Can you believe it? We are saying farewell to another year. And a busy one it’s been from the medical necessity coding and compliance perspective.
The Feds were engaged in 2013 – at least three cardiologists were sentenced to jail time for issues such as placing stents in patients who did not meet criteria even though the physicians believed they were necessary. I recall that in once case the physician misrepresented the diagnosis in the record in order to meet medical necessity criteria. Continue reading
We’re still talking about converting policies – lists of ICD-9 codes or clusters that mean something that could be stated in English. These lists may be in documents, spreadsheets, the database tables that drive payment or quality assessment, or patient selection systems of any kind. In my last blog post we discussed recoding the policies, understanding what they are for and then re-creating the code lists in ICD-10. We noted some reasons why recoding may not be practical: the original intent of the policies may be obscure, or you may have more policies than your coding resources can handle, or both.
The MS-DRG grouper consists of about 500 interacting policies, APR-DRG has around 4,000, and our other groupers and editors have policy counts in that range. The meaning of each list (e.g. “minor bowel procedures”) is well understood and we have top-flight clinical analysts and physician advisors. However, we went to the trouble to develop and refine translation software for two additional reasons. First, we discovered that a clinical analyst with both an understanding of a policy’s purpose and a machine translation of its ICD-9 representation could produce a recoded policy in about a fifth of the time that it would take without the machine translation to start from. Continue reading
In November I was reviewing a report by the Office of Inspector General for the Department of Health and Human Services (OIG) and I started to wonder, where is the annual Work Plan? The one slated for 2014? Did the government shutdown have anything to do with the delay? I had not heard any buzz about it so I went looking and found that the OIG released a Strategic Plan in advance of the Work Plan. My curiosity was aroused: Why would they do this?
The OIG website described the delay as necessary to better align with priorities in a time of continuing fiscal challenges and the Work Plan is to be released in January 2014. Is the OIG worried about funding being cut for fraud and abuse activities? Continue reading
In his book Blink, Malcolm Gladwell writes about Dr. Brendan Reilly’s work at Cook County Hospital in Chicago from back in the late 1990s. At that time, the hospital was stretched thin, running low on resources and struggling to deal with roughly 250,000 patients coming through the Emergency Department every year. Patients routinely waited hours to be seen. One of the hospital’s key struggles was determining which patients coming into the Emergency Department with complaints of chest pain were actually having a heart attack and thus required expensive, resource-intensive care.
It’s an interesting case study if you get a chance to read it, but I’ll just give a brief summary here. Dr. Reilly used work that had been done from back in the 1970s by a cardiologist named Lee Goldman. Goldman took the data from hundreds of cases and ran it all through a computer program to identify what kinds of symptoms and clinical findings actually predicted a heart attack. Continue reading
You’ve found a policy in ICD-9. You’ve figured out which Fiscal Year the codes are from and expanded any old codes that are now headers, so you are dealing with this year’s codes. You’ve correctly identified alternatives and, if any, clusters. You’ve carefully preserved leading and trailing zeros. You are now ready to convert your policy to ICD-10-CM/PCS.
There are two ways to do this: recoding and translation. Recoding entails understanding what the policy means and reconstructing that meaning using ICD-10. Translation is running each of the policy codes through maps to get ICD-10 codes and then consolidating and verifying the results. Continue reading
Blog by Julia Palmer and Sue Belley
The results are in for the latest scenario in the ICD-10 coding contest! We’re back this week with the correct answer to the scenario and some analysis of the answer.
Read the following operative report then assign the appropriate diagnosis and procedure code(s). Continue reading
Since completing my training in internal medicine in 1976, I’ve been seeing low income patients as a primary care internist two days a week. Not infrequently, we take up a collection among the clinic staff for any number of issues that impact the lives of our patients. For people who live in the margins, the most heartrending of these situations is not being able to afford the burial of a loved one. More than once, I have seen patients face this tragedy, and one of the most poignant instances occurred a few weeks ago with the death of the husband of a diabetic woman, both of whom were patients of mine. We were able to collect a few hundred dollars to help her pay for the funeral, but not enough to avoid cremation, despite the fact that her husband had explicitly stated in his will that he wished to be buried.
Thinking about the challenges facing these patients (and even the clinic’s medical assistants, many of whom are single moms and often one step away from poverty themselves) made me consider the issues involved in reimbursing facilities for their care. Continue reading
If any one person deserves author credit for ICD-10-PCS, it is Dr. Robert Mullin. His career included cardiothoracic surgery in the Navy and at St. Raphael’s in New Haven, Connecticut among other places, as well as research in healthcare payment methodologies, beginning with his role in developing the original DRGs in the 1970s. Toward the end of his career, he spent five years working with Rich Averill and a team of coding specialists and physicians, developing the initial version of ICD-10-PCS. PCS was first released by CMS for public comment in 1998.
At the time, when he gave talks about ICD-10-PCS, Dr. Bob was often introduced as “the father of PCS.” Continue reading
In a legislative report on the Accountable Care Collaborative (ACC), the Colorado Department of Health Care Policy and Financing details how the program helped the state avoid $44 million in costs during the 2012-2013 fiscal year. That’s less than one percent of the total federal and state spending for Colorado Medicaid this year.
The ACC program has assigned about 350,000 Medicaid clients to patient-centered medical homes. These clients make up about half of Colorado’s Medicaid population. Primary care medical providers and case managers coordinate medical and non-medical care and services within seven regional care collaborative organizations.
The goal is to improve health outcomes within a sustainable care delivery system. Continue reading
In DIY Part 2 we digressed from learning how to convert a policy to answer, “What is a code?” We continue with:
Common confusion 2: What is ICD-10?
Wikipedia says , “ICD-10 is the 10th revision of the International Statistical Classification of Diseases and Related Health Problems” developed by the World Health Organization (WHO) and released in 1992. Countries, including the U.S., use it to report mortality and morbidity statistics to the U.N. and other international bodies.
Hold on. This isn’t the ICD-10 we’re talking about. What comes out of WHO is viewed as insufficiently detailed to support payment systems, so countries extend it. Continue reading