Why So Many Coding Software Releases?

Take a glance at your phone, or your laptop screen, or your desktop monitor. Do you see an alert about downloading a new software release or system update? We ignore them, we avoid them, and we put off installing them for days. When we finally get around to it, inevitably a new alert pops up with yet another set of updates!

Many of you may have wondered… why does 3M provide so many releases for the 3M Coding and Reimbursement System? Well, in this blog I hope to address the question of updates in a way that will help you understand how these releases impact you and which ones are critical for you to perform to keep your coding system updated. Continue reading

Accuracy Matters

Thinking about all of the various quality initiatives currently out there or under development, I can’t help but think about what we DO with all of this information. Certainly accuracy is important for accurate quality scores, but isn’t accuracy important for a more basic and important reason?

Prior to joining 3M, I was employed as a nurse manager at a 600+ bed hospital. I was responsible for the CCU, CVICU and CV step-down units. Early on in my tenure, the quality and infection control departments presented statistics to the nurse managers on our infection rates by unit. To say it was concerning would be an understatement. We were tasked with developing a meaningful strategy to reduce the incidence of hospital-acquired infections and our strategy was two-fold: education and surveillance. We educated all stakeholders on the current statistics and the hospital protocols for reducing hospital acquired infections. Continue reading

Four Mistakes My Doctors Make with High Deductible Plans

A year ago my family changed to a high deductible health plan and started using a health savings account. Because we expect to pay higher upfront out-of-pocket expenses, we pay careful attention to the network requirements and out-of-pocket thresholds. Our local providers, though, seem to manage patients with high-deductible plans as if they were no different from traditional PPO plans.

There are several things I wish my providers would do differently, and not just to make it easier for me to manage my family’s health care. My providers inadvertently increased administrative time, delayed payment, and resulted in denials and write-offs. They would do better if they adapted their processes in light of the different plan requirements. Here are four suggestions for avoiding the mistakes my doctors made with my high-deductible plan: Continue reading

Who Will Win at Population Health Management?

Healthcare by transaction is dead. This economic model cannot be sustained. The new frontier involves aligning care providers across the continuum so they can think differently – and act differently. Successful population health management involves the strategic use of data to deliver the right care to the right population at the right time. Instead of managing the health of an individual episodically, providers will be challenged to manage the health of a group of individuals over time. The shift from volume to value requires providers to take on accountability for the total cost of care, the quality of care and the outcomes of care – rather than simply provide services when people are sick. Continue reading

Integrating Sociodemographic Factors into Risk Adjustment: Important Considerations for NQF’s “Robust Trial Period”

Why is it necessary that risk adjustment incorporate sociodemographic factors for my diabetic schizophrenic patients who have unstable housing?

Healthcare is fundamentally about people. That’s why, at the end of the day, it is the differences and disparities among individuals that are at the heart of the challenge facing the National Quality Forum (NQF) as it debates incorporating sociodemographic factors into risk adjustment.

Here’s a real-life example of the importance of SES factors to risk adjustment: Robert is a diabetic patient of mine who is schizophrenic with episodes of psychosis. He has difficulty with his meds in part because his housing situation is not stable. From time to time he is homeless. If there is any possibility of stabilizing his diabetes, he will need additional case management time over and above a diabetic schizophrenic who does not have the added SES burden. The case manager would not just deal with “medical” issues like making sure that Robert is taking his meds every day but also working with Robert to address conflict with neighbors that in turn are making him extremely anxious. In this case, the neighbors were extremely rowdy with loud music. The case manager was able to defuse the situation – when the neighbors were told by the housing authority to move. The same challenge applies to my asthmatic patients who live in substandard housing and are exposed to different allergens than those impacting middle-class asthmatics. In this situation, the case manager might help with making sure that insects exacerbating the asthma attacks are eliminated from the apartment. Continue reading

Alert Fatigue: The Implications for Reducing Preventable Hospital-Acquired Conditions

Blog post by Krysten Brooks, RN, BSN, MBA

Hospitals across the country have launched a wide-range of initiatives to reduce hospital-acquired conditions (HACs), but despite their efforts, a quarter of the nation’s hospitals face reimbursement penalties according to a preliminary analysis released in June by CMS that scored hospitals based on rates of acquired conditions and patient complications. While Medicare’s HAC Reduction Program plans to release final scores later this year, the healthcare organizations facing penalties can expect to lose approximately one percent of each Medicare payment from October 1, 2014 through September 30, 2015, translating into billions of dollars in lost reimbursement.

The Medicare penalties will undoubtedly hit some organizations hard, and these hospitals are moving quickly to analyze avoidable complications and intervene to improve quality. Facilities are also auditing clinical documentation for completeness and accuracy and examining documentation workflow to analyze process breakdowns and problems. Continue reading

New Partnerships and New Metrics for Better Population Health

“How do we achieve better population health?”

This is the question on the minds of health care leaders across the country today.

At a recent 3M health care executive conference in Saint Paul, Minnesota, representatives from health plans, hospitals, Medicaid and several non-profit organizations gathered to discuss patient-centered models of care as a way to achieve better population health outcomes.

But attendees didn’t walk away with a clear-cut answer to the question “how do we achieve better population health?” There is no such thing. Instead, they left with affirmation that better population health is going to require (1) new collaborative partnerships and (2) thoughtful consideration of the right metrics for measuring population health. Continue reading

E&M Coding: The Final Level of Care

In keeping with the theme of previous blog posts–the professional realm of E&M coding–I’d like to discuss medical necessity as it relates to the final level of care. CMS has stated that medical necessity is the over-arching criterion for payment of E&M services, which, in pure CMS fashion, gives us a goal, but not guidelines as to how to get there. We have no medical necessity policies for the differing E&M codes.

I think we all understand the intent of that statement, which I interpret as “don’t game the system”. But how do I, as a coder, teach a provider how to do that? And, how does the provider document a record to reflect the medical necessity clearly? So, let’s put a pin in that and talk about the calculation of the E&M codes, then circle back. Continue reading

AHIMACon vs. Comic-Con: We All Have a Role to Play

Last week I checked in on Facebook from the AHIMA convention in San Diego. My brother, who attends San Diego Comic-Con religiously every year, decided to weigh in:

Brother: My San Diego convention is superior to your San Diego convention.

Me: My convention is more conventional than your convention.

Brother: I expect you’ll have better Cosplay, though.

Me: Lots of Clark Kent and Lois Lane types.

It turns out this exchange fit perfectly with the vibe at #AHIMACon14 over the following three days. I arrived at the Monday general session in time to see and hear several inspirational messages about how innovation and, as AHIMA CEO Lynne Thomas Gordon put it, “embracing reinvention,” are the keys to success in health information management. Continue reading

CMS: CDI Take Note – Physician Claims Related to Hospital Denials Will Soon Be Scrutinized

On September 4, 2014 CMS replaced Transmittal 534 with Transmittal 540, Change Request 8802 to “adhere to CMS Inpatient recoding policy standards, which was accomplished by removing the recoding language in section 3.2.3 in the Manual Instructions.” They went on to specify “The purpose of this CR is to allow the MACs and ZPICs the discretion to deny claims that are ‘related’ and provide approved examples of such situations.”

Effective September 8, 2014 CR 8802 allows MACs and ZPICs to deny “related” professional claims submitted before or after the facility claim being questioned. CMS determines that “documentation associated with one claim can be used to validate another claim, (then) those claims may be considered ‘related.’” Continue reading