CURRENT TODD'S TIPS
nn nnBilling/Accounts Receivables/Revenue Cycle Management: The blood that keeps a practice alive:nnPick a patient seen one month ago and follow that revenue cycle. Look at the claim, compare it to the notes, has it been paid? Did the patient pay a co-payment or deductible if so when? (Co-payments and deductibles should be paid at the time of service). Did the insurance pay, if a clean claim was sent electronically it should be paid within 30 days. Was it paid properly? How do you know? If it hasn’t been paid, find out why! Revenue Cycle is a Cycle! Follow it! You may be surprised at what you find.nn
The Department of Health and Human Services has pushed forward several alternative payment models for the healthcare industry.nnIn recent years, the federal government has positioned the healthcare industry to adopt new reimbursement tactics aimed at strengthening pay-for-performance initiatives. These regulations consist of alternative payment models such as bundled payments or value-based care reimbursement. The Centers for Medicare & Medicaid Services (CMS), for instance, established the Comprehensive Care for Joint Replacement Model, which consists of implementing bundled payments or reimbursement based on an episode of care within hip and knee replacement surgeries.The proposed rule for the bundled payment model was initially was published on July 9, 2015 and the finalized legislation was made available on November 16, 2015. The start date of the Comprehensive Care for Joint Replacement Model is set for April 1, 2016. “The CJR [Comprehensive Care for Joint Replacement] model holds participant hospitals financially accountable for the quality and cost of a CJR episode of care and incentivizes increased coordination of care among hospitals, physicians, and post-acute care providers,” CMS stated on its website.nn“The episode of care begins with an admission to a participant hospital of a beneficiary who is ultimately discharged under MS-DRG 469 (Major joint replacement or reattachment of lower extremity with major complications or comorbidities) or 470 (Major joint replacement or reattachment of lower extremity without major complications or comorbidities) and ends 90 days post-discharge in order to cover the complete period of recovery for beneficiaries. The episode includes all related items and services paid under Medicare Part A and Part B for all Medicare fee-for-service beneficiaries, with the exception of certain exclusions.” CMS has had a rich history of supporting bundled payment models starting in the 1980s when an inpatient prospective payment system was created. This was the first step in which the Medicare program reimbursed hospitals based on a fixed amount for each patient’s hospital stay and diagnosis.n
Hospitals amassing more and more administrative, clinical, financial and ICD-10 data are looking to harness statistics, data science and mining tools and the electronic health record market is expanding but new obstacles are arising. nnThe predictive analytics market is gaining traction and driving EHR growth. But in something of a twist the costs of new EHR tools are simultaneously creating a significant barrier to big data and analytics, according to a new Research and Markets report.nnIndeed, as healthcare providers continue to amass copious amounts of healthcare data, including clinical, administrative and financial information as well as the shift from ICD-9 to ICD-10, are all leading healthcare organizations to implement analytics tools to make use of accrued data, according to the report.nnEHR adoption, meanwhile, is growing among healthcare providers, and the market will continue to expand at a CGR of 5.53 percent over the next four years, Research and Markets projected.nn“One trend impelling growth in this market is the increased adoption of predictive analytics,” one of the report’s analysts commented. “The ever increasing volume variety, and velocity of clinical and non-clinical data have compelled healthcare organizations to implement statistical tools, data science and mining technology.”nnBut implementation of healthcare information systems, encompassing EHR software, hardware and network installation costs, are also some of the greatest hindrances en route to a future of big data and predictive analytics, Research and Markets noted.nnWhat’s more, the extra hardware and software installation involved when integrating EHR systems with pharmacy and laboratory data may prove to be too expensive for smaller hospitals and providers in developing countries to put new analytics to work anytime soon, the report said.nnThis 
nnMore small practices may qualify for exclusions from the Quality Payment Program (QPP), claim hardship exceptions from electronic health record (EHR) requirements, and earn automatic bonus points if the proposed QPP rule released June 20 is finalized.nnThe Centers for Medicare & Medicad Services has proposed increasing two low-volume thresholds that would grant additional exclusions in 2018:n
The ICD-10 2021 updates include over 500 significant changes. These updates, set to take effect on October 1, 2020, include 490 new codes, 47 revised codes, and 58 codes deemed invalid. We will also see increased instructions on reporting manifestations of COVID-19. New guidance on social determinants of health, insulin use & acute kidney failure. See Welter Healthcare Partners’s summary of these changes in the information below!nnWith over 500 diagnosis coding changes just around the corner, the FY 2021 ICD10CM Official Guidelines bring updates that are set to be significantly larger than the FY2020 update brought to us last year.nnUpdates that are set to take effect October 1st, 2020 include 490 new codes, 47 revised codes and 58 codes deemed invalid (see table below), additional instructions on reporting manifestations of COVID-19, as well as new guidance on social determinants of health, insulin use and acute kidney failure, among several other changes.nnBelow is a summary of the anticipated FY2021 ICD10CM Updates by Chapter:nnChapter 1: Certain Infectious & Parasitic Disease brings a new section 1.g for reporting Coronavirus infections.nnChapter 3: Diseases of Blood & Blood-forming organs has eighteen new, detailed codes available for sickle cell anemia. These new codes describe complications associated with sickle- cell and hemoglobin-C (Hb-C) diseases. For example, a note for new sickle-cell thalassemia code D57.418 (Sickle-cell thalassemia, unspecified, with crisis with other specified complication) instructs the coder to code any identified complications such as cholelithiasis (K80.-) or priapism (N48.32).nnChapter 4: Endocrine, Nutritional & Metabolic Disease includes new coding instructions to follow for diabetic patients treated with insulin, oral hypoglycemics and injectable non-insulin drugs. For example, if the patient is taking both insulin and an injectable non-insulin antidiabetic drug, assign both Z79.4 (Long term [current] use of insulin) and Z79.899 (Other long term [current] drug therapy). If the patient is taking oral hypoglycemic drugs and an injectable non-insulin antidiabetic drug, assign code Z79.84 (Long term [current] use of oral hypoglycemic drugs) in addition to code Z79.899.nnChapter 5: Mental, Behavioral and Neurodevelopmental Disorders contains twenty-one new codes that describe withdrawal from substances including alcohol, cocaine, and opioids. For example, F10.932 (Alcohol use, unspecified with withdrawal with perceptual disturbance).nnChapter 6: Diseases of the Nervous System has added “pseudotumor” as a clarifying term to G93.2 (Benign intracranial hypertension) and coders are instructed to code G98.81- (intracranial hypotension) with G96.0 (Cerebrospinal fluid leak) when applicable.nnChapter 9: Diseases of the Circulatory System contains many revisions to the includes and excludes notes for existing codes. For example: Atherosclerosis of native arteries of the legs with ulceration (I70.2-) now includes both critical and chronic ischemia of native arteries with ulceration. Hypertensive Heart Disease (I11) has been revised to exclude Takotsubo Syndrome (I51.81), also known as “broken heart” syndrome.nnA new hypertension guideline provides instruction that when a patient has hypertensive chronic kidney disease and acute renal failure, code both conditions and sequence the codes based on the reason for the encounter.nnChapter 10: Diseases of the Respiratory System now has code also instructions for cases of acute laryngitis and tracheitis (J04) and acute obstructive laryngitis (croup) and epiglottitis (J05). Coders are instructed to code also influenza if present, including influenza due to identified novel influenza A virus with other respiratory manifestations (J10.1). This chapter also has a new section 10.e specifically for vaping-related disorders.nnChapter 13: Musculoskeletal System found several updates this year including twelve new codes to capture other pathological fractures (M80.8AX- and M80.0AX-). Updates include an expanded list of codes for rheumatoid arthritis, as well as primary and secondary arthritis, and arthritis caused by trauma. New codes in the M24 category for other articular cartilage disorders, disorders of ligament, pathological dislocation, recurrent dislocation, contracture and ankylosis.nnChapter 14: Disease of Genitourinary brings two new sub-stages to Stage 3 chronic kidney disease (CKD). The new codes are: N18.30 (Chronic kidney disease, stage 3 unspecified), N18.31 (Chronic kidney disease, stage 3a) and N18.32 (Chronic kidney disease, stage 3b).nnChapter 15: Pregnancy, Childbirth and the Puerperium contains new language that warns coders they should not report O85 for sepsis that follows an obstetrical procedure. A notenpoints them to the Sepsis due to a postprocedural infection of Chapter 1 Certain Infectious and Parasitic Diseases (A00-B99), U07.1.nnA new section 15.s provides instruction on reporting COVID-19 infections in pregnancy, childbirth, and the puerperium. E.g. when a newborn tests positive for COVID-19 and the provider has not documented a specific method of transmission, assign code U07.1 and the appropriate codes for associated manifestations. Code P35.8 (Other congenital viral diseases) followed by U07.1 when the provider documents that the newborn contracted the disease in utero or during birth.nnChapter 16: Certain Conditions Originating in the Perinatal Period has a new section 16.h for reporting COVID-19 Infections in Newborn.nnChapter 18: Symptoms, Signs and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified contains several changes. Code R51 (Headache) will be split into two codes: R51.0 (Headache with orthostatic component, not elsewhere classified) or R51.9 (Headache, unspecified).nnAnother source of new headache coding will come from five new codes for intracranial hypotension – the severe orthostatic headache that is a common symptom of a cerebral spinal fluid (CSF) leak: For example, G96.810 (Intracranial hypotension, unspecified), G97.83 (Intracranial hypotension following lumbar cerebrospinal fluid shunting) and G97.84 (Intracranial hypotension following other procedure). Five new codes for CSF leaks can now be found in place of the current code G96.0 (CSF leak).nnChapter 19: Injury, poisoning & certain other consequences holds 128 additions that include new codes for adverse effects and poisoning by fentanyl and tramadol as well as other synthetic narcotics.nnChapter 21: Factors influencing health status and contact with health services includes new observation language. The new language creates a second exception to the rule that observation codes are primary. The GL state, “An observation code may be assigned as a secondary diagnosis code when the patient is being observed for a condition that is ruled out and is unrelated to the principal/first-listed diagnosis.”nnNEW Chapter 22: Codes for Special Purposes (U00-U85) includes just two codes: U07.0 Vaping- related disorder and U07.1 COVID-19, these codes took effect in the earlier this year.nDeletions from the 2021 ICD-10-CM code set include: Q51.20 (Other doubling of uterus, unspecified), and the entire code family of T40.4X- (Poisoning by adverse effect of and underdosing of other synthetic narcotics).nnThe general coding guidelines clarify that social determinants of health may be coded if self- reported by patients, “as long as the patient self-reported information is signed off by and incorporated into the health record by either a clinician or provider.” Social determinants of health, found in code categories Z55-Z65, report potential health hazards related to socioeconomic and psychosocial circumstances that may complicate the care of the patient (e.g., the patient is unemployed).nn