CMS, the Veterans Health Administration, and some states measure our care quality based on risk-adjusted readmission rates after inpatient admissions. In fact, up to 3% of our hospital’s Medicare inpatient revenue (used to pay physician subsidies) is at risk if we don’t manage our patients’ readmissions in concert with Medicare’s algorithms.
In advance of ICD-10-CM/PCS, many institutions implemented computer-assisted coding (CAC) hoping to mitigate the anticipated productivity losses, but research has confirmed suspicions that there is an inverse relationship between coding productivity and accuracy.
The implementation of an EHR is a multifaceted, comprehensive project for healthcare organizations. To avoid coding issues during EHR implementation and ensure discharged-not-final-coded is not adversely impacted, dedicated HIM focus and detailed project planning are paramount.
Organizations and CDI specialists must have a thorough understanding of how regulations and guidelines impact risk adjustment in the outpatient setting. A misinterpretation can easily lead to inadvertent upcoding—and that can lead to costly audits, settlements, and accusations of fraud.
CMS' 340B FAQ reviews modifiers -JG (drug or biological acquired with 340B drug pricing program discount) and -TB (drug or biological acquired with 340B drug pricing program discount, reported for informational purposes) and requires 340B hospitals to report modifiers even on drugs that are not subject to the discount policy.
In May, we expect to see the release of the International Classification of Diseases, 11th Edition, for Mortality and Morbidity Statistics (ICD-11-MMS) by the World Health Organization. Work will then begin in the U.S. to adapt it for our clinical use as ICD-11-CM. Hopefully, with the benefit of foresight and lessons learned from the past, we will not reenact the pain we all had with the ICD-10-CM/PCS implementation.
