Category: Audits

RIHIMA kicks off 2020 with lively discussions of HIM ‘hot topics’

On By Lisa A. EramoIn AHIMA, Audits, Data analytics, EMR and EHR, HIM management, Uncategorized

By Lisa A. Eramo, MA

Presenters touched on a variety of hot topics at the most recent RIHIMA meeting: Data mining, patient matching, and evaluation and management (E/M) coding. Approximately 40 people attended the event held in Warwick, Rhode Island on January 17, 2020.

Data management skills a ‘must’ for HIM

Lolita M. Jones, MSHS, RHIA, CCS, healthcare data mining consultant at iquerydata.com encouraged attendees to gain data management skills so they can continue to add value in an increasingly artificial intelligence-driven healthcare environment. In the not-so-distant future, Jones said HIM professionals will be charged with auditing large data sets, identifying patterns, and recommending physician education. They’ll no longer manually assign codes and perform audits with limited sample sizes. Those with data management skills will be able to weather the storms of change and prevail, she added.

HIM professionals with data management skills, for example, can convert official coding guidelines into database queries to identify potential coding problems proactively—before payers and Recovery Audit Contractors do, said Jones. Why is it critical for HIM to write these queries? They possess the subject matter expertise to identify all of the diagnosis and procedure codes that apply to each query, said Jones. They can also help decision makers draw accurate conclusions and glean actionable insights from the data, she added.

How does one obtain data management knowledge without obtaining a master’s degree? Grassroots education at local and regional AHIMA meetings, said Jones. HIM professionals can also attend data management-related tracks at the annual AHIMA conference or take a variety of courses online.

Patient matching is more critical today than ever before

Letha E. Steward, MA, RHIA, director of customer relations at Quadramed gave an informative presentation on patient matching in the context of mergers, acquisitions, and health information exchange. A duplicate record doesn’t just affect one hospital—it affects many providers in real-time, said Steward. “As soon as you create a duplicate, the patient’s medical record is fragmented,” she added.

When hospitals and physician practice merge onto a single EHR platform, they must have a process in place to identify and resolve duplicates, said Steward. She encouraged organizations to use referential data because it’s updated as life events occur, and it can enhance automated matching. She also encouraged attendees to think about using cell phone numbers as unique identifiers because they don’t change often.

E/M documentation problems persist

Oby Egbunike, CPC, COC, CPC-I, CCS-P, director of professional coding at Lahey Health Care System, Burlington, MA spoke about the importance of the chief complaint—a detail that’s often omitted from E/M documentation. “This is the driver for whatever else the physician is going to do,” she said.

When documenting the exam, Egbunike said physicians should consider this question: Is the exam for the purpose of diagnosing and treating the patient or for coding? For example, a full organ system exam isn’t necessary for an ear infection, she added.

 

Targeted probe and educate audits coming to a provider near you

On By Lisa A. EramoIn AAPC, Audits, Data analytics, medical coding, Revenue integrity, Uncategorized

“When Medicare claims are submitted correctly, everyone benefits.” That’s what CMS says verbatim on its website about the newly-launched targeted probe and educate audits that are designed to reduce denials and appeals through one-on-one education.

During an AAPC chapter meeting on February 13 in Providence, Rhode Island, Lori Langevin, education consultant at National Government Services (NGS), walked attendees through the process. NGS is the Medicare Administrative Contractor (MAC) for jurisdictions 6 and K.

“It’s all about lessening the burden on providers,” she said.

Here’s how it works: MACs use data analysis to identify providers/suppliers with high error rates or unusual billing practices. Common claim errors include an omitted physician signature, lack of medical necessity, or incomplete certification. The initial probe includes a review of 20-40 claims. Practices have 45 days to respond to the request for documentation, though Langevin says 30 days is best practice. A lack of response equates to an error, she added.

After the review, providers receive a letter detailing the results. They’ll also have an option to receive one-on-one education via teleconference or webinar. During these sessions, providers will have the opportunity to ask questions and learn about the specific CMS policies that apply to each claim.

Langevin was unable to provide a concrete definition of what constitutes a high error rate, though she did say that she anticipates E/M codes and prolonged services will be targeted due to the high error typically associated with these services. Other targets will likely include topics that have surfaced during CERT and RAC audits, she added.

The overarching goal of these audits is to reduce the administrative burden on providers and MACs, said Langevin. Not only is it costly for providers to appeal denials, but it’s also costly for MACs to review the appeals and potentially overturn the denials. The probe and educate audits will hopefully drive process improvement, she said.

To learn more about targeted probe and educate audits, view this FAQ.

 

 

What HIM can expect in 2018 and beyond

On By Lisa A. EramoIn AHIMA, Audits, EMR and EHR, HIM management, HIPAA, ICD-10, medical coding, Revenue integrity, Uncategorized

The list of topics covered at the recent RIHIMA meeting truly ran the gamut: Medicare payment reform, Office for Civil Rights (OCR) enforcements, the 21st Century Cures Act, FY 2018 ICD-10-CM coding changes, and more. The meeting, which drew approximately 50 people, was held in Warwick on October 20. The theme? Looking ahead to 2018 and beyond.

Health IT updates

Jennifer L. Cox of Cox and Osowiecki, LLC kicked off the morning with an update on health IT, the future of which she said is unclear in light of unprecedented budget cuts to infrastructure. What can HIM professionals expect during the next year and beyond? Cox told attendees to keep their eyes open for the 21st Century Cures Act, which she said is one of the most significant regulations that will affect the HIM profession. The legislation, which was enacted in December 2016, includes a section on health IT interoperability that requires data sharing and prohibits data blocking. A first set of draft rules is due by March 2018.

“This is going to be bigger than HIPAA and Meaningful Use–it will be the biggest thing in our careers that will shift how we use health information,” said Cox.

Cox also touched on the federal government’s efforts to remove Social Security Numbers (SSN) from Medicare cards by 2019. Although this may reduce identity theft, she said it creates an inability for HIM professionals to verify patient identity using this unique identifier. HIM may eventually need to create consistent verification standards in lieu of having access to the SSN, she added. They may also need to retrospectively sanitize records to remove the SSN. Cox encouraged attendees to make a list of all the ways in which they currently rely on the SSN so they can work collaboratively with the legal/compliance department to develop a strategy for how they’ll handle these scenarios once the SSN is no longer available.

Cox also warned of increasing OCR activity, stating that high-dollar settlements have increased over the last year and a half. She encouraged attendees to monitor the OCR’s running list of resolution agreements because she said it’s often a roadmap for potential vulnerabilities. “Learn from your colleagues’ misfortune,” she said. “This is what [the OCR] cares about, and what they care about, we should care about.”

Risk assessments should be a top priority, she said, adding that many independent physician practices are failing Meaningful Use audits because they didn’t conduct an assessment during the year of attestation. Also remember to fix any problems discovered during the assessment, she added.

Staff education is equally as important, said Cox. For example, employees should notify their IT department when a computer is particularly slow, as this could signal an impending cyber attack. “These are very sophisticated attacks,” she added. “It takes minutes–not hours–to infect the entire system.”

FY 2018 coding updates

Mary Beth York, senior associate at Barry Libman, Inc. discussed several important ICD-10-CM coding changes that took effect October 1, 2017. She encouraged attendees to review the FY 2018 ICD-10-CM coding guidelines as well as the 2018 Addendum. When coders rely entirely on the encoder–and don’t review all of the additions, deletions, and revisions–they aren’t as aware of these oftentimes subtle changes, she said.

Third-party release of information

Amy Derlink and Laureen Rimmer, both of MRA Health Information Services, gave an informative presentation on ROI best practices.

Derlink encouraged attendees to create a third-party audit record review policy that addresses these and other questions: Will you ask to see the business associate agreement between the health plan and third-party auditor before releasing information? Will you allow the third-party auditor onsite? What access will you provide to the third-party auditor? Will it include remote access? How will you comply with HIPAA’s minimum necessary requirements? “We need to protect privacy,” she said. “That’s our number one obligation.”

Don’t let auditors bypass HIPAA to access protected health information, said Derlink. Quality audits (e.g., HEDIS) are not included in uses and disclosures for treatment, payment, and operations, she added.

Rimmer said HIM must leverage technology and tap into data analytics to identify compliance risk and prepare for audits. “Understand your data, and know what’s going on so you can be proactive with your own internal audits,” she said. “As you see themes, you need to drill down.”

Embracing leadership qualities

Karen A. Benz of Benz Strategic Group gave an interesting presentation on leading vs. managing. “Management is doing. Leadership is being,” she said. “As a leader, you set the culture and tone of your department.” She described managers as productivity-oriented implementers, and she identified leaders as open-minded agents of transformational change. Managers ask people to follow, but when you’re a leader, people will follow naturally, she explained.

She challenged attendees to embrace leadership qualities and not succumb to negativity. Doing so improves employee retention and satisfaction. And when employees are happy, they’re often willing to go the extra mile for patients as well.