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

From the OSEHRA Summit

Senthil Nachimuthu Blog post by Senthil Nachimuthu

I had the opportunity to talk about 3M’s open source HDD Access at the 2014 OSEHRA Open Source Summit in the Washington D.C. area (Bethesda, to be precise) earlier this month. This was my first time attending OSEHRA; I enjoyed the conference and I hope to be back to learn and contribute more. The title of my talk was “Enabling Interoperability between Standard and Local Terminologies using HDD Access.” The two other speakers in the session talked about the difficulties encountered when trying to achieve interoperability. This turned out to be a good introduction to my talk, which focused on how HDD Access can help to achieve interoperability. Continue reading

The Future Is Now: Transformation to Value-Based Care Is Underway

Barbara DeBuono and Richard KellerBlog post by Barbara DeBuono and Rich Keller

Over 85 attendees at 3M’s healthcare conference in New York City heard from the payer, government and provider speakers on how the ground is shifting from underneath us all. Value-based care is no longer the new frontier; it is right where we are standing. Linking payment to performance is here to stay. Financial incentives that reward high volume are going away; they are part of a model that is on its way to becoming the exception rather than the rule. Consider that:

  • 45% of hospitals are already part of an ACO;
  • Payers expect fee-for-service payment to represent less than 1/3 of all payments in 5 years;
  • 40% of all commercial in-network payments are value-oriented; and
  • 50 percent of delivery systems say they will be in the insurance business in the coming years.

Continue reading

The Ethics of Quality…Should Hospitals Be Incentivized to Improve Quality?

I believe most human beings have some sort of a moral compass, especially in the healthcare arena. I might be naïve in my view but I believe most healthcare professionals choose to work in health care to care for others. As part of that drive, I also believe that we informally and formally have always assessed the care we give and look for opportunities to improve — often acting as a Monday morning arm chair quarterback review. As part of that review, many root cause analyses and written protocols for care and/or critical pathways have been developed to ensure patients received the best quality and most efficient health care. Continue reading

HIMagine That! ICD-10: What’s in it for Physicians?

Donna: Hey Sue, I have a new goal!

Sue: And what would that be?

Donna: I want to get the word out to physicians about the real benefits of ICD-10. You know, address the “what’s in it for me” aspect.

Sue: Well, I think you need to debunk some of the myths around ICD-10. For example, the one about the huge volume of codes that ICD-10 brings – 145,000 of them, that will make it “impossible” for physicians to find a specific code. Continue reading

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


A two-year old was brought to the Emergency Department by his parents with a chief complaint of wheezing. The parents stated that the child developed what appeared to be a cold the day before admission, with symptoms of a runny nose and slight cough. On the morning of admission, the child started wheezing and appeared to have difficulty breathing. The child was examined and lab tests were performed. The patient was admitted to the Pediatric unit for respiratory support and treatment with an admitting diagnosis of bronchiolitis. Laboratory testing isolated and identified enterovirus D68 (EV-D68). The patient’s respiratory symptoms stabilized then abated and patient was discharged home after four days with a diagnosis of acute bronchiolitis with bronchospasm due to EV-D68. Continue reading

What Can Go Wrong with PCP Attribution and How It Can Be Prevented

Attributing a person to a primary care physician (PCP) is an essential feature of population health management because it enables an accurate and fair assessment of the quality of care a provider delivers. Attribution is based on the concept that a PCP is responsible to a person across time and the entire continuum of care. It establishes this responsibility, creating a relationship between a person and his or her PCP. When members have a designated PCP, plans are able to consider the overall health of a PCP’s unique panel of patients, enabling them to measure and reward provider performance on an apples-to-apples basis. Continue reading

Flaunt Your (Quality) Assets

“That’s it baby. When you got it, flaunt it. Flaunt it!”

The famous line is shouted by theater producer Max Bialystock in the 1968 movie The Producers. It could just as easily be the advice of strategists to health systems and hospitals today. When you got good quality, flaunt it. Show it off in the marketplace.

The key is to demonstrate quality—which, like beauty, lies in the eye of the beholder. Some hospitals and health systems might feel they don’t have much to show off, but rankings aren’t the only measure of quality in health care. Continue reading

Meaningful Use and Laboratory Data Management: Getting to the Next Level

I am known for having a “glass is half full” optimistic view of life, so when I was recently presented with the opportunity to be a panelist at a Meaningful Use discussion, I accepted. The discussion was held at the American Association for Clinical Chemistry (AACC) 2014 annual meeting in Chicago. This year’s Healthcare Forum session was held jointly with American Society for Clinical Laboratory Scientists (ASCLS). I pondered the best way to adequately portray the complexity (a.k.a. frustration and confusion) occurring across the industry as hospitals attempt to keep up with MU (not to mention all of the other federal mandates). Continue reading

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