Clinical Documentation Integrity – Success in Written Policies and Procedures

Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, AHIMA Approved ICD-10-CM/PCS Trainer AHIMA Leave a Comment

While writing policies and procedures often seem to be time-consuming and a challenge, they have many positive benefits that cannot be overlooked. For Clinical Documentation Integrity (CDI) program having written policies and procedure is part of compliance and the day-to-day operations of the CDI staff. When we think about written policies and procedures (P&Ps) we often...

CERT Overpayment Report - Documentation is the Key

Gloryanne Bryant, RHIA, CDIP, CCS, CCDS HHS 1 Comment

The 2021 Comprehensive Error Rate Testing (CERT) report contains statistics on improper payment made by the Medicare program to providers and is published annually. The CERT data is supported by a sample of Medicare Fee-For-Service (FFS) claims that were reviewed by an independent medical review contractor to determine if they were paid properly under Medicare coverage,...

Medicare Part C Improper Payment Measurement

Gloryanne Bryant, RHIA, CDIP, CCS, CCDS Compliance Leave a Comment

The Improper Payment Measurement or IPM provides statistical data on parts of the Medicare programs and reports overpayments and underpayments. The Medicare Part C beneficiary-level of payment errors from a given year is included and certainly is something to keep an eye on. The CMS IPM sample taken is extrapolated to determine the payment error to the risk adjustment...

Walking the Tightrope in HCC Coding

Dana Brown, MBA, RHIA, CHC, CCDS, CRC HCC/Risk Adjustment Leave a Comment

The “coding” for HCCs (Hierarchical Condition Categories) is not for the faint of heart. As an outsider or non-coder, looking in, it would appear to be so simple, BUT, It is not simple or easy. No one should do HCC coding without extensive documentation and coding training as well as HCC code capture training – and preferably this person should be a certified coding...

OIG MA DX Audit Report – UPMC Overpaid

Gloryanne Bryant, RHIA, CDIP, CCS, CCDS Compliance Leave a Comment

Another Office of Inspector General (OIG) audit report which targets Medicare Advantage (MA) risk adjustment (RA) diagnoses has been released. This November audit report was focused on University of Pittsburg Medical Center (UPMC) Health Plan, Inc, and “high-risk” diagnosis from 2015-2016. This focused audit may sound familiar as we have seen several audit reports from...

The OIG Focus on Clinical Coding

Gloryanne Bryant, RHIA, CDIP, CCS, CCDS OIG Leave a Comment

The last 12-18 months has brought the healthcare industry many audit reports from the Office of Inspective General (OIG). These reports are always an important part of every Compliance Program and the related audit and educational activities. Certainly, for Health Information Management (HIM), the OIG audit reports can provide a lens into issues, vulnerabilities, and...

2022 OIG Work Plan: Balancing a focus on overall compliance and the public health emergency

Aurae Beidler, MHA, RHIA, CHC, CHPS OIG Leave a Comment

What another crazy year, huh?! In 2021, the OIG continued to publish its work plan with monthly updates including OIG audits and evaluations for the fiscal year and beyond. Although the COVID-19 pandemic continues on, healthcare operations and government oversight entities such as the OIG continue their work. As of the end of November 2021, the OIG had published 12 new...

DOJ: Medical Unnecessary Stent and Ablation Procedures Back in the News

Gloryanne Bryant, RHIA, CDIP, CCS, CCDS Compliance Leave a Comment

We’ve heard about government investigations into unnecessary cardiac stent placement and cardiac ablation procedures in the past. On September 15th, 2021, the Department of Justice (DOJ) announced a settlement was reached in a case involving unnecessary cardiac procedures once again. This case is titled, “Orlando Cardiologist Pays $6.75 Million to Resolve Allegations of...

OIG Reports: Some Medicare Advantage Companies Leveraged Chart Reviews and Health Risk Assessments to Disproportionately Drive Payments

Gloryanne Bryant, RHIA, CDIP, CCS, CCDS Compliance Leave a Comment

The Office of Inspector General (OIG) released another Medicare Advantage (MA) report, this time indicating the several Medicare Advantage companies were/are leveraging chart reviews and health risk assessments (HRAs) to drive up MA hierarchical condition category (HCC) diagnosis payments. One certainly can notice that the OIG has been publishing reports on a variety of...

A Refresher to Understanding . . . Acute and Chronic Respiratory Failure (Part 2)

Gloryanne Bryant, RHIA, CDIP, CCS, CCDS Compliance Leave a Comment

We continue with our discussion of “Respiratory Failure, please refer to Part I for information on the clinical aspects and on the ICD-10-CM coding classification of this diagnosis. Often we think of “respiratory failure” as a condition occurring in the inpatient setting, but it can also occur in the Emergency Room, but usually results in an admission. Medicare-Severity...

CMS and OIG Focus on Improper ICD-10-PCS Ventilation Coding

Gloryanne Bryant, RHIA, CDIP, CCS, CCDS Compliance 1 Comment

The Medicare-Severity Diagnostic Related Groups (MS-DRGs) with ICD-10-PCS mechanical ventilation code(s) have been cited by the Centers for Medicare and Medicaid Services (CMS) and the Office of Inspector (OIG) as problematic and a compliance risk. In a June 2021 CMS Medicare Learning Network (MLN) publication #17107 ”revised”, this included mechanical ventilation...

DOJ Annual Healthcare Fraud and Abuse Control Program Annual Report for FY2020 is Released

Gloryanne Bryant, RHIA, CDIP, CCS, CCDS Compliance Leave a Comment

For twenty-four (24) years now the Department of Justice (DOJ) has been in combat against healthcare fraud and abuse through the “Healthcare Fraud and Abuse Control Program” or HCFAC. We can be thankful for HIPAA (Health Insurance Portability Accountable Act) which put in place the national program. The HCFAC program is under the joint direction of the United States...

7 Signs Your Cancer Registry is Performing Well

Suzanne Neve, RHIA, CTR - Director, Cancer Registry Cancer Registry Leave a Comment

The cancer registry network is a powerful resource in oncology healthcare. The connections and relationships with members of the cancer care team are a valuable source of knowledge and provide many opportunities for resource-sharing and growth. The cancer registry should never be maintained solely for the purpose of meeting minimum reporting requirements. Instead, it...

CMS MACs Begin to Audit Again – DOS After 3/2020

Gloryanne Bryant, RHIA, CDIP, CCS, CCDS Compliance Leave a Comment

According to a recent Centers for Medicare and Medicaid Services (CMS) MLN Connections, Medicare Administrative Contractors (MAC) are beginning to conduct post-payment medical reviews for dates of services (DOS) after March 2020. After a pause in audits due to the COVID-19 pandemic, the MACs already did resume audits on post-Payment items or services before March 2020....

OIG: Medicaid Fraud Control Units 2020 Report

Gloryanne Bryant, RHIA, CDIP, CCS, CCDS Compliance Leave a Comment

Medicaid provides coverage and healthcare services with federal and state funding to 72.2 million people in the Unites States. This coverage is for those with limited income and resources i.e., low-income adults, children, pregnant women, elderly adults, and people with disabilities. Medicaid is administered by the “States” under federal requirements and guidelines. Like...

Medicare and Medicaid Recovery Audit Contractors... Continue Their Efforts

Gloryanne Bryant, RHIA, CDIP, CCS, CCDS Auditing Leave a Comment

Protecting the Medicare Trust Fund is an important priority for the Department of Health and Human Services (HHS) Centers for Medicare and Medicaid Services (CMS), the Office of Inspector General and thus we have Recovery Audit Contractors or “RACs”. Through the Medicare Modernization Act of 2003, CMS established the Recovery Audit Contractor program with a focus on...

OIG Specific Medicare Audit Report: Compliance with Inpatient and Outpatient Claims

Gloryanne Bryant, RHIA, CDIP, CCS, CCDS Compliance Leave a Comment

Another Office of Inspector General (OIG) Medicare audit report was released in early May 2021 titled, “Medicare Hospital Provider Compliance Audit: Virtua Our Lady of Lourdes Hospital”, this hospital is located in New Jersey. These ongoing OIG Medicare audit reports are important to review, internally discuss and determine if any additional or specific steps should be...

Infusions, Injections and Hydration

Susan Morton, CPC, CPC-I, CEMC, CGSC, COBGC, COPC, Approved Instructor HIM Leave a Comment

Certain elements of documentation must be present to code infusions, injections, and hydrations properly. An order by the physician, which must be dated, timed, and signed with the name of the drug, the dose and the route of administration should be on file for services performed. Infusion services require direct supervision by medical staff. The coder should next ask a...

OIG Reports on Humana MA HCC Dx

Gloryanne Bryant, RHIA, CDIP, CCS, CCDS Compliance Leave a Comment

The Office of Inspector General (OIG) released a recent report (4/2021) titled “Medicare Advantage Compliance Audit of Diagnosis Codes that Humana, Inc., (Contract H1036) Submitted to CMS”, which should wave a flag for compliance and Health Information Management coding professionals. Under Medicare Advantage (MA), the risk adjustment (RA) determination is made using...

Project Management for Risk Adjustment Coding Review

Dott Campo, RHIA, CRC, COC HCC/Risk Adjustment Leave a Comment

Risk Adjustment coding reviews can take many different shapes and forms. When starting a new project/review, there are many things to consider. A “Project Management” approach is key to success. Project Management includes four phases: Project Planning Phase; Project Build-up Phase; Project Implementation Phase; and Project Completion & Closure Phase. In this article we...

Get Your PEPPER . . . MS-DRG Data and More

Gloryanne Bryant, RHIA, CDIP, CCS, CCDS Revenue Cycle Leave a Comment

The Program for Evaluating Payment Patterns Electronic Report (PEPPER) was developed in 2002 by TMF Health Quality Institute in support of CMS’ Hospital Payment Monitoring Program. State Quality Improvement Organizations (QIOs) began distributing PEPPER to the short-term acute care hospitals in their state in 2003. PEPPER provides provider-specific Medicare data...

Compliance with Post-Acute Care Transfers (Discharge Status)

Gloryanne Bryant, RHIA, CDIP, CCS, CCDS Compliance Leave a Comment

The Centers for Medicare and Medicaid (CMS) MLN Matters recently published (2/25/2021) a provider compliance reminder regarding “Post-Acute Care Transfers”, often referred to as the PACT rule, and the correct coding and billing for these inpatient hospital claims. CMS quoted information from the recent Office of Inspector General (OIG) report which identified incorrect...

OIG Releases Report: IP Hospital Severity Levels Under Scrutiny (February 2021)

Gloryanne Bryant, RHIA, CDIP, CCS, CCDS Compliance Leave a Comment

The Office of Inspector General (OIG) released a report on the concerns surrounding inpatient hospital stays with high levels of severity between 2014-2019. There was a reported 20 % increase found in the DRG (Diagnostic Related Group) severity levels, which are the most expensive and costly. The report was titled: “Trend Toward More Expensive Inpatient Hospital Stays in...

The OIG Workplan and Building Your Own Coding Compliance Program

Gloryanne Bryant, RHIA, CDIP, CCS, CCDS OIG Leave a Comment

Each year the Office of Inspector General (OIG) publishes their annual work plan for healthcare, which is a highly anticipated publication. The OIG Work Plan sets forth various projects including OIG audits and evaluations that are underway or planned to be addressed during the fiscal year. In addition, the OIG updates their workplan on a monthly basis, so their areas of...

The Hospital-Acquired Conditions Reduction Program – Hospitals Impacted

Gloryanne Bryant, RHIA, CDIP, CCS, CCDS Compliance Leave a Comment

We have now been familiar with the Hospital-Acquired Condition Reduction Program (HACRP) for seven years (how time flies). Under the Affordable Care Act (ACA), the Centers for Medicare and Medicaid Services (CMS) reduces payments to hospitals based on their performance on measures of hospital-acquired conditions. The program encourages hospitals to implement best...

HCC Coding Audits . . . A Must!

Gloryanne Bryant, RHIA, CDIP, CCS, CCDS HCC/Risk Adjustment Leave a Comment

The words “Hierarchical Condition Categories” or HCCs can conquer up some anxiety for HIM Coding, and Clinical Documentation Integrity (CDI) professionals, even for Revenue Cycle and Compliance leadership. Add to that, the word “audit” and we now have uneasiness and even fear. Well, it does not need to be this way. Understanding the HCC basics and the coding audit ins and...

Social Determinants of Health (SODH) are Underreported per Recent Study

Gloryanne Bryant, RHIA, CDIP, CCS, CCDS Compliance Leave a Comment

A recent medical research publication titled: International Classification of Diseases, Tenth Revision, Clinical Modification social determinants of health codes are poorly used in electronic health records; describes the underreporting of the Social Determinants of Health (SDOH) via ICD-10-CM (International Classification of Disease, Tenth Revision, Clinical...

USING CERT (Comprehensive Error Rate Testing) to Improve Coding Quality

Gloryanne Bryant, RHIA, CDIP, CCS, CCDS Compliance Leave a Comment

The Centers for Medicare and Medicaid Services (CMS) has several programs they sponsor and/or support that target “improper payments”. One of those programs is Comprehensive Error Rate Testing or CERT. The purpose of CERT is to measure the Medicare Fee-For-Service (FFS) improper payments, which include Medicare Part A, Part B and Durable Medical Equipment and Suppliers....

The OIG Workplan and Building Your Coding Compliance Plan/Program

Gloryanne Bryant, RHIA, CDIP, CCS, CCDS Compliance Leave a Comment

Each year the Office of Inspector General (OIG) publishes their healthcare workplan and this is an “opportunity” for us in review and learn from their areas of focus. The workplan can be viewed at: Work Plan | Office of Inspector General | U.S. Department of Health and Human Services (hhs.gov) In addition, the OIG updates their workplan on a monthly basis, so focused...

2021 OIG Work Plan: An Overview and Auditing Priorities

Aurae Beidler, MHA, RHIA, CHC, CHPS Auditing Leave a Comment

This article will provide some key points on how you can incorporate the current Office of Inspector General (OIG) items and future items into your organization’s auditing and monitoring functions. Paying attention to what the OIG for Health and Human Services (HHS) plans to audit and monitor during the upcoming year should be a one of the key drivers in developing your...

Top Coding Issues Found During Audits

Marquita Rawlins RHIA, CCS Auditing Leave a Comment

A compliance task that each facility should perform to support the Health Information Management (HIM) department is performing coding audits. Coding audits are performed to access the accuracy of the diagnosis and procedures codes assigned to each patient’s chart. The timing of these audits can be performed monthly, quarterly, bi-annually, annually, or as often as the...

Outpatient Clinical Documentation Improvement . . . Achieving a Successful Program (Part I)

Gloryanne Bryant, RHIA, CDIP, CCS, CCDS Compliance Leave a Comment

With more and more patient services moving to the outpatient setting we need to be ready and prepared for the implementation of an outpatient (OP) Clinical Documentation Improvement/Integrity (CDI) program. CDI has a strong footprint in the inpatient hospital setting where there are longer periods of time of patient interaction, longer time to review the health record and...

Compliance in the Physician Office setting

Margaret (Peggy) Scherrer, RN, BSN, MBA, CHC, CHPC Profee Coding Leave a Comment

Small physician practices may find themselves challenged when managing a practice that has to address billing issues with payors, the adoption of complex workflows, and staying aware of all rules and regulations (Adler, 2015). Developing a Compliance Program may feel like a large task, but a Compliance Program can be an important tool for physician practices of all sizes...

ICD-10-PCS Coding For Venous Access Lines and Catheters

C. Matheson, RHIA, CCS IR/Catheters Leave a Comment

One challenging coding area with the ICD-10 transition is the coding of venous and arterial lines and catheters. This article aims to provide greater clarity with regard to procedure coding tips for coding of venous catheters. Types of Lines: Central Lines- (CVC)- Central Venous Catheter or central lines are inserted into large veins, typically the jugular, subclavian,...

Why it’s important to seize new opportunities in HIM

C. Matheson, RHIA, CCS Compliance Leave a Comment

Each of us has the power to change our lives as well as the lives of those around us. This is the theme of a recent article I read by Jeff Haden titled 19 Things Remarkable People Think Every Day. The article, which was published on Inc.com, includes a lot of salient points that are relevant to HIM professionals. My favorite point that Haden mentions in the article is,...

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