Tag Archives: DRG

Revenue Neutrality in ICD-10: How Will You Know?

No one likes surprises, especially when it comes to financial performance. In order to reduce unexpected results, many hospitals and payers have decided to address the issue up front. You can call it risk reduction, revenue neutrality, or negotiated reimbursement, but in all cases the goal is to reduce the financial impact ICD-10 has on your organization. Continue reading

“The Times They Are a-Changin’”

Sing along with me! We are entering a time of unprecedented change in healthcare. I had the pleasure of attending and speaking at the Healthcare Finance Management Association (HFMA) Region 11 Symposium in San Diego recently. This was one of the most dynamic conferences I have ever attended and I came away, by far, with more knowledge than I was imparting. There were certainly some clear surprises which I would like to share with you. The biggest reward for me was listening to finance leaders express their compassion and determination to care for their populations. Not only were they committed to ensuring all had access to healthcare and the means to pay for it, they were extremely focused on making it affordable and were open to an overhaul to pricing and pricing structures. It is moments like this that make me proud to be a member of the healthcare community.

What other lessons did I learn? 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

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

How Progressive Hospitals Operationalize Their Quality Data

You’ve got your quality data. Now what?

Hospitals don’t lack for data on quality outcomes. The real question is what to do with it. Even after making sure the data is sound—by checking documentation, coding for accuracy, and verifying the integrity of data in the EHR, for example—people often wonder how to understand and use the information.

There aren’t easy answers. But, there are good answers and many, many good examples. A number of 3M customers are improving patient outcomes through deliberate and innovative uses of their quality data. Continue reading

HIMagine That! Coding Variance from ICD-9 to ICD-10

Donna: Sue, I have been reviewing data files with ICD-9 codes translated to ICD-10 to determine if there are DRG changes between the two coding systems.

Sue: Well, Donna, what have you found?

Donna: As you would suspect, there are some variances from the MS-DRG assigned using ICD-9 codes to the MS-DRG assigned using the ICD-10 codes. But that is not the most interesting finding in my review. The issues I have come across are some strange pairings of ICD-9 codes that do not translate well into ICD-10.

Sue: I have heard that there are some variances in a small number of cases. I think one of the most common is when there is an anemia caused by a malignancy. This causes the MS-DRG to change from the anemia MS-DRG to the malignancy MS-DRG. Almost everyone has heard of this change, though, so describe what other things you are finding. Continue reading