Post Author: Betsy Nicoletti, MS

5 urban legends about risk-adjusted diagnosis coding

Policy
October 1, 2018

When I talk to medical practices about hierarchical condition category (HCC) and risk-adjusted diagnosis coding, I receive a lot of questions that point to the existence of persistent urban legends!

Let’s separate fact from fiction.

Urban legend #1: CPT fee-for-service coding will be a distant memory when we switch from volume to value

Not anytime soon. Medicare’s newer payment models starting with Medicare Shared Savings Programs (MSSP) and Accountable Care Organizations (ACOs) are …

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How to do risk-adjusted diagnosis coding the right way

Policy
April 3, 2018

Medical practices with risk-adjusted contracts must sharpen their diagnosis coding. Practices that are part of accountable care organizations (ACOs) or that have risk-adjusted contracts with commercial payers have an economic incentive to accurately report the disease burden of their patients. In fee-for-service medicine, physicians are paid based on the fee schedule associated with a CPT code, and any modifier attached to that code. The diagnosis code establishes the medical necessity …

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How to perform services that increase primary care revenue

Policy
April 24, 2016

CMS states it wants to increase pay to primary care physicians.  And while we might quarrel with their strategies or with the speed of achieving the goal, few would quarrel with the goal itself.  In recent years, CMS has developed HCPCS codes and adopted CPT codes, some limited to primary care and some not specialty restricted but all likely to be reported by primary care practices. Meanwhile, although payment systems …

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The ICD-10 emperor has no clothes

Policy
April 21, 2014

The howling about the delay of ICD-10 was loud and fierce. It seems the quality of health care in the United States depends on our ability to use 68,000 diagnosis codes. The rest of the world has switched to ICD-10, and we alone insist on using an outdated coding system. Here’s a secret. The World Health Organization’s version of ICD-10 has about 16,000 codes, equivalent to ICD-9-CM. The rest of …

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Sleight of hand: The SGR bill’s important policy changes

Policy
April 8, 2014

What would you think if I told you that Medicare will require laboratories to disclose to CMS payment rates from private insurers? Or that they will identify physicians who order a high volume of CT tests and require them to pre-authorize those tests in 2020?  How about that CMS will begin its own analysis of the time and cost of providing services in order to determine RVUs, a job currently …

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Cloning: Great for Dolly the sheep, not so good for EHRs

Physician
February 2, 2014

Certain medical stories are irresistible to the popular press: ICD-10 external cause codes that are ridiculous (W61.43XD, pecked by a turkey, subsequent encounter) or medical practices using their electronic health records in a way that increases their revenue.

A recent headline was eye-catching, as headlines are meant to be, “Report finds more flaws in digitizing patient files.”  The New York Times reported that the Office of Inspector …

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Visiting my family member: A tale of two facilities

Conditions
May 29, 2013

Recently, a member of my family was involuntarily admitted to the psychiatric unit of a major teaching hospital in New York City and remained there for two and a half weeks.  During that time, the unit kept him safe and provided medication for mood stabilization and thinking.  After seeing my family member, my first priority was to talk with the attending physician and care team.

Evidently, the attending doesn’t like to …

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The EMR template: I want to believe

Tech
February 15, 2013

The X-Files fans will remember the poster that Agent Mulder had on his bulletin board with a picture of a flying saucer and the words, “I want to believe.”  That’s how I feel reading EMR notes sometimes.  I want to believe, but I doubt.

I know how this happens.  The EMR vendor, the practice implementation team and the doctor have a meeting to develop the “normal” template for a hospital admission …

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