When the Quality Improvement Organizations (QIO) took over the role of education and enforcement for the 2-midnight rule on October 1, 2015, many anticipated that their reviews would only look at records from that date forward. But in an unpleasant turn of events, some hospitals have reported QIO record requests zeroing in on cases as far back as May 2015, says Ronald Hirsch, MD, FACP, CHCQM, vice president of the Regulations and Education Group for AccretivePAS in Chicago.
"It caught everybody off guard. No one expected them to audit any earlier than October 1," he says. "But audits are starting hot and heavy, and it's important for organizations to understand that it's permitted and that the QIOs can request charts going back six months."
According to a fact sheet, CMS is specifically using "Beneficiary and Family Centered Care (BFCC) QIOs, rather than MACs or Recovery Auditors, to conduct the initial medical reviews of providers who submit claims for short-stay inpatient admissions on October 1, 2015. Beginning in 2016, BFCC-QIOs will begin reviewing inpatient cases under the revised Two Midnight Rule being announced today." (For more information, visit www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-10-30-4.html.)
Another surprise? BFCC-QIOs are requesting charts for inpatient-only surgeries, something they weren't supposed to do, says Hirsch.
by Shannon Newell, RHIA, CCS, AHIMA-approved ICD-10-CM/PCS trainer
Approximately 800 hospitals across the country that perform inpatient total hip and knee joint replacements will be required to participate in the latest value-based payment initiative launched by CMS, the Comprehensive Care for Joint Replacement (CJR) model, which becomes effective April 1.
A recent Healthcare Financial Management Association webinar on the CJR noted it as one of the biggest Medicare changes since the implementation of diagnosis-related groups (DRG). Not surprisingly, various impacted parties continue to push for delays in implementation of the model. The CJR model holds participant hospitals financially accountable for the cost and quality of an episode of care and incentivizes increased coordination of care among hospitals, physicians, and postacute care providers.
The assignment of ICD-10 codes on both inpatient and outpatient claims impacts these outcomes by triggering which discharges are included in the program, the actual (or observed) complication rates for these patients, and?equally important but often overlooked?their risk-adjusted expected complication rates. If ever there was an opportunity for clinical documentation improvement (CDI) programs to step up to support their organizations with documentation that impacts both quality and financial outcomes, this is it!
Q: The chief executive officer of the hospital where I work is talking about having our hospital coding done in India. What are the potential ramifications of this plan for our hospital? I know a prominent hospital in Palo Alto, California, was going to do this in 2011.
Have any U.S. hospitals actually outsourced their medical record coding to foreign countries? What are the liability risks? What do we need to be aware of in terms of HIPAA compliance?
A: Yes, many organizations send coding and transcription work overseas. Despite business associate agreements (which you must get with any such vendor, offshore or not), it may be difficult to ensure that these vendors are HIPAA compliant, although one could make the same argument about U.S. vendors as well. Be sure to do your due diligence by carefully checking your vendor's references (and documenting the results) should you choose to go this route. You might also discuss this with your organization's insurance carrier and/or attorney for an assessment of the risks.
Editor's note: Chris Simons, MS, RHIA, the director of health information and privacy officer at Maine General Medical Center in Augusta, answered these questions. Simons is also an HIMB advisory board member. This information does not constitute legal advice. Consult legal counsel for answers to specific privacy and security questions. Send your questions related to HIPAA compliance to Editor Jaclyn Fitzgerald firstname.lastname@example.org.
One of the last major shifts in coding before the transition to ICD-10 was the introduction of diagnosis-related groups (DRG) in 1982. Now that the struggle to implement ICD-10 has passed, how do the two transitions measure up? Both Wendy Coplan-Gould, RHIA, president of HRS Coding in Baltimore, and Sallee Silverman, RHIA, an AHIMA-approved ICD-10 trainer and a manager with HRS Coding, were actively working in healthcare through both shifts and shared their thoughts with HIM Briefings shortly after ICD-10 went live in October 2015. When DRGs were introduced, Coplan-Gould was working as the associate director of the Maryland Resource Center in Maryland.
Over-querying is a common concern in CDI. It can influence productivity and workflow. It can cause delays in documentation and coding processes. It can also overwhelm and frustrate physicians, who in turn may be less likely to support or engage with CDI program efforts.