We Need a New Way to Finance Hospital Externalities

Paying hospitals for beneficial mission-related costs has been a hit and miss affair. These costs fall under the general headings of providing indirect medical education, ensuring standby capacity for trauma services, piloting new technologies, supporting medical research and treating those unable to pay for care. Providing funding for each of these categories is not without controversy – principally over how much support is warranted and how much contributes to wasteful inefficiency or just plain inequitable hospital funding. Whether we believe too much or too little is being given to support these community benefits, the existing structural problems for financing these mission-related costs are being exacerbated by changes in the insurance market. Continue reading

Follow-up: August Coding Challenge on Ebola

Since writing about coding of the Ebola virus disease in ICD-9 and ICD-10 for last month’s Coding Challenge, an interesting conundrum has come to light that I want to share with you.

It turns out there are two different codes that can be assigned to Ebola virus disease in ICD-9 depending on the way Ebola is located in the ICD-9 Alphabetic Index. Continue reading

Will you pass Meaningful Use Stage 1 for Natural Language Processing?

The MU of NLP. Haven’t heard of that yet? Well, it’s a new concept and I think it’s going to become as standard and important as Meaningful Use of EHRs. As important as MU is for EHR adoption and in fully evolving healthcare from the paper era, the true revolutionary advances are going to come from making sense of all of the digital data being collected in an electronic health record.

So, what are the Stage 1 requirements for meeting Meaningful Use of Natural Language Processing? The criteria are twofold. The first part is the criteria for establishing a fully integrated NLP platform with your clinical workflows. The second part is meeting two key use cases. Continue reading

The Oops Factor: Not All Documentation Errors are Created Equal

When reviewing and evaluating healthcare documentation from a quality and integrity perspective, a QA reviewer is looking to capture and address any error, regardless of source and severity. However, some errors are more critical in nature because of their potential impact upon patient safety, care, or treatment. Other errors may have an impact upon documentation quality, but their presence does not change the meaning of a document or affect patient care. In this post I would like to discuss critical errors discovered through documentation QA, but stay tuned for future posts addressing noncritical errors and educational feedback opportunities. Continue reading

ICD-10: A Common Language for Monitoring Ebola and Other Global Health Threats

As the fourth American Ebola patient, a physician serving in West Africa, was flown to the U.S. for emergency care this week, I was reminded that public health also wins from the implementation of ICD-10.

According to World Health Organization (WHO), the latest Ebola outbreak has killed almost 2,300 people in five West African countries. Medical workers have been hit hard by the Ebola epidemic. As of late August, more than 240 healthcare workers had developed Ebola and more than 120 had died. Continue reading

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

CONTEST QUESTION:

A 65-year old female was seen as an outpatient by her internist for monitoring of her hypertension and type 2 diabetes mellitus. During the course of the visit, the patient told her physician that she had been feeling sad and depressed as of late. After discussion, the patient agreed to a trial of antidepressant medication therapy. Prescription renewals for enalapril and metformin along with a new prescription for the antidepressant were sent to the patient’s pharmacy electronically. The diagnoses for the visit were hypertension, type 2 diabetes mellitus and depression. Assign diagnoses codes for this outpatient encounter. Continue reading

Four Things Providers Need Before They Can Embrace Value-Based Payment

The concept that payment for health care should be based on quality and clinically meaningful outcomes is not new, but the current breadth, variety and rapid adoption of value-based models is unprecedented. Value-based payment models now include accountable care organizations (ACOs), patient-centered medical homes (PCMHs), bundled and episode-based payments, and pay for performance structures.

There are now more than 600 Medicare and non-Medicare ACOs. This is more than a 300% increase from the end of 2011 when the first 32 Medicare ACOs were announced, at which time there were approximately 160 private sector ACOs. The increase in PCMHs is no less remarkable with a 5-year increase from 28 in 2008 to nearly 6,000 in late 2013 – and that only includes those with NCQA accreditation.

Continue reading

Warning: Abuse of Modifier 59 – CMS Makes Changes

In 1996, CMS implemented the National Correct Coding Initiative or NCCI, sometimes referred to as CCI. The claim system edits were developed to “promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims.” CMS realized that even if they created edits that bundled or disallowed procedures performed on the same date of service, there would be rare instances that would support using a modifier to override an edit. Thus, certain CPT modifiers were given that designation – modifier 59 among them.

On August 15, 2014, CMS released Transmittal 1422, CR8863 “Specific Modifiers for Distinct Procedural Services” effective January 1, 2015. The Transmittal explains that modifier 59, which is the most highly utilized of the CPT modifiers that CMS allows to override for NCCI edits, has been overused. It is associated with considerable abuse of high-level, costly manual audits, reviews, appeals and even cases of fraud and abuse. Continue reading

Getting their Money’s Worth…Value-Based Purchasing

Value-based purchasing further emphasizes the ripple effect and spider web of CDI, HIM and Quality. Everyone “knows” about value-based purchasing, but what is it comprised of?

Value-based purchasing (VBP) is both a broad and narrow quality measurement tool. Broadly defined, pay for performance (P4P)/ VBP is payer-developed metrics to measure value compared to reimbursement given. Two examples are accountable care organizations (ACOs) and bundled payments. A narrow definition is a program mandated by the Affordable Care Act of 2010 and administered by CMS. VBP has been in development for almost 10 years but was formally introduced for FY 2013. Through the Medicare program, incentive payments are made to hospitals based on either how well they perform or improve against their own baseline on each domain comprising VBP. There are four domains: clinical process of care, patient experience of care, outcome (FY 2014 forward) and efficiency (FY 2015 forward). Each domain is assigned an associated weight. For example, in FY 2015 clinical process is 20 percent of the total VBP score, patient experience is 30 percent, outcome is weighted at 30 percent and efficiency rounds it out at 20 percent. Continue reading

Will 2014 be a Year to Remember for Outpatient CDI?

The other day, I was thinking back to the year 1987: Ronald Reagan was President, the New York Giants won the Super Bowl and the Minnesota Twins won the World Series. Michael Jackson released his third album, Bad, and “Walk Like an Egyptian” by the Bangles was the number one hit on The Billboard Top 100.

1987 was also the beginning of an important initiative in healthcare and health information management. This was the year that 3M created its inpatient clinical documentation improvement (CDI) program. Continue reading