Category Archives: Compliance & RACs

Regulatory Audit Contractors; ABN; Advanced Beneficiary Notice; Centers for Medicaid & Medicare Services; CMS news; CMS rules; CMS regulations; Medical Necessity; Recovery Audit Contractors; Compliance; RAC audit

Documenting medical necessity

CMS recently released a new National Coverage Determination (NCD), which was implemented on January 4. NCD 210.14 titled “Lung Cancer Screening with Low Dose Computed Tomography” is good news and expands the preventive services CMS offers its beneficiaries. Continue reading

Copy-paste in the EHR

Should physicians use the “copy-paste” function to document in the EHR?  In his latest blog post, 3M HIS blogger Jeremy Zasowski uses a whiteboard to sketch out the pros and cons, and offers two case studies that get to the heart of the copy-paste issue.

Watch the video here.

Copy-paste in the EHR title screen

 

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CMS releases clarifications regarding NCDs and LCDs

I feel a bit like January, 2000 – much ado about little. Looks like (so far) ICD-10 is a go. I’m not saying there haven’t been bumps in the road, or that there are no obstacles we have yet to recognize, but I think I can say, “so-far-so good.” Something I have spent the last few years deeply involved with is the translation of the National Coverage Determinations (NCDs) to ICD-10. On November 20, 2015, CMS released information regarding feedback on some of the NCD translations and issues discovered in some of the LCD policy translations prepared by the MACs. Continue reading

Healthcare compliance more important than ever

On September 10, 2015, while most of us in health care were deeply involved in ICD-10 preparation, the Department of Justice (DOJ) released a ruling that will significantly impact every healthcare provider – facility and professional alike. The DOJ announced that no civil or criminal settlements will be made absent the names of the individuals involved. The DOJ will not allow culpable individuals to avoid punishment when it settles cases. Continue reading

More changes contemplated for short stays

As we all focus on the looming deadline for the ICD-10 go-live, CMS is quietly floating more changes to short stay requirements.

CMS reiterated its goals of “respecting the judgment of physicians, supporting high quality care for beneficiaries, providing clear guidelines for hospitals and doctors and incentivizing efficient care to protect the Medicare trust funds.” So, what’s new? Continue reading

Attention Physicians and Coders: CMS’ Advanced Analytics Paying Off – Big Time

My mother taught me that it’s impolite to say “I told you so.” My daughter tells me I’m bossy and health care compliance is pretty dry (she’s trying not to be impolite and say “boring”) but when millions of dollars are connected, it’s much more interesting and news worthy.

So, sorry Mom, but I told you so and I’ve been telling you since I began blogging. And yes, big brother and his whole family are watching. Continue reading

Supervision and Incident-to Guidelines

In past blogs, I’ve written about a variety of E&M services and how to code those visits. In case that seemed straightforward, many years ago mid-level providers were added into the mix. You will see these types of providers abbreviated as MLP (mid-level providers), NPP (Non-physician practitioners), NP (Nurse Practitioners), PA (Physician’s Assistants), and some others. For the purpose of this blog, I’ll use MLP. The introduction of these types of providers created a new education opportunity for all of us. CMS created “Incident-to” guidelines and published them in the Medicare Benefit Policy Manual (S60.1-S60.4). This means that an MLP can provide services to a patient and report those services under the physician’s name when those services are provided incident to an established plan of care for that patient. Continue reading

A Tale of Two Hospitals…Ethics in Reporting Quality Outcomes

Pardon the bad play on words, but “it was the best of hospitals, it was the worst of hospitals.” Within the past week I interacted with two healthcare organizations and had the chance to discuss not only how they report, but improve their quality outcomes. In order to protect both the guilty and the innocent, I will only state that both are large academic medical centers with similar services, physician leadership and quality organizational structures. In comparing the two organizations, the gargantuan differences in reporting frustrate me, and the ethics of the leaders involved in quality at one institution frankly disgust me. How can we accurately measure, and ultimately improve, quality outcomes if all are not “playing” honestly? And yes, I acknowledge that “gaming” in quality scores has been occurring for decades. But does that make it right?
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Where Would We Be Without Clinical Coders?

I’m sitting on a plane today, traveling through the air as a result of some very bright people that enabled this mode of transportation. I’m doing so safely, thanks to strict airport security practices. Many years ago, when more stringent airport security screening was established, I would listen to fellow travelers complain about the invasion of privacy, the maybe not-so-random searches and the added expense tacked on to everything. And the lines in security, oh the lines! However, as a frequent traveler I’m forever thankful for the process we flyers have to go through to ensure the safest passage possible. Continue reading

Observation Services: Documenting Medical Necessity (Part Two)

In last week’s blog, I discussed observation services and private payer requirements. Now let’s take a look at CMS requirements which are a bit different. Observation is expected to be used when the physician presumes the patient will need less than 48 hours of care and the time in the hospital does not cross two midnights. Specifically, CMS says “The physician’s ‘expectation …should be based on such complex medical factors as patient history and comorbidities, the severity of signs and symptoms, current medical needs, and the risk of an adverse event.’” The CMS clinical and time expectations are similar to BCBS of NC. Continue reading