Thursday, February 9, 2017

CMS to Clear Medicare Appeals Backlog

6 things to know

In an effort to help clear the backlog of Medicare appeals, CMS has offered to pay hospitals 66 percent of the net allowable amount for short-term inpatient stays in exchange for hospitals dropping their pending appeals of denied claims.
Here are six things to know about CMS' offer.
1. Acute care hospitals and critical access hospitals are the only types of providers permitted to take part in the settlement process with CMS.
2. The settlement does not apply to any short-term hospital admissions that occurred after Oct. 1, 2013.
3. Claims subject to pending appeals before an administrative law judge or the Medicare appeals board are eligible for the settlement.
4. CMS will make the settlement process available Dec. 1. The deadline for hospitals to submit an Expression of Interest is Jan. 31, 2017.
5. CMS will host a call Nov. 16 to offer more details on the settlement process.
6. CMS made a similar offer to help clear the Medicare appeals backlog in September 2014. That settlement offer resulted in CMS paying nearly $1.5 billion to 2,022 hospitals across the nation.

100 Things to Know About Medicare Reimbursement in 2017

Since its launch in 1965, Medicare has been one of the most influential programs for hospitals, health systems and other providers. Medicare has played a prominent part in various reform movements, including the shift from fee-for-service to value-based payment models, and the program's policies and reimbursement rates have acted as a catalyst for change nationwide.
The following list sheds some light on several facets of Medicare reimbursement, covering everything from the latest update to the Inpatient Prospective Payment System to mandatory bundled payment models.
Inpatient hospital reimbursement1. Hospitals that fall under CMS' Inpatient Prospective Payment System agree to pre-determined rates to serve Medicare beneficiaries. More than 3,300 acute care hospitals and 430 long-term care hospitals receive payments under the IPPS.
2. Hospitals generally receive IPPS payments on a per-discharge or per-case basis for Medicare beneficiary inpatient stays. Discharges are assigned to diagnosis-related groups, which sort them by similar clinical conditions and procedures administered by the hospital during the stay.
3. CMS updates the IPPS each fiscal year. CMS released the FY 2017 final rule in early August.
4. Under the FY 2017 final rule, acute care hospitals that report quality data and that are meaningful users of EHRs will receive a 0.95 percent increase in Medicare operating rates.
5. That overall 0.95 percent payment increase reflects a positive 2.7 percent market basket update, a negative 0.3 percentage point update for a productivity adjustment, a negative 0.75 percentage point update for cuts under the ACA, a negative 1.5 percentage point documentation and coding adjustment as part of the American Taxpayer Relief Act of 2012 and an increase of about 0.8 percentage points to remove the adjustment to offset the estimated costs of the two-midnight rule.
6. Hospitals that do not submit quality data lose a fourth of the market basket update (2.7 percent), and hospitals that are not meaningful users of EHRs will be subject to a three-fourths reduction of the market basket update in FY 2017.
7. Under the two-midnight rule, which was introduced in the 2014 IPPS rule, CMS expected a decline in the number of long observation stays and an increase in the number of inpatient admissions. CMS proposed offsetting the cost through a 0.2 percent reduction in inpatient payments. The payment reduction was strongly opposed by hospitals and sparked lawsuits challenging the payment cut.
8. CMS removed this adjustment for FY 2017 and also its effects in FYs 2014 through 2016. "CMS believes the assumptions underlying the -0.2 percent adjustment were reasonable at the time they were made," wrote CMS in the final rule. However, in light of the unique circumstances surrounding this adjustment, the agency decided to remove it.
9. As part of the ACA, Medicare disproportionate share hospital payments will be reduced by 75 percent, or $49.9 billion, by 2019. CMS said in the FY 2017 final IPPS rule it will distribute nearly $6 billion in DSH payments in FY 2017, about $400 million less than in FY 2016.
10. In the FY 2017 final rule, CMS added four new claims-based measures (three clinical episode-based payment measures and one communication and coordination of care measure) for the FY 2019 Inpatient Quality Reporting Program and subsequent years.
11. CMS removed 15 claims-based measures for the FY 2019 payment determination and subsequent years in the final rule.
12. CMS made changes to the Hospital Value-Based Purchasing Program, which was established under the ACA, in the final FY 2017 rule. The agency added two condition-specific payment measures (one for acute myocardial infarction and one for heart failure) beginning in FY 2021 and a 30-day mortality measure following coronary artery bypass graft surgery beginning in FY 2022. CMS said the condition-specific payment measures capture payments for all care, including readmissions and subsequent cardiac events, across multiple care settings, services and supplies during the 30-day episode of care.
13. CMS made several changes to existing Hospital Acquired Conditions Reduction Program policies in the FY 2017 final rule, including changing the program scoring methodology from current decile-based scoring to a continuous scoring methodology.
For outpatient reimbursement & other CMS issues CLICK HERE.

Saturday, January 7, 2017

Three things that can affect ICD-10 coding in 2017

Carl Natale
Three things that can affect ICD-10 coding in 2017
U.S. healthcare has been using ICD-10-CM/PCS coding for more than a year so there doesn't seem like anything new could happen. But there are three things that might make their marks on the code sets.

New coding updates

Obviously any ICD-10-CM/PCS updates are considered developments. But I'm interested in seeing how the updates are handled.
Healthcare providers are going to panic because the 2017 ICD-10 updates set them back (which we do not know yet) or they will yawn because they have coding systems that tackle the new codes without creating hassles.
If the latest updates don't throw healthcare providers out of sorts, it's possible physicians will appreciate the new granularity they wanted to be able to document on medical claims.


There are reports that diagnosis coding productivity is returning to ICD-9 levels. The procedural coding levels are another matter. But that is a challenge for hospitals that have resources to throw at the problem.
How productivity levels for clinicians and medical coders trend will greatly affect how ICD-10 coding is perceived.

Soon-to-be President Donald Trump

This isn't meant as an insult, but it is doubtful that President-elect Donald Trump knows what ICD-10 coding is. Very few successful and intelligent people outside of healthcare do. So he probably has no opinion on what should happen to it.
But he has nominated Rep. Tom Price to lead Department of Health and Human Services (DHHS). Price never has been a fan of ICD-10 coding. He has co-sponsored anti-ICD-10 bills.
But it's hard to imagine Price asking Congress to revert U.S. healthcare back to ICD-9 coding. That would create more havoc and cost than the original ICD-10 transition. Besides, he's going to be busy reimagining Obamacare and reforming Medicaid.
By the way, I predict in 2018 I will have to write posts explaining why we still have ICD-10 coding despite the repeal of Obamacare.
But whatever Trump and Price come up for healthcare, they're going to want to target waste and fraud. Politicians love to campaign against waste and fraud. So it would be a great idea to create a healthcare system that pays for benefits by eliminating waste and fraud.
Someone could persuade Trump that ICD-10 coding will be a great tool to identify the waste and fraud. That could be more persuasive than physician complaints about how onerous and burdensome this ICD-10 mandate is.
If Trump promises the best electronic health records (EHRs) and massive reductions in healthcare regulations and red tape, ICD-10 will work beautifully.
This could be the year that great change comes to healthcare, and ICD-10 coding stands a chance of being part of that.

Wednesday, December 28, 2016

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An old problem with DRG assignments

 has ICD-10 repercussions

Carl Natale
An old problem with DRG assignments has ICD-10 repercussions
The Office of Inspector General (OIG) is applying greater scrutiny to a couple DRG assignments.
One focuses on mechanical ventilation. An OIG audit found a 95 percent error rate in Medicare billing from 2009 to 2011. That isn't an ICD-10 problem. The problem has existed long before ICD-10 implementation. But if there is greater scrutiny of medical ventilation diagnoses, healthcare providers need to make sure they nail the right assignments of ICD-10 codes and DRGs.
It underscores the need for healthcare providers to continue training. Their medical coders need to know more than just new codes. They need to understand the rule and guidelines. The correct application is as tricky and important as it every was.

Monday, December 5, 2016

Why Black Friday was a Big Day for ICD10 Coding!

Carl Natale 

Why Black Friday was a big day for ICD-10 coding
After processing the Thanksgiving Day calamities, it would be nice to get a break. Except Black Friday isn't known as a day of recuperation.
The good news is that most of the possible diagnoses will come from one section of the ICD-10-CM code set. The bad news is this:
  • R46.1 - Bizarre personal appearance (just saying)
  • W03.xx - Other fall on same level due to collision with another person (Please, watch where you're going)
  • W10.0XXA - Fall on/from escalator, initial encounter (What happens on the escalator doesn't always stay on the escalator)
  • W21.01 - Lack of adequate sleep (After a day of giving thanks, who got enough rest to get the best Black Friday deals?)
  • W50.3XXA, Y92.512 and Y99.0 - Clerk accidentally bit by another human while at work (It's a jungle out there.)
  • W51.XXXA - Accidental striking against or bumped into by another person, initial encounter (Which can cause the W03.xx.)
  • W52.XXXA - Crushed, pushed or stepped on by crowd or human stampede, initial encounter (That mad rush when doors open at midnight.)
  • Y04.0xxA - Assault by unarmed brawl or fight (Deep discounted appliances bring out the worst in us.)
After all of that, it seems like the safest strategy is to avoid the crowds and do the shopping online. But there's always G56.00 (carpal tunnel syndrome).

Thursday, December 1, 2016

AHA pens letter to Trump calling for support of hospital policies

Written by Emily Rappleye   | November 30, 2016

The letter called on Mr. Trump not to make any abrupt changes or to repeal the ACA without a replacement plan, and it outlined the following five areas of healthcare policy for Mr. Trump to consider."To help advance health in America, we ask that your administration — in collaboration with Congress and the courts, and in partnership with healthcare providers — help modernize the public policy environment to enhance providers' ability to improve care and make it more affordable for patients," wrote Richard Pollack, president and CEO of AHA.
1. The AHA called for some regulatory trimming and pruning. They specifically called for the elimination of Stage 3 meaningful use for hospitals, implementation of a penalty for high rates of incorrect denials under the Recovery Auditor Contractor program, protection of clinical integration arrangements under the Anti-Kickback Statute, standardization of the Federal Trade Commission's merger review process and elimination of several post-acute care regulations.
2. The organization called for the President-elect's support on several financial policies. These include addressing drug prices, protecting the 340B Drug Pricing Program, challenging mergers among payers and considering Medicare reforms, such as raising the eligibility age.
3. It asked the Trump administration to consider redesigning many quality reporting requirements. The AHA wrote that requirements are excessive, redundant and not always meaningful. Notably, it called for suspension of the hospital star ratings on the Hospital Compare website.
4. The AHA urged Mr. Trump to ensure access to care in his healthcare policies. Particularly, the hospital association pointed to continued funding for CHIP, expanded mental health services, elimination of site-neutral payment cuts and establishment of a permanent Veterans Choice Program, which allows veterans to access care outside of the VA health system.
5. The association also called for the preservation of value-based care models adopted under the ACA. The AHA asked that several models be updated, including several ACO requirements and the advanced alternative payment models under the Medicare Access and CHIP Reauthorization Act.
"We look forward to working with you and your administration on public policy solutions to achieve our vision of a society of healthy communities where all individuals reach their highest potential for health," Mr. Pollack concluded.