Tag Archives: CMS

Analyze this! Administrative claims data or EHR data in health services research?

One of the ongoing debates in health services research concerns the relative merits of using administrative claims data versus electronic health record (EHR) data for research. Should one be preferred over the other? Some question the degree to which administrative claims data continue to be valuable for health services research given the growth of EHR systems. Continue reading

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

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

Coast to coast with ICD-10

We’re now almost two months into ICD-10. I’ve been, literally, coast to coast during that time and have asked everyone how their transition is going. To my surprise, regardless of where physician practices were in their preparation when ICD-10 was delayed last year, everyone that I’ve visited with was well prepared for this year’s Oct. 1 implementation.

Many practices used the extra time to work on dual coding, testing of clearinghouses, reviewing new LCD policies, etc. Some groups were glad the implementation date was pushed back, but equally as many were not, having to retrain coders and providers on the new code set. As mentioned last month, there have been a few bumps, but the only consistent comment I hear is about coder productivity and documentation. Continue reading

MedPAC financing recommendations for rural hospitals should be extended to all

In the MedPAC October meeting, the commission returned to the seemingly intractable problem of equalizing access to health care for rural communities. Medicare payment offers three sources of support within the inpatient prospective payment system (IPPS) for rural hospitals—through designation as a Medicare-dependent hospital, a sole-community hospital or qualification for a low-volume adjustment. A fourth avenue of support is exempting a hospital from IPPS and allowing it operate as a Critical Access Hospital (CAH). Continue reading

ICD-10: No news is good news

It seems that wishes are not just for fairy tales, they can come true after all. So far, it looks like the wish for an uneventful ICD-10 transition is a reality. Even the month-end report from CMS was fabulously dull.

The bottom line is, coding issues are historically a tiny percentage of the total claim denials, and that is just as true for ICD-10 as for ICD-9. Historically, total claim denials run around 10% of total, and of those, 2% are due to incomplete or invalid information of any kind, including things like provider ID. Both the 10% and the 2% statistic remained stable across the transition to ICD-10. Continue reading

Focus on patient preferences

I am a Registered Nurse. I won’t admit to how many years’ experience I have, but suffice to say, this is not my first rodeo. I had to chuckle when I read the October 29, 2015 news release from CMS titled, “Discharge Planning Proposed Rule Focuses on Patient Preferences.”

For those who are not case managers, and I know there are a ton of you out there, “discharge planning” is the term we apply to the act of planning a patient’s discharge as soon as they are admitted to the hospital or other facility. Continue reading

Getting it “right”: Risk-adjusted rates for potentially preventable readmissions

Ever wonder how states (or CMS) set thresholds for readmission rates? Much has been said about and written on the subject, but there a few things I think are highly overlooked.

1. Organizations actually set readmission rates themselves

Now before you fire off an email to me, let me clarify. Documentation (or lack thereof) on a patient’s health status is gathered by government agencies via claims data and analyzed.   In determining readmission rates, what else is at their disposal on a detailed claim besides diagnoses and health status? As a whole, lack of complete documentation for many years gave data to CMS and state agencies that may not have told the whole story on the health of a populations. And remember, CMS and states are typically utilizing a three-year rolling period of data. So not only did our documentation probably not accurately reflect the health of our populations three or even five years ago, we probably aren’t doing it correctly now either. Continue reading

HIMagine That! ICD-10 fallout?

Donna: Hey, Sue! We haven’t talked since AHIMA. Did you get back in time for ICD-10 go-live?

Sue: Yes, I was in my office, bright and early on October 1. I couldn’t wait to see how it was going to go!

Donna: Well, I talked to a lot of people at AHIMA and it was clear the general mood was one of excitement. Finally, we’re able to move forward with ICD-10 after all these years of preparing and practicing.

Sue: I heard pretty much the same thing. One HIM director captured it perfectly when she said, “Bring it on!” I think everyone was confident, anxious to get going and ready to deal with the fallout, if any. Continue reading

ICD-10: Keep up the calm

Keep calm and carry on…that was the title of the first thing I ever wrote, in early 2010, about the hype surrounding ICD-10. Less than six months after the CMS final rule for implementation of ICD-10 on October 1, 2013, the engines of hysteria were already churning out alarmist rhetoric.

In a moment of nostalgia, I went looking for that article. Here are a couple of examples of ICD-10 sound bites that were popular in 2010, and my reaction to them. Continue reading