“Special Edition” Disruption in 2018: Providers & Payers

appeal academy | finally friday | medical audit

Friday, May 4, 2018

Disruption in 2018:
Providers & Payers


It’s a banner year for somebody. Somewhere. Maybe.

appeal academy | finally friday | medical audit


Finally Friday! Broadcasts are Sponsored by
The Health Law Partners, and The Sixth National PA/UR Boot Camp

THIS WEEK, we are welcoming back Day Egusquiza, along with John Montaine, a past master and expert at Contracting! 

appeal academy | medical audit

Day Egusquiza, full of passion as always!

This is the second of two webinars Day is doing as a prelude/preview of her class at the Pre-conference for the Sixth National PA/UR Boot Camp in July. 

Previously, she identified four areas of impact: Patients, the Nation, Providers, and Payers. And as usual, she has TONS to say about whatever she talks about. She had plenty to say, last time, on March 23, and we expect even more for this talk. And lemme tell you… the things that are happening are highly significant, and will mean many more changes are on the horizon for healthcare providers, especially.

John Montaine, MBA, FHFMA, HRM

And then we have John Montaine, CEO at Creative Managed Care Solutions, who heads a team of managed care negotiators with 25 years experience working with national payers to successfully negotiate hospital and physician contracts that deliver improved results to achieve their clients’ goals. Trust me: he has plenty to say on this subject, too!

This week, we’ll be talking about what disruption looks like for Providers and Payers.

SO… we will be discussing these questions:

  • WHAT is the move from Volume to Value doing to Providers?
  • WHAT is the move from Volume to Value doing to Hospitals?
  • WHAT is the Convergence in healthcare?
  • WHO are the players that are “converging”?
  • WHAT is Walmart doing NOW?
  • WHAT are Aetna and United Healthcare doing NOW?
  • WHAT is TRUE reason the payers want pre-auths?
  • WHAT should you take from this into your contract meetings?

So join us, share your own insights and bring your questions for us!


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AHA shares new resource on ICD-10-CM coding for social determinants of health


The American Hospital Association (AHA) recently released a new resource that hospitals and health systems can use to educate caregivers and coding professionals about the important need to collect data on the social determinants of health. AHA successfully advocated changing the requirement for these codes to be based on information documented by all clinicians involved in the patient’s care instead of physician documentation only.

Please share this resource with your physicians, nonphysician health care providers and coding professionals.

Previous article

via AHA shares new resource on ICD-10-CM coding for social determinants of health


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CMS terminates Kansas hospital’s Medicare billing privileges: 5 things to know


CMS revoked Overland Park, Kan.-based Blue Valley Hospital’s Medicare billing privileges April 11, and the hospital is now suing HHS and CMS over the decision.

Here are five things to know.

1. Under rules enacted last September, healthcare facilities must average at least two inpatients per day and an at least two-night average length of stay to be considered an inpatient hospital for Medicare reimbursement. Facilities that fall short of these requirements may instead be considered same-day surgery centers, which have different reimbursement rates, according to The Kansas City Star.

2. CMS said Blue Valley Hospital doesn’t meet the new federal requirements for Medicare participation. A survey by state health officials last November found Blue Valley Hospital did not have any inpatients at that time, and a subsequent report showed the hospital performed about 309 outpatient surgeries, compared with 146 inpatient surgeries over a yearlong period, according to KCUR.

3. Blue Valley Hospital officials acknowledged that the hospital fell short of the two-night average stay requirement, but they say the new federal requirements are arbitrary. “This action taken by CMS was not related to any patient safety or quality of care issue, but results from CMS’ change in the definition of hospital under the Code of Federal Regulations,” Blue Valley Hospital CEO D. Chris Dixon said in a statement to The Kansas City Star.

4. In its recently filed lawsuit against HHS and CMS, Blue Valley Hospital says many of its patients have an expected length of stay of two nights, but they are able to go home earlier than expected due to the high-quality care they receive at the hospital. “CMS’ new criteria suggests that hospitals should keep patients longer than necessary just to meet arbitrary CMS requirements, which is against public policy,” the lawsuit states.

5. Blue Valley Hospital is requesting to keep its Medicare billing privileges while it appeals CMS’ decision to terminate its participation in the Medicare program, according to The Kansas City Star.

More articles on healthcare finance:

Henry Ford’s operating gains partially offset by Epic implementation costs, wage rate increases
Idaho hospital faces cash crunch after software glitch causes billing problems
5 latest hospital bankruptcies, closures

© Copyright ASC COMMUNICATIONS 2018. Interested in LINKING to or REPRINTING this content? View our policies by clicking here.

To receive the latest hospital and health system business and legal news and analysis from Becker’s Hospital Review, sign-up for the free Becker’s Hospital Review E-weekly by clicking here.

via CMS terminates Kansas hospital’s Medicare billing privileges: 5 things to know


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MIPS Updates: 2018 Eligibility Tool Now Available; CMS Announces ‘Study on Burdens’ for Quality Reporting


At the risk of sounding like a broken record …

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CMS axes a Medicare Advantage star rating measure: 5 things to know

Written by Morgan Haefner | April 04, 2018 | Print  |Email


Here are five things to know about the decision.

1. Medicare ranks Medicare Advantage plans on a quality scale of one to five stars, and pays bonuses to plans with high ratings. Beginning in 2019, CMS will remove its Beneficiary Access and Performance Problems measure from its star rating calculations.

2. The BAPP measure considers CMS’ sanctions, civil money penalties and compliance data like notices of noncompliance, warning letters and corrective action plans.

3. When CMS solicited feedback on BAPP in 2018, commenters recommended revising the measure due to “differences in methodologies and goals, the subjective nature of audits, and the absence of audit information for each plan each year.” Advocates of the measure strongly opposed omitting BAPP.

4. “Based on the feedback, the strong support for a change to the measure specification, and concerns for providing additional notice and time to prepare for the significant changes, CMS decided to retain the current BAPP measure in the 2018 Star Ratings.” However, BAPP will be retired in 2019 and CMS will “introduce a new measure for the display page.”

5. CMS received mixed reactions to its decision to axe the BAPP measure from its 2019 star ratings. Those opposed to the decision were beneficiary advocacy groups, who said the removal will “mask plan behaviors that could pose a serious threat to the health and safety of beneficiaries.” Insurers, conversely, largely supported the decision.

More articles on payer issues:
UnitedHealth, Anthem shares up on possible Walmart-Humana merger
Why a Pennsylvania woman’s hospital bill spiked $393 after she proved her daughter was insured
Poll: 61% of ACA enrollees satisfied with marketplace insurance options

© Copyright ASC COMMUNICATIONS 2018. Interested in LINKING to or REPRINTING this content? View our policies by clicking here.

To receive the latest hospital and health system business and legal news and analysis from Becker’s Hospital Review, sign-up for the free Becker’s Hospital Review E-weekly by clicking here.

via CMS axes a Medicare Advantage star rating measure: 5 things to know


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CMS Finalizes Medicare Advantage and Part D Changes for 2019 – Medicare Rights Blog


This week, the Centers for Medicare & Medicaid Services (CMS) released the final Medicare Advantage and Part D 2019 Rate Announcement and Call Letter. This is the finalized annual update to Medicare Advantage and Part D programs, which includes payment updates and policy changes for calendar year (CY) 2019. CMS also released a preview and fact sheet of the Final Rule Implementing Policy and Technical Changes to Part C and Part D for CY 2019, which will be formally published at a later date.

Notable changes for the 2019 plan year include:

  • Eliminating the Star Rating Measure that separately captures the results of audits and enforcement actions.
  • Expanding the ability for plans to offer supplemental benefits that are health related but are not covered by Traditional Medicare, including benefits that address the social determinants of health, like nutritional support.
  • Finalizing a new method for calculating payments to Medicare Advantage plans that employers can offer to Medicare enrollees.
  • Expanding the list of conditions included in the CMS-HCC Risk Adjustment Model.

Together with the changes in the proposed rule, this Rate Announcement and Call Letter provides for increased plan flexibility and reduced oversight. As Medicare Rights outlined in our comments to both draft documents, this flexibility will require increased understanding, vigilance, and research by beneficiaries as they choose and utilize coverage through Medicare Advantage Plans.

View the CMS fact sheet.

View the 2019 Rate Announcement and Call Letter.

via CMS Finalizes Medicare Advantage and Part D Changes for 2019 – Medicare Rights Blog


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10 key trends for ASCs and outpatient surgery in the next 10 years


Written by Laura Dyrda | April 02, 2018 | Print  |Email

Here are 10 predictions and key trends for outpatient surgery and ASCs, including key specialties and outpatient growth, through 2027.

1. Over the next decade, inpatient discharges are expected to decrease 2 percent while outpatient volumes will likely grow 15 percent across the U.S., according to Sg2 predictions. As the government and payers scrutinize costs and push the shift to value-based care, outpatient surgery is expected to see an overall 11 percent increase from 2017 to 2022.1

2. Inpatient orthopedic and spine surgeries are expected to deceases 3 percent over the next 10 years while spine surgeries including spinal fusions are expected to increasingly head to the outpatient setting. Orthopedics and spine are expected to grow 35 percent in the outpatient setting over the next 10 years, according to Sg2.

3. Consumers will drive choice in the outpatient setting for orthopedic and spine care. This will dampen growth in rehab follow-up visits and shift care away from the hospital and emergency department setting.2

4. Cardiovascular care is declining in the inpatient setting, but the shift to outpatient is limited because the patient population is typically older and needs additional care support. However, interventional cardiology and electrophysiology procedures could go outpatient with continued technology advances and payment approvals.

5. The shift to outpatient care among gynecology procedures is expected to accelerate over the next several years. Inpatient gynecology is expected to drop 28 percent in the next decade while hysterectomies will become more common as an outpatient procedure.

6. Since CMS has begun removing high-revenue procedures like knee replacements from the inpatient-only list, there will likely be an increase in competition for outpatient care. The Advisory Board reports a renewed interest in ASCs and health systems examining their ambulatory footprints.3

7. Non-provider organizations have an increased interest in outpatient surgery and ASCs as the industry moves toward value-based care. New market entrants and out-of-industry players such as private equity firms or insurance companies will become competitors in the space as well, according to Advisory Board.

8. The ASC market is expected to grow at a 4 percent compound annual growth rate from 2017 to 2027, according to Future Market Insights. The hospital-based ASC segment is expected to hit $69.7 billion by 2027, and multispecialty ASCs are expected to dominate reaching $76.8 billion over the next decade.4

9. ASC surgical volume in 46 of the 50 largest markets in the U.S. grew 10 percent from 2015 to 2016, and market factors are expected to continue pushing for growth.5 “We’re seeing the symptoms of a changing marketplace nationally,” said Managing Director of Franklin Trust Ratings John Morrow. “As payment reforms collide with consumer sentiment, and technology pushes outpatient care to new limits, lower priced settings are disrupting traditional care models. Hospitals and ASC operators need to understand the market stage and transitions taking place in their service line markets as they mature.”

10. In the 50 largest markets, the overall ASC surgical procedure volume increased 22.9 percent nationwide, with 35.8 million outpatient procedures occurring in hospital-based outpatient departments and ASCs annually. GI procedures grew 19.4 percent from 2015 to 2016, while eye procedures jumped 2.8 percent.

More articles on surgery centers:
21 statistics on ASC annual case volume by region
Physicians Endoscopy wins best place to work honor
5 things to know about orthopedic certifications


1. Sg2: Sg2 2017 Impact of Change Forecast: Finding Growth. Posted May 5, 2017; Accessed April 2, 2018: https://www.sg2.com/health-care-intelligence-blog/2017/05/sg2-2017-impact-change-forecast-finding-growth/

2. Sg2: Sg2 2017 Impact of Change Forecast: Finding Growth. Posted May 5, 2017; Accessed April 2, 2018: https://www.sg2.com/health-care-intelligence-blog/2017/05/sg2-2017-impact-change-forecast-finding-growth/

3. Advisory Board: Our 2018 growth predictions: What planners should watch for. Posted Feb. 15, 2018; Accessed April 2, 2018: https://www.advisory.com/research/market-innovation-center/the-growth-channel/2018/02/2018-growth-predictions

4. Future Market Insights: Ambulatory Surgical Centres Market to Garner US$113,046.7 Mn By End of 2027 – Future Market Insights. Posted Sept. 27, 2017; Accessed April 2, 2018: https://globenewswire.com/news-release/2017/09/27/1133626/0/en/Ambulatory-Surgical-Centres-Market-to-Garner-US-113-046-7-Mn-By-End-of-2027-Future-Market-Insights.html

5. Franklin Trust Ratings: Ambulatory Surgical Care Growth: ASC Surgical Volumes Grow in 46 of 50 Largest Markets while Hospitals Lose Share. Released Feb. 2, 2018.

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Letter to CMS: 5 insights on what orthopedic surgeons think about removing TKA from the Medicare Inpatient Only list

The American Academy of Orthopaedic Surgeons, along with several orthopedic specialty and state societies, sent CMS administrator Seema Verma a letter commenting on CMS’ decision to take total knee arthroplasty out of the Medicare Inpatient Only list.

Here are five things to know.

1. The letter claims that there has been confusion regarding how to implement this new rule. CMS designates the Medicare beneficiary’s physician as the medical professional responsible for determining the care setting in this rule, but AAOS is concerned that unqualified decision making on the site of service will harm beneficiaries, especially those who have multiple risks such as comorbidities and advanced age that are not conducive to an outpatient procedure.

2. AAOS asks for clarification on whether surgeons’ reimbursements will be affected by this policy change.

3. In addition to deciding to remove TKA off the IPO list, CMS made TKA procedures subject to the “Two-Midnight Rule,” in which a hospital admission should span at least two midnights in order to be covered as an inpatient procedure. The letter requests CMS issue an exception to the “Two-Midnight Rule” for TKA procedures.

4. The letter requests the CMS Center for Clinical Standards and Quality to direct quality improvement organizations to get involved and take up any compliance questions and issues related to potential audits.

5. The letter identifies the issue of wrongly defaulting TKA cases to the outpatient setting as especially concerning for surgeons and patients in Medicare Advantage plans. The letter asks CMS to use its MA plan oversight authority to intervene to ensure that MA plan beneficiaries are not unfairly disadvantaged over their fee-for-service counterparts.

More articles on practice management:

South Dakota is No. 1 state for physicians in 2018 — Which is the worst?


Physician Partners of America, Capstone Pain and Spine Group partner: 4 things to know

Dr. Dror Paley expands Paley Orthopedic & Spine Institute team: 3 highlights

© Copyright ASC COMMUNICATIONS 2018. Interested in LINKING to or REPRINTING this content? View our policies here.

via Letter to CMS: 5 insights on what orthopedic surgeons think about removing TKA from the Medicare Inpatient Only list


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Study: More ‘Collaboration and Consistency’ Needed Between PTs and Surgeons in TKA, THA Measures

As health care moves toward value-based approaches, it’s going to become increasingly important for physical therapists (PTs) and orthopedic surgeons (OSs) to pursue more “collaboration and consistency” when it comes to outcome measures used in total knee and hip arthroplasty cases, say authors of a new study.

That study, based on a survey of PTs in New England, found that many PTs relied on a range of performance-based outcome measures (PBOMs) and were less likely to use certain patient-reported outcome measures (PROMs) preferred by OSs—though that could be changing.

The study, which appears in Arthroplasty Today, is based on a survey of 122 PTs in Maine, Vermont, New Hampshire, Massachusetts, Rhode Island, and Connecticut. Researchers were trying to uncover differences between outcome measures commonly used by PTs, and those recommended for use in the American Joint Replacement Registry (AJRR), which authors of the study believe reflects measures most commonly used by OSs.

To qualify for inclusion in the survey, a PT must have treated patients undergoing total hip arthroplasty (THA) and/or total knee arthroplasty (TKA) in the past 5 years. PTs were asked to rate their current use of various outcome measures on a 4-point scale, from “not familiar” to “considerable experience.” The respondents further were asked to estimate their future use of the outcome measures, also based on a 4-point scale: “unable to rate,” “unlikely to use,” “likely to use,” and “will use and recommend.”

As for the outcome measures being evaluated, authors selected the Lower Extremity Function scale (LEFS), the numeric pain rating scale, Oxford Knee Score (OKS), Oxford Hip Score (OHS), EQ-5D quality of life measure, Knee Injury and Arthritis Outcome Score (KOOS), Hip Injury and Arthritis Outcome Score (HOOS), and the Western Ontario and McMaster Universities Arthritis Index (WOMAC) as the PROMs. For PBOMs, they asked PTs to rate walking speed, the 6-minute walk test, timed up-and-go (TUG), timed stair climb, Tinetti Mobility Test, Single-Leg Balance Test, and functional reach test.

Here’s what they found:

Respondents. The PTs included in the survey were mostly from mixed urban-rural areas (62.3%). Over half (53.5%) reported practicing in a private practice clinic; nearly 1 in 5 (18%) practiced in an outpatient clinical associated with an academic hospital or medical center. About a third of respondents (32.8%) reported 25 years’ experience or more; 17.2% reported between 10 and 14 years of experience, and 13.9% listed experience at between 15 and 19 years. Just over 42% of PTs surveyed said they’d treated 25 or fewer TKA/THA patients in the past year; nearly that many (38.9%) reported treating between 26 and 49 such patients during the past year.

Use of PROMs. The Numeric Pain Rating Scale and the LEFS were the measures most often cited by the respondents in terms of both current and future use of patient-reported data. Nearly all (99.2%) of the PTs reported current considerable experience with the pain rating scale, with 97.5% saying that they’d use and recommend the scale in the future. LEFS was also popular among the PTs, with 76.2% reporting considerable current experience and 77% supporting future use and recommendation.

Use of PBOMs. In the performance-based category, the PTs cited the Single-Leg Balance Test and the TUG as the most relied-upon measures. For the Single-Let Balance Test, 90.2% of respondents reported current use, with 87.7% saying they would use and recommend that test in the future. The TUG was even more popular, with 93.4% of the PTs reporting current use, and 85.2% reporting future use and recommendation.

The problem, according to the study’s authors, is that the PTs’ choices for PROMs don’t line up with the AJRR recommendations, which lean more toward general quality of life measures and specific joint measures such as the HOOS, KOOS, and Oxford knee and hip measures. “It is difficult to explain why [the surveyed PTs] prefer the LEFS,” authors write. “LEFS is easy to implement and broadly applicable to all lower extremity sites in various stages of disability, but is not specific to hip and knee osteoarthritis. The HOOS and KOOS are joint specific, including the [WOMAC] score, and have been shown to be more sensitive and responsive than the LEFS in total joint replacement. However, they take longer to administer.” [Editor’s note: APTA encourages the use of HOOS and KOOS for PTs participating in the Comprehensive Care for Joint Replacement bundled care model.]

And while authors point out that PROMs are probably more reflective of the direction health care is heading, they acknowledge that PBOMs such as TUG have their place, too.

“PROMs may overestimate patient mobility, especially in the immediate postoperative phase after both TKA and THA,” authors write. “Because [PTs] evaluate TJA [total joint arthroplasty] patients multiple times in the early postoperative period, they may utilize PBOM more frequently to avoid overestimation of function during the early phase of rehabilitation.” It’s an approach that the researchers say echoes recommendations from the Osteoarthritis Research Society International, which supports use of the sit-to-stand test, walking speed test, timed stair climb, 6-minute walk test, and TUG.

“PROMs and PBOMs also assess different time periods of recovery,” authors write. “PROMs generally assess a period of weeks of overall symptoms and function while PBOMs objectively measure function at a particular point in time. Both types of information are valuable in assessing patient recovery.”

Still, they argue, the evolution toward patient-centered care means that patient-reported outcomes are likely to become more important in the future. And while the PTs surveyed may not yet be fully in sync with this trend in THA and TKA measures, there are some signs of positive movement.

“This study showed that of the 16 outcome measures queried for clinical decision making, [PTs] indicated that they were less likely to use 4 of them in the future, all them PBOMs, and more likely to use 2 in the future, both PROMs,” authors write. “As surgeons and [PTs] work more closely, developing better understanding and consensus in the use of PROM and PBOM between surgeons and physical therapists will allow for improved assessment of TJA patient outcomes.”

Authors acknowledge several limitations of their study, including a low response rate and the lack of data indicating when the various measures were used in the course of treatment. Another potential limitation: a large proportion of PTs (42.6%) reported seeing fewer than 25 patients with THA or TKA annually.

Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association’s PTNow website.

Posted by News Now Staff at

via Study: More ‘Collaboration and Consistency’ Needed Between PTs and Surgeons in TKA, THA Measures


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Proper Documentation is Critical to Our Modern Healthcare System | Journal of AHIMA

Posted By on Mar 29, 2018

This monthly blog will discuss all the components of quality clinical documentation with a comprehensive approach to cover all areas of the healthcare industry.

By Allen Frady, RN, BSN, CCS, CCDS, CRC


Is documentation improvement and proper use of ICD-10-CM critical to the nation’s healthcare debate? I say definitively yes, in every way. The bulk of the information coming from the Centers for Medicare and Medicaid Services (CMS) via the Federal Register and a large part of policy decision-making about the shifting paradigm towards pay-for-performance revolves around one single data point—the ICD-10-CM codes. These codes are being selected at the inpatient, outpatient, and ambulatory surgical levels and drive 100 percent of our data in terms of what is making America sick, which patients are getting better, outcome locations, and successful treatment plans. They are also used to track the cost of various illnesses in numerous patient populations. These are the same ICD-10-CM codes that give us our profiling and outcomes, our value-based purchasing, MACRA/MIPS, MS-DRGs, APCs, HCC levels, and even the continued payment of FFS claims.

For the coding system to work correctly you must first start with proper documentation and ensure you have expert coders at the ready. Proper documentation must start with physician buy-in and appropriate physician education.

Physician education for proper documentation and coding sounds ominous—maybe even impossible—but it doesn’t have to be. I typically focus provider education on letting them know what’s being lost in translation. If you have a willing physician who is ready to listen, you can quickly gain their attention with a few very simple questions like the ones listed below:

  • “Did you know flash pulmonary edema gets reported as chronic pulmonary edema?”
  • “Did you know healthcare associated pneumonia gets reported with the same pneumonia code as community acquired pneumonia (and with the same cost and outcomes expectations)?”
  • “Did you know if you document blood loss anemia in a patient with a 4gm loss in hgb who received two units of blood and endoscopic procedure for control of hemorrhage, the ICD-10-CM code that gets assigned is for chronic blood loss anemia?”

Documentation improvement is the mechanism by which these issues are fixed before they get into the healthcare data. Generally, we start with the ICD-10-CM code to figure out what is being reported and then work backwards. An example of this might be in discussing the pitfalls of using delirium and encephalopathy interchangeably. There is no shortage of these types of problems such as Renal insufficiency vs. Acute kidney Injury vs. Acute renal failure to SIRS vs. Sepsis, and even Respiratory Insufficiency vs Respiratory Failure. Sometimes the meaning of the ICD-10-CM code will drive the conversation with the provider, in favor of altering the written nomenclature, so that the data will accurately match the true clinical presentation as opposed to potentially getting false data.

While clinical documentation improvement (CDI) professionals do not get into the business of dictating clinical criteria to establish a diagnosis to medical staff. We will work with physician advisors and their extended physician champions to further the conversation about the documentation of the patient’s clinical picture in a way that represents their true pathological status in defense of the trend towards “clinical validation.” If the conversation with a physician is criteria-based, then I tend to take a collaborative tone, jointly discussing the pros and cons of various criteria (e.g. 3rd Univ Def of an MI, Sep 3, KDIGO, Aspen or how many mm of a shift on a head CT constitutes clinical significance) with focus on helping the physician understand how they may want to set the query parameters for CDI professionals at their facility. The comfort levels of the providers with various criteria thresholds for reporting varies depending on the level of the facility (academic teaching versus community) and the specific training the physician advisors received in medical school and in their residency. More importantly, their comfort thresholds with criteria-based decision making will vary depending on the patient. For example, sepsis indicators in an immunocompromised cancer patient look very different than sepsis indicators in a health 25-year-old athlete. CDI professionals routinely work with physician champions to make sure documentation accurately reports the severity of illness with a facilities patient population, leaving no stone unturned and no important data left off the claim form. This means that the CMS statistical data pool, which is often used for helping determine public health policy via CMS and the Federal Register will be accurate to the highest extent possible.

There is an important caveat for those looking to build a successful CDI program: strong administrative support is essential. An emphasis on getting documentation right must come from the top-down, from CMS all the way down to the provider, CDI professional, and, finally, to the coding professional. To get documentation right, it is crucial for the physician to have an open mind and be ready to learn.


Allen Frady is a CDI education specialist at ACDIS.

via Proper Documentation is Critical to Our Modern Healthcare System | Journal of AHIMA


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