If you are a provider, you probably put ICD-9 codes on claims in order to get paid. If you are a payer, you receive claims with ICD-9 codes on them. (The “you” in those sentences has to be taken very broadly – it could mean, for example, “the software used by the coders employed by the company you outsource your revenue management to – or your claims adjudication to.”) In any case, I’m not going to talk just now about the ICD-9 codes on your claims.
So where else do you have ICD-9 codes? You might be surprised. They can turn up anywhere someone wants to identify a set of patients clinically and isn’t satisfied just using English and trusting that everyone will interpret it consistently. Continue reading
I don’t like math; numbers are not my friends. And statistics? Let’s not even go there – but Office of Inspector General (OIG) is already barreling down that road leaving hospital administrators shaking their heads.
Consider: In October, OIG fined the University of Miami Hospital $3.7+ million for extrapolated (assumed) medically unnecessary short stay admissions. To determine the fine, OIG used data mining techniques coupled with ‘statistical sampling ‘methodology. They then extrapolated to determine a total likely error rate. It works something like this: If Hospital A has X number of errors identified on Y number of claims, then Z likely represents the total number of medical necessity errors in their entire universe of short stay claims for a given date range. Using statistics, OIG determined a number of claims they believe were likely to have contained errors. This technique – according to OIG – is not new: Continue reading
Last month I attended the AHIMA Convention in Atlanta, and everywhere I looked it was all about ICD-10. With less than a year left to implement, there will be an increasingly frenzied push to make the Oct. 1, 2014 date. I hope organizations won’t be short-sighted when planning for the IT side of the implementation equation. All too often, solutions are put into place with the goal of meeting an immediate need without a lot of thought about long-term implications. Next year the immediate need will be success at processing claims coded under ICD-10. I worry that within many organizations once that is done the “box will be checked” so to speak and the project will be seen as a success. Obviously in the short-term this part has to go well, but what comes next? Continue reading
From the moment I arrived in the Atlanta airport and saw the welcome banners celebrating AHIMA’s 85th anniversary and announcing the theme for this year’s Convention, “Dream Big and Believe,” I felt Kathleen Frawley’s presence. As many of you know, Kathleen was serving at AHIMA President and Chairman before her sudden passing this summer. She inspired the theme “Dream Big and Believe” and touched all of us with her passion for the HIM profession she loved. Continue reading
Blog by Julia Palmer and Sue Belley
The results are in for the latest scenario in the ICD-10 coding contest! Check out the correct ICD-10 codes and an explanation for the scenario from 3M consultants.
On September 25, 2013, a rare fetal cardiac procedure was performed for the first time in southern California. The procedure, percutaneous balloon aortic valvuloplasty, was performed successfully in utero on a 23-year-old female who was 25 weeks pregnant. The procedure was performed to correct critical aortic stenosis and evolving hypoplastic left heart syndrome in the fetus. If left untreated, critical aortic stenosis may result in a severely damaged left ventricle in the newborn. Additionally, hypoplastic left heart syndrome may be fatal and typically requires multiple surgeries after birth. Continue reading
Most of us don’t like to be nagged to do something, especially when it’s good for us. As a thing you can put off till you have “more time,” ICD-10 preparation is right up there with a screening colonoscopy.
Unfortunately, the earth didn’t change its work habits any more than you changed yours—there are still only 24 hours in a day, and ICD-10 is now less than a year away. In school you could pull an all-nighter and get caught up, but an all-yearer? Not recommended. So what will you do? You can bemoan your fate and start composing excuses, or you can hitch your sleeves well above the elbow and get to work. If you are still reading, chances are you chose the second option. Excellent. I admire your spunk. And as a token of my admiration, I offer this glass-half-full version of your situation. Continue reading
Healthcare data should be structured within a standardized information model so it can be easily and safely shared among patients, consumers, and providers. This structure would advance the vision of a transformed health system while enabling improved outcomes, quality of care, and lower costs. Standardized nursing assessment charting can enhance continuity of care yet research has demonstrated a lack of standardization in codified point-of care nursing assessment data. There is an international initiative in progress to develop guidelines for the creation detailed clinical models (DCMs) that can be used for standardized care. The goal of DCMs is to provide sharing of data, information, decision support, reports and knowledge to support evidence based practice and ultimately translates into a higher level of quality care. Continue reading
Well, the federal government is back to work after two and a half weeks off. I will refrain from any political comments. However, I would like to discuss the implications it might have on the OPPS changes for 2014.
All comments on the proposed rule were due about the middle of September. Normally CMS would have six to eight weeks to review the comments and publish the final rule on November 1st. However, with the government shutdown, there is not going to be anywhere close to six weeks, let alone eight weeks, to review the comments and publish a final rule.
Our government teams are back, and now the question: What is going to happen with the final rule? Continue reading
Although there is growing consensus that quality-based financial incentives can achieve higher quality and lower cost care, healthcare policy researchers differ on which model will bring about the most improvement. There are three overarching clinical controversies one needs to keep in mind when focusing on outcomes measures for payment adjustment:
- Categorical vs. Statistical Regression Model
- Case-by-case vs. Rate-Based Approach
- Outcomes Measurement vs. Process Measurement
We have discussed two of these issues (categorical vs. statistical and outcomes vs. process measurement) in previous blogs. In this blog we will focus on the case-by-case vs. rate-based approach. By highlighting the approach the State of Maryland uses to reduce potentially preventable complications (PPCs), we will also show the differences between PPCs and other approaches to identifying complications. Continue reading