Pneumonia discharges impact hospital payments under the Hospital Value-Based Purchasing Program as well as the Hospital Readmissions Reduction Program. The selection of a principal diagnosis, secondary diagnosis, present on admission (POA) status, and discharge status on each claim determines whether a pneumonia discharge will be included in the measure.
Even though we are set to inaugurate a new president of the United States who vowed to abolish Obamacare, I believe that Donald J. Trump will not touch provisions that address perceived cost inefficiency or quality within our healthcare system. In fact, if you’ve read CMS’ game plan for transforming healthcare published in JAMA in 2014, note that many of these provisions began with George W. Bush and have been embraced by the AMA with the implementation of MACRA.
The implementation of ICD-10 in 2015 was considered an industrywide success. Coders were trained, HIM departments were prepared, and outsourced coding companies expanded their roles. As we enter the second year of ICD-10, what should HIM directors expect from their coding teams and outsourced vendor partnerships?
Most of us are familiar with ICD-10-CM through picking codes from a list in our EHRs or perusing a printed code book. Allow me to suggest that unless we understand the coding rules in the ICD-10-CM Official Guidelines, we may mistakenly pick the wrong code, leading to a potential false claim.
The 30-day all cause acute myocardial infarction (AMI) mortality outcome measure has been linked to hospital payments since the inception of the Hospital Value-Based Purchasing Program (HVBP) in fiscal year 2013. In February 2016, CMS announced that 70% of commercial payers have agreed to use this measure as one of the cardiology outcomes linked to payment.
Today’s HIM professional needs to understand the various programs and the impact that coding and documentation may have on an organization’s performance. By 2018, 50% of Medicare payments will be tied to value-based alternative payment models.
Most healthcare systems already have a proven process in place to monitor revenue integrity and ensure correct reimbursement. Beyond the day-to-day revenue cycle staff involved in revenue integrity, more than 60% of hospital executives believe revenue integrity is essential to their organization’s financial stability and sustainability, according to a survey by Craneware, Inc.
If your hospital resides in one of the 67 metropolitan statistical areas (MSA) required to participate in the Comprehensive Joint Replacement Model (CJR), you will also be required to participate in a new orthopedic payment model called 'SHFFT' (surgical hip and femur fracture treatment) if an August 2 proposed rule is finalized. The impact? The following assigned MS-DRGs will no longer define hospital reimbursement:
Major Joint Replacement or Reattachment of Lower Extremity (MS-DRGs 469, 470)
Hip and Femur Procedures Except Major Joint (MS-DRGs 480, 481, 482)
Coder accuracy in ICD-10 may suffer if the focus is on productivity—and poor accuracy will hit hospitals’ revenue streams hard under value-based purchasing programs, experts at AHIMA’s 2016 convention agreed.
