs

Benefits enrollment season has me reflecting on health plan options, premiums, and out-of-pocket (OOP) costs. I think I’ve made the right decisions, but I’m making a lot of assumptions because I don’t have good information to estimate costs.

I’ve come to view healthcare costs as similar to my mortgage or utility bills: a huge cost-of-living expense, even though everyone in my family is healthy (knock on wood). It’s especially sobering considering I, like many others in the workforce, essentially pay two healthcare premiums, one for my employer-sponsored plan and the other as Medicare payroll taxes for a program that may not benefit me by the time I qualify. Continue reading

Putting Patients at the Center of Their Health Home

Much of what we seek to achieve in health reform centers upon improving the quality of patient care. We are strong advocates of outcomes quality, things that matter to patients, but in general the industry falls short of creating pathways to realistic engagement with those experiencing those outcomes. However, there are interesting models of coordinated care that seek to place patients at the center of care decisions, rather than just at the center of financial fallout, when they encounter the health system. One such model is the integrated social/health care personal budget for the chronically ill being piloted in the United Kingdom by the National Health Service (NHS).

There are two main planks to this model. The first recognizes that social care, social support that enables the chronically ill to maintain function within the community is an essential component in reducing medical care costs. Where possible, living at home with support has dual benefits: it is cheaper and it provides a higher quality of life compared to institutional care. Support is often required for the chronically ill to maintain daily living arrangements that in turn keep them in better health and out of the emergency room. In fact recent NHS spikes in admissions may be related to reductions in social care budgets. The second acknowledges that patients engaged in their own care, and more importantly the goals of their care, will both work harder to adhere to a treatment plan and will achieve something of greater meaning to them than the well-intentioned plans of health care professionals. Continue reading

All-Payer Claims Databases (APCDs) and More: Key Takeaways from the NAHDO Annual Conference

The 2014 National Association of Health Data Organizations (NAHDO) 29th Annual Conference and APCD Workshop was recently held in downtown San Diego. With over 200 attendees and speakers from government, research and healthcare institutions, the event explored the current challenges and discoveries related to healthcare data and reform. Here are some key takeaways from the three-day event:

1. APCDs are not going away.

This is the eighth year the APCD Workshop has been added to the NAHDO Conference. Its increasing prominence testifies to the importance of APCDs in healthcare market analysis, policy-making and consumer reporting. They continue to grow in number and variety—11 are now live and more are in development. Additionally, more vendors continue to enter this space—proof of the rising demand for APCDs. Continue reading

What Can an 18th Century Botanist Teach Us about 21st Century Healthcare?

Carl Linnaeus’s Systema Naturae, the taxonomy of living things he developed in the 18th century to classify living organisms, named only about 10,000 species of organisms, including roughly 6,000 plants and 4,000 animals. Linnaeus, a Swedish botanist, is reported to have stated categorically that there couldn’t possibly be more than 10,000 different plants in the whole world.

Even super smart guys like Linnaeus don’t know what they don’t know—there are currently 250,000 named plant species and 350,000 distinct species of beetles alone. The current estimate of the total number of species in the world is about 8.7 million. In other words, we have no idea how many kinds of living organisms there are, but we know we don’t know. And thanks to Linnaeus, we have a system that allows us to record what we learn as we learn it. Continue reading

Taking a Closer Look at the October ICD-10 Coding Challenge


A 70-year old man presented at an Ambulatory Surgery Center for an upper GI endoscopy to be evaluated for the cause of his recent complaints of some dysphagia. The patient received Midazolam 6mg IV and Fentanyl 100 mcg IV and Benzocaine spray was applied to the back of his throat. After obtaining informed consent, the endoscope was passed under direct vision. It was introduced through the mouth and advanced to the second part of the duodenum. A small hiatal hernia was present. A mild Schatzki ring was found at the gastroesophageal junction at 35 cm. A TTS dilator was passed through the scope. Dilation with at 15-16.5-18 mm x 240 cm CRE balloon (to a maximum balloon size of 18 mm) dilator was performed with mild treatment effect. The esophageal body mucosa appeared mildly corrugated. Biopsies were taken from the upper and lower esophagus. At that point, the patient went into cardiac arrest. We quickly removed the endoscope and began resuscitative efforts. The patient was emergently transferred to the local hospital. Postprocedure diagnoses: Schatzki ring, hiatal hernia, cardiac arrest. Continue reading

The Impact of ICD-10 on Reimbursement: What’s Realistic?

HFMA Reg 2On a beautiful fall day in upstate New York, I joined a group of healthcare financial executives at the HFMA Region 2 Fall Institute. Meeting hot topics included change management, the CMS Two Midnight rule, big data, and Medicaid updates.

Attendees also learned about the impact of ICD-10 on reimbursement in my presentation “ICD-10: Determining the Realistic Reimbursement Impact on MS-DRGs and APR DRGs.” While ICD-10 may impact many areas of the revenue cycle after October 1, 2015, including the DNFB and cash flow, my presentation focused on analyzing the potential shift in reimbursement by comparing claims coded in ICD-9 and ICD-10. Continue reading

CMS is Serious about Overuse of Modifiers: More on 59

On September 10, 2014, OIG announced it settled with a physician group practice in Illinois for overuse of modifiers.  The practice exceeded the number of units allowed for certain services as regulated by CMS. According to the OIG, the physician practice used a code to bypass computer edits that otherwise would have rejected their claims. The group entered into a $590,763.45 settlement to resolve allegations of submitting false or fraudulent claims to Medicare. In addition, OIG contends the group upcoded services and submitted claims for high complexity tests when it performed less expensive, low or moderate complexity tests.

My take:

In September, I posted a blog regarding the modifications CMS plans to make to modifier 59 by creating four new, more specific modifiers that can be used to bypass an NCCI edit. CMS is requiring providers to be more specific with regard to what they believe a separate service really is. What is not new is that using the new modifiers will require documentation that adequately supports their use. A few thoughts on the new modifiers: Continue reading