A Culture of Openness Pays Off

When I read the results of a recent survey on helpline calls completed by the two prominent compliance associations, the Society of Corporate Compliance and Ethics (SCCE) and the Health Care Compliance Association (HCCA), I started to think about the organizations I’ve worked for in the past. What made me comfortable telling the organization of a perceived situation requiring change? How was the report received?

As noted in the survey results, employees are mainly reporting through internal means. While a company may not know for years of a whistleblower lawsuit, the survey respondents did not indicate a significant rise in these reports made outside of the organization even with the increased attention being paid to whistleblowers and the incentives involved.

What can we do to create an environment where employees are willing to report to their organization? Continue reading

CMS, 2-Midnights, and linking payment with what you want to achieve

A recurring theme in our blog posts is the need for payment policy to reflect a clearly defined purpose. Start with what you want to achieve and work backwards to a policy that delivers it. The ongoing saga of the CMS 2-Midnight rule is an excellent case study for this principle.

First, some history: CMS was/is faced with two related but distinct challenges. The first is the inexorable rise in observation stays, particularly those stays which exceed 48 hours. CMS observed an increase in the average duration of observation cases exceeding 48 hours from three percent in 2006 to eight percent in 2011. A subsequent OIG study put the rate at 11 percent in 2012. Extended observation creates a knock-on effect for beneficiaries, both for personal liability and qualification for post-acute care benefits. Hospitals blamed the increase upon aggressive Recovery Audit Contractors and rules that only paid for ancillary tests for inpatient admissions deemed unnecessary after review. This is not a determination that the service was not medically necessary, but rather that it need not have required an inpatient stay. Continue reading

Regulatory Updates: Changes to Billing for Laboratory Services

It is the Ides of May (not quite as famous as the Ides of March), but a good time to think about changes to billing for laboratory services and what to expect in the CMS July 2014 OPPS update. It has been a topic of discussion since the beginning of the year, and continues to create questions given what we know will be coming this summer.

Before this year, clinical laboratory services were assigned a status indicator of A and paid based on the clinical laboratory fee schedule whenever they were present on a claim, even if there was a medical visit APC or a procedure APC also present on the claim. This changed with the January 2014 update to OPPS. CMS decided to package clinical laboratory, with two major exceptions. Meaning, if a lab service is billed with a medical visit APC or with a procedure APC on the claim, it will be packaged (not paid separately). The exceptions are: Continue reading

…Ah yes, the patient!

Quality and integrity were the final syntheses at the end of the journey for enlightenment in Zen and the Art of Motorcycle Maintenance. As is true of many things in life, we can often learn vicariously from reading about the discoveries of others, and author Robert Pirsig’s philosophical reflections of 40 years ago still have relevance today. Quality and integrity are the foundation of all that is good in health care. Caregivers strive to maintain these goals, even in the face of “flavor of the month” initiatives that often superficially address the perceived ills and flaws of healthcare processes and systems.

One need only observe the spreading trend of hospitals advertising care “Navigators” to assist patients in their course of care. Care navigators are viewed as increasingly necessary for certain patients who need advocates to scrutinize and question every aspect of care delivered – from dietary choices to medication type and doses, to the indication and diagnostic yield of scheduled tests, to the relevant experience of surgeons proposing operations. Continue reading

Accepting the Status Quo: Cost of Non-Compliance vs. ICD-10

Like many in the healthcare industry, I’ve spent the last few weeks reading about the ICD-10 delay. Depending on which camp you are in, the opinions are lining up predictably. I’ve read a lot of comments about the ”cost of ICD-10.” Though many agree the adoption of a more sophisticated code set brings important benefits, the conversation always circles around to the expense of implementation.

If high costs are really the issue with ICD-10, why do we continue to ignore known cost-saving measures that would easily offset the expense of implementation for the average physician practice? For instance, I find the willingness to accept the enormous cost of years of non-compliance with medical necessity perplexing. Or consider the continued practice of submitting poorly coded claims based on subpar clinical documentation. What about the cost of claim denials, write-offs, and fraud in ICD-9 – or any other coding language for that matter? In my opinion, complaints about the cost of doing business have less to do with the expense of implementing ICD-10 and more to do with human nature. Continue reading

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

The results are in for the latest scenario in the ICD-10 coding challenge! Check out the correct ICD-10 codes and an explanation for the scenario from 3M consultants.

Contest Scenario:

A patient with multiple extensive skin lesions of the labia determined to be condyloma acuminata had cauterization performed. Here is the pertinent portion of the operative report: Bovie electrocautery was then used to remove the multiple condyloma taking care to achieve meticulous hemostasis throughout the course of the procedure. After all visible condylomas were removed, the area was washed with acetic acid solution. Residual condylomas were then cauterized at this time. The area was examined for any residual bleeding and there was none.

What is the ICD-10-PCS code for the procedure performed? Continue reading

HIMagine That! ICD-10 Coding Quality Review

Sue: Donna! CMS has finally addressed a new ICD-10 compliance deadline. Looks like we’ll be working toward an October 1, 2015 go-live date.

Donna: Yes, I’m glad we’re not in waiting mode any longer! Even with an extra year to prepare, I’m concerned that nobody is really talking about their Quality Review plans to assure accurate I-10 coding and CDI practices. Talking about their QA plans will really help the prep!

Sue: How so?

Donna: As I talk to people who are practicing with I-10 coding I am hearing that they are identifying discrepancies in their data between I-9 and I-10. I think that reviewing mismatches between MS-DRGs in I-9 and I-10 is a good place to start the QA process in the inpatient setting. Continue reading

When Squirrels Attack! Disaster Averted with ICD-10

This latest ICD-10 implementation delay stinks even more than the first one, when HHS succumbed to pressure and moved the implementation date from 2013 to 2014. I could pretend to be a wine connoisseur, and describe the taste of this delay in great detail—the acidic AMA “mouth feel,” the conspiracy theory “notes,” the voice vote “finish.” But why bother? And there, my friends is the dilemma we all face—why bother indeed? If a massive effort to do something sensible and constructive in health care can have the rug pulled out from under it at the last minute, why do we bother? As a friend said after the “doc fix” bill became law and ICD-10 was put in limbo for (at least) another year, “It makes me feel like moving to Montana to live in a cave.”

Nevertheless, we are going to continue to push for ICD-10 implementation as soon as possible, because it is what we can do. The industry is so thoroughly committed to ICD-10 it cannot turn back now. At the same time, how do we as rational human creatures try to make sense of a situation that has become patently absurd? My advice is, don’t even try. Just let yourself enjoy the absurdity, because it is likely to be with us for some time. Continue reading

DIY ICD-10 Conversion – Part 12

To summarize policy translation using the GEMs so far:

Phase 1: Use the 10-to-9 singles GEM with reverse lookup to find all the ICD-10 codes that select patients currently selected by the ICD-9 codes in the policy.

Phase 2: For any unused ICD-9 codes, use the 9-to-10 singles GEMs to find other ICD-10 codes which may, after clinical review, be worth including

Phase 3: Look up all the ICD-9 codes in the 10-to-9 cluster GEM with reverse lookup. ICD-10 codes you find there will have a narrower definition than the ICD-9 code you find them with, so you must review them to ensure they contribute to the intent of your policy. Continue reading

Keeping up with HIT Regulations



Guest blog by Amy Sheide, Clinical Analyst with 3M Health Information Systems’ Healthcare Data Dictionary (HDD) team

The ICD-10 delay announcement is over a month old but there still are a lot of Health Information Technology (HIT) regulatory changes to keep up with. The new 2015 Electronic Health Record (EHR) Technology Certification Criteria Proposed Rule and implementation of the 2014 Meaningful Use requirements remain top priorities across the industry. The unfortunate take away is that the amount of change in the HIT landscape is not going away and the amount of effort required by organizations to keep up with and successfully implement these requirements is becoming more and more difficult to maintain. For example, look at the trends in EHR certification criteria. Vendor readiness was stated as a serious concern in meeting the 2014 stage two certification requirements and many organizations were held captive to the promise from their vendor that the EHR technology would be ready in time to meet the 2014 requirements. The release of the 2015 EHR certification requirements supports the goal of the Office of the National Coordinator (ONC) to provide more frequent releases of certification criteria that were less cumbersome for EHR vendors to meet. Despite the goal of more nimble updates and requiring changes to EHR technology in smaller increments, nearly half of the 2015 certification criteria are new or revised (Figure 1). Continue reading