Do You have Questions About Edits 71 and 77?

I live in the Salt Lake City area, but last week I ventured east for the public Hospital Outpatient Payment (HOP) Panel meeting at CMS. As I listened to the testimony, I thought about some of the emails I have received about OCE edits 71 (Claim Lacks required device code) and 77 (Claim Lacks allowed procedure code). I have been asked a number of questions about these edits along with requests to talk to CMS to see if they would reinstate them, or as a last resort, have 3M create similar edits. Continue reading

Data Value: Important Mammogram Coding Change

A policy and data specialist colleague of mine was working with the 2015 NCCI data and noted that CMS had, for the first time, added screening and diagnostic mammogram codes to the edit.

Specifically, CPT 77055 and 77056 and HCPCS G0204 and G0206 (diagnostic mammography) and CPT 77057 (screening mammography) and 77063 (screening digital breast tomosynthesis, bilateral) cannot be billed on the same claim on the same date of service (DOS). Continue reading

Compliance Confusion: Observation Coding

I wonder how many millions of dollars are lost due to coding errors that have nothing to do with ICD-10 but everything to do with complex and confusing requirements and new rules. I’ve said this before: I don’t believe folks make mistakes intentionally, especially when it impacts reimbursement, but I think there is a lot of coding compliance confusion. And, in my humble opinion, it’s not the coders “fault” when errors are encountered. Continue reading

Refining the Definition of Health Service Units Will Help Control Prices and Gain Value

In recent years there has been a great deal of attention on the variation in service volume across providers and regions. Our suite of tools, collectively entitled Potentially Preventable Events (PPE), has led our research group to engage with a variety of stakeholders in their efforts to minimize volume variation. This variation typically results from inefficiencies, poor quality of care leading to the use of otherwise unnecessary services or the overuse of services resulting from practice pattern. Volume is a sensible target for cost reduction efforts and, when detailed as variation across peer providers or regions, is hard to justify. Price (transaction price) comparisons are more complex but, arguably, have greater bearing on total U.S. healthcare cost. At least this is what we are told each year by the policy folks at the Organisation for Economic Co-operation and Development (OECD). Continue reading

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

CHALLENGE QUESTION:

An 11-year old boy with severe autism presents to the Emergency Department with a fall from a 4-5 foot round hay bale. He landed backwards on his left arm and chest two hours ago at his family’s farm. His father was present at the time of the fall and states that he did not lose consciousness, but might have “gotten the wind knocked out of him.” He got up afterwards and was ambulatory. His parents brought him in because he was not moving his left arm and was supporting it with his right arm. On examination, the left arm is minimally swollen and there is moderate pain. Pain is relieved with positioning and immobilization of the arm. The exam was difficult due to pain and the patient’s autism. Intranasal fentanyl was administered so proper assessment could be completed. Continue reading

We Are All “Patients” – The Reason Interoperability REALLY Matters

Last month, the Office of the National Coordinator (ONC) released A Shared Nationwide Interoperability Roadmap. A recent blog written by Amy Sheide describes the contents of the document, but I want to discuss why it really matters. The vision outlined in the roadmap is the reason I work as a terminology leader in the standards industry. It answers a common question I frequently get: “Why do you do what you do and why does it matter?” I truly believe that human beings deserve the best healthcare they can get. This means that their information, such as past medical history, medications, labs, etc., should be at the fingertips of those who are providing care. Continue reading

Top Issues Facing Payers on the Journey to Value

We recently held our biannual payer client conference in Orlando, FL, and it was another very productive meeting. Several plans shared their respective progress and challenges as they each journey forward on the path to value. Based on the feedback, my colleague, James Lawson, Vice President, Client Experience, Payment and Population Solutions, shared some key takeaways from the meeting: Continue reading

Partial Dictation: A Smart Compromise for Quality Documentation

Last month, AHDI created a new Facebook group called “SR Errors – Funny or Fatal?” as a forum for healthcare documentation specialists (HDS) to share speech recognition “bloopers” that they caught during the editing process.

The submissions vary from hilarious:
“The patient slipped on the ice and fell on her Botox.”

To scary:
Dictated: “Lipitor 20, two pills a day”
Speech recognition result: “Lipitor 22 pills a day” Continue reading

What’s Getting Between People and Better Outcomes?

Patient reported outcome measures matter. The subject is capturing an increasing amount of attention as clinicians strive to reduce suffering by trying to figure out what matters to people (see the New York Times article, “Doctors Strive to Do Less Harm by Inattentive Care”).

Helping people with chronic conditions achieve better outcomes is a foundational principle of population health management and value-based contracting. Continue reading

It’s Complicated! Just Because You “Can” Doesn’t Mean That You “Should”

Remember as a child using the argument, “Everyone else’s parents are letting them” and your mother asking, “If everyone else jumped off a bridge, would you jump too?” When it comes to capture of diagnoses, the same type of argument can occur between HIM and Quality. Coding professionals will refer to the alphabetical/tabular indexes, official Coding Guidelines and AHA Coding Clinics for ICD-9-CM to support the capture of a diagnosis or for specific code assignment.  Quality staff will refer to the clinical picture, the probable intended meaning of the author and in applicable cases, the CDC diagnostic criteria as support for not assigning a code. I can remember a very passionate “discussion” between myself and a coding professional about a complication and whether or not it had to be assigned as a complication.  I stated, “Just because you can code it that way does not mean you have to code it that way!” Continue reading