Tag: HIM

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.

 

 

 

 

Inspiration, innovation key themes at the 2016 annual AHIMA convention

On By Lisa A. EramoIn AHIMA, Apprenticeship, EMR and EHR, information governance, Patient advocacy, Patient communication, Patient engagement, Patient portals

20161018_211108“Inspire big thinking to launch our future” was the theme of the 88th annual AHIMA convention held October 16-19 in Baltimore, MD. And wow, did it inspire. I imagine that most HIM professionals walked away from the event feeling incredibly energized about the role they’ll play in this new era of big data and patient engagement.

In my opinion, the most powerful presentation was that of Dr. Bennet Omalu, the first doctor to diagnose chronic brain damage in NFL athletes. He also inspired the movie “Concussion” starring Will Smith. Dr. Omalu received frequent applause as he shared his personal journey–one in which he overcame insurmountable odds in war-torn Nigeria to not only attend medical school at the age of 15 but also to ultimately make a discovery that revolutionized neuroscience and sports medicine/safety. I had goosebumps just listening to him. As I watched and listened in awe, I was reminded that with hard work, passion, and a little luck, anything is possible. This is an important lesson for everyone, including HIM professionals working tirelessly to improve compliance and data integrity within their organizations.

Retired American astronaut and U.S. Navy Captain Mark Kelly continued the theme of inspiration as he spoke about his career flying 39 combat missions over Iraq and Kuwait during the first Gulf War. He also described in vivid detail what it felt like to blast off in a rocket when he served as the commander of space shuttle “Endeavor” on its final flight. His talk then turned personal as he spoke about the day his wife, former congresswoman Gabrielle Giffords, was severely wounded after being shot in the head at near point-blank range. Giffords joined him on stage at the conclusion of the talk and received a standing ovation.

Many of the sessions throughout the duration of the conference focused on thinking ‘outside the box’ of traditional HIM roles.

For example, ONC Chief Medical Information Officer Andrew Gettinger, MD, encouraged HIM professionals to help their organizations integrate patient-generated data into the EHR–especially as medical care continues to move outside of a hospital’s four walls. He said HIM is also well-suited to help organizations “harvest digital dividends” from EHRs–that is, use the technology (and big data) to solve operational challenges and problems.

During a panel discussion about the future of healthcare, AHIMA CEO Lynne Thomas Gordon, MBA, RHIA, CAE, FACHE, FAHIMA, encouraged attendees to imagine the HIM jobs of the future–and take steps now to prepare. Is higher education warranted? A specialty credential? She said to embrace industry changes–not simply react to them.

Panelists identified these healthcare trends that will continue to shape HIM in the years to come:

  • Push for transparency around healthcare costs
  • Integration of patient-generated data for a 360 degree holistic view of one’s health
  • Increased interoperability to meet patients’ demands and coordinate care more effectively
  • Best practices to educate patients about their health information
  • Best-of-breed strategic partnerships
  • Availability of clinical information at the point of care

Others spoke about new and emerging roles in HIM, including data scientist and healthcare data quality manager. Michelle Basco, RHIA, of Children’s Medical Center spoke about her own journey to become a personal health record coordinator. HIM professionals are uniquely qualified to engage and educate patients. “They need to learn, and they need us by the side,” she said.

Various speakers also talked about the importance of developing an HIM workforce to meet the job demands of the future. Apprenticeship programs are critical, said Bill Rudman, PhD, RHIA, executive director of the AHIMA Foundation. “We’re evolving so quickly with technology. On-the-job experience is so necessary,” he added.

Marci Wilhelm, of MedPartners, said apprentices with whom she’s worked achieved a 95% coding accuracy rate in only 90 days. Debra Boppre, MSM, RHIA, CCS, CCS-P, FAHIMA, of Trinity Health recounted a similar experience with apprentices who helped address coding backlogs at their facility.

Boppre encouraged other HIM professionals consider serving as mentors. “You owe it to these HIM professionals,” she said. “Invest the time, and you will see the return on investment over and over again.”

Information governance was also a hot topic. During a panel discussion, panelist Sally Beahan, RHIA, MHA, director of HIM at UW Medicine said to start small by identifying the ways in which HIM is already striving to enhance data integrity. Others shared their journeys toward information governance and encouraged HIM professionals to champion the effort within their organizations.

Did you attend the AHIMA convention? If so, what did you take away from it? What inspired you the most?

 

 

 

OCR audits, risk-adjustment coding discussed at RIHIMA

On By Lisa A. EramoIn AHIMA, Clinical documentation improvement, HIM management, HIPAA, ICD-10, Physician practices, Risk adjustment

OCR audits, FY2017 coding updates, and risk-adjustment coding were among the many topics covered during the most recent RIHIMA meeting on October 7 in Warwick, RI. These meetings provide an affordable opportunity to stay abreast of industry changes and network with peers. Another perk: Free coffee and donuts. 🙂

HIPAA branding, OCR audits

Norma Chitvanni, RHIT, CHPS, privacy officer and director of privacy and confidentiality at Beth Israel Deaconess Medical Center, spoke about her efforts to lead an awareness campaign to help employees understand the importance of HIPAA. She reminded attendees that employees are an organization’s biggest vulnerability, and she urged others to consider creative ways to brand an internal privacy and security program.

For example, Chitvanni worked with the hospital’s communications department to create an educational video in which members of a patient/family advisory group spoke about the importance of keeping information private (KIP). She and her team also:

  • Created a padlock logo for the program
  • Identified internal KIP coaches to help educate staff
  • Put KIP labels on salad contains and food wrappers in the cafeteria
  • Created a staff portal with resources about how to secure laptops
  • Handed out promotional materials about KIP (e.g., pens, phone wipes)

Chitvanni also urged attendees to prepare for upcoming OCR audits. She provided these tips:

  • Provide HIPAA education to all staff. Ensure that you have some way to monitor and assess staff member’s understanding along the way (e.g., test-your-knowledge questions or a final exam).
  • Use the OCR audit tool as a foundation for compliance. Do your policies and educational materials support each of the 109 elements included in the tool?
  • Compile information for your business associates in advance. HHS provides a complete list of necessary information.
  • Use technology to monitor and mitigate risk. For example, some applications can identify and flag unencrypted emails that include medical record numbers, patient information, or medical codes.

FY 2017 coding updates

Mary Beth York, CCS, CCS-P, CIC, senior associate at Barry Libman Inc., provided a helpful overview of important coding changes that took effect October 1. She encouraged attendees to review the updated ICD-10-CM guidelines and also pointed out several surprises, including:

  • 1.A.19: The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists.  The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.

“I think we have to see how this is going to play out,” she said, adding that it remains unclear as to how insurance companies and Recovery Auditors will handle this guideline when a condition doesn’t meet clinical criteria.

  • 1.C.12.a(6): If a patient is admitted with a pressure ulcer at one stage and it progresses to a higher stage, two separate codes should be assigned: one code for the site and stage of the ulcer on admission and a second code for the same ulcer site and the highest stage reported during the stay.

She urged HIM professionals to work with members of the quality team to raise awareness of this new guideline.

Risk-adjustment coding

Gerry Petratos, MD, MS, CEO of Hiteks Solutions, Inc. said HCC coding is becoming the “gold standard” in healthcare because of its ability to capture clinical complexity and predict costs.

Many organizations are already using HCC modeling in the outpatient arena, necessitating the need for documentation improvement, he said. “Ambulatory CDI will be the biggest growth area in which there are the fewest people to do the work,” he added.

Accountable Care Organizations can also use HCC data to segment populations and target preventive care.

Information governance, cybersecurity discussed at RIHIMA

On By Lisa A. EramoIn AHIMA, HIM management, ICD-10, medical coding, Uncategorized

Last week, I attended the annual meeting of the Rhode Island chapter of AHIMA. The event, held in Warwick, drew 70+ people as well as several vendors. It was a day filled with a wide variety of presentations, a delicious breakfast and lunch, and many opportunities for networking. The best part was that I only needed to travel 10 minutes from my home!

The day began with an overview of AHIMA’s strategic goals and initiatives. Tim J. Keough, MPA, RHIA, FAHIMA, of the AHIMA board of directors, spoke about the importance of data in healthcare — and why HIM is well-suited for the role of data analyst. He urged HIM professionals to lead the charge in the current data revolution — that is, to look for ways in which their organizations can turn data into health intelligence that can mitigate risk and improve outcomes.

Keough also talked about information governance through data transparency, data protection, and data integrity. As the industry continues to tap into big data for precision medicine, he said HIM should be at the forefront managing, using, and improving this data.

Cybersecurity expert, John H. Rogers, CISSP, gave a great presentation on the growing risk that hackers pose to health information privacy and security. “Healthcare information is more valuable than any other information on the market,” he said.

HIM professionals must make cybersecurity a core mission of the organization. This requires ongoing staff education, virus protection/patch updates, and social engineering testing. “It’s not just about the technology. Situational awareness is your power,” he said.

On the coding side, Barry Libman, MS, RHIA, CDIP, CCS, CCS-P, CIC, provided a helpful overview of important ICD-10-CM/PCS changes that will go into effect for FY 2017 on October 1, 2016. In particular, there are 3,651 new PCS codes (many of which are cardio-related) and 1,943 new CM codes, including a new code for the Zika virus (A92.5).

Attorney Jennifer Cox, JD gave an update on the ever-evolving Meaningful Use (MU) program, urging attendees to perform a security risk analysis if they haven’t done so already. Cox said this analysis is the number one reason providers fail to meet MU criteria.

David L. Rousseau, director of cancer information systems at the Hospital Association of Rhode Island, talked about the importance of cancer registries and why this is a good fit for HIM.

Perhaps the most riveting presentation was given by Michael G. Cooley, executive director of Nalari Health. Cooley shared his personal journey to overcome many challenges and hardships to ultimately find success both personally and professionally. His story, which also serves as the basis for his memoir “Rock Bottom: From the Streets To Success,” was extremely inspirational and unexpected. It also serves as a reminder of the strength of the human spirit — a good lesson for all of us.