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...

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