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MEDICAL/LEGAL IMPACT OF 2021 E&M CHANGES Without detailed documentation, providers may face an uphill battle in defending themselves from quality audits and even malpractice issues. Up until 2021, at least for the prior two decades, coders and clinicians relied upon the established Evaluation and Management (E&M) guidelines to determine which E&M code was appropriate for eachspecific encounter.
RAC UNIVERSITY
The Social Determinants of Health: Case Management's Next Frontier The Social Determinants of Health: Case Management’s Next Frontier is designed to help case managers develop strategies to manage and intervene with the populations predisposed to the risks associatedwith SDoHs.
BATTLING THE BACKLOG AT THE ALJ Battling the Backlog at the ALJ. Frank D. Cohen, MPA, MBB. April 21, 2021. A federal judge ordered the government to reduce the massive backlog of healthcare hearings – and if recent events are any indication, it may finally be happening. I imagine that pretty much everyone who touches on coding and billing compliance in our industryis
CMS RELEASES FY 2022 PROPOSED RULE FOR INPATIENT This brings the Proposed FY 2022 Standard Payment Conversion Factor to $17,273 as compared to $16,856 for FY 2021. The proposed rule also includes an adjustment to the outlier threshold to maintain outlier payments at 3.0 percent in FY 2022. The adjustment would result in a 0.3 percentage point decrease to overall outlier payments. MAKING SENSE OF SHARED VISITS CMS has deleted official guidance on the topic but promised that new guidance is still to come. It was pure coincidence that I was going to write an article on shared visits when Ronald Hirsch, MD called my attention to the fact that the Centers for Medicare & Medicaid Services (CMS) pulled the shared visit language from the Manual on May3.
UTILIZATION REVIEW: IMPLEMENTING A “TIGHT” PROCESS TO The best place to start would be utilization review (UR), with the implementation of a “tight” process. This will require precise, accurate, compliant knowledge of the UR process, followed by a gap analysis. This analysis is like building a puzzle. The picture on the box reveals the intended result. The individual pieces are the partsof
FEDERAL AUDIT FINDINGS FOR MEDICAL DEVICE CREDITS Federal Audit Findings for Medical Device Credits. There are five critical mistakes made by providers. By now, healthcare providers that perform “device-dependent” or “device-intensive” procedures know the follow-up steps necessary in reporting vendor or manufacturer warranty credits for replacement devices or free-of-charge initially PRESUMPTIVE COMPLIANCE FOR IRFS: ARE YOU FACING A DESK A formal letter from your Medicare Administrative Contractor (MAC) is rarely a welcome surprise. For inpatient rehabilitation facilities (IRFs), a letter informing the provider that they have not met IRF classification requirements related to the 60 percent rule based on “presumptive methodology” and thus will be subject to “medical review methodology” is pretty much never welcome. BEWARE: IS YOUR WRITTEN NOTIFICATION FOR CONDITION CODE 44 The topic of Condition Code 44 is not new. Detailed by the Centers for Medicare & Medicaid Services (CMS) in September 2004 via MLN Matters SE 0622, titled Clarification of Medicare Payment Policy When Inpatient Admission is Determined not to be Medically Necessary, Including the Use of Condition Code 44: Inpatient Admission Changed to Outpatient, many others have also described the MONITOR MONDAYS PODCASTS Quality Audits and Malpractice Suits: How 2021 E&M Guidelines Raise Medical/Legal Issues Monday, June 7, 2021 10-10:30 a.m. EST; 7-7:30a.m. PST
MEDICAL/LEGAL IMPACT OF 2021 E&M CHANGES Without detailed documentation, providers may face an uphill battle in defending themselves from quality audits and even malpractice issues. Up until 2021, at least for the prior two decades, coders and clinicians relied upon the established Evaluation and Management (E&M) guidelines to determine which E&M code was appropriate for eachspecific encounter.
RAC UNIVERSITY
The Social Determinants of Health: Case Management's Next Frontier The Social Determinants of Health: Case Management’s Next Frontier is designed to help case managers develop strategies to manage and intervene with the populations predisposed to the risks associatedwith SDoHs.
BATTLING THE BACKLOG AT THE ALJ Battling the Backlog at the ALJ. Frank D. Cohen, MPA, MBB. April 21, 2021. A federal judge ordered the government to reduce the massive backlog of healthcare hearings – and if recent events are any indication, it may finally be happening. I imagine that pretty much everyone who touches on coding and billing compliance in our industryis
CMS RELEASES FY 2022 PROPOSED RULE FOR INPATIENT This brings the Proposed FY 2022 Standard Payment Conversion Factor to $17,273 as compared to $16,856 for FY 2021. The proposed rule also includes an adjustment to the outlier threshold to maintain outlier payments at 3.0 percent in FY 2022. The adjustment would result in a 0.3 percentage point decrease to overall outlier payments. MAKING SENSE OF SHARED VISITS CMS has deleted official guidance on the topic but promised that new guidance is still to come. It was pure coincidence that I was going to write an article on shared visits when Ronald Hirsch, MD called my attention to the fact that the Centers for Medicare & Medicaid Services (CMS) pulled the shared visit language from the Manual on May3.
UTILIZATION REVIEW: IMPLEMENTING A “TIGHT” PROCESS TO The best place to start would be utilization review (UR), with the implementation of a “tight” process. This will require precise, accurate, compliant knowledge of the UR process, followed by a gap analysis. This analysis is like building a puzzle. The picture on the box reveals the intended result. The individual pieces are the partsof
FEDERAL AUDIT FINDINGS FOR MEDICAL DEVICE CREDITS Federal Audit Findings for Medical Device Credits. There are five critical mistakes made by providers. By now, healthcare providers that perform “device-dependent” or “device-intensive” procedures know the follow-up steps necessary in reporting vendor or manufacturer warranty credits for replacement devices or free-of-charge initially PRESUMPTIVE COMPLIANCE FOR IRFS: ARE YOU FACING A DESK A formal letter from your Medicare Administrative Contractor (MAC) is rarely a welcome surprise. For inpatient rehabilitation facilities (IRFs), a letter informing the provider that they have not met IRF classification requirements related to the 60 percent rule based on “presumptive methodology” and thus will be subject to “medical review methodology” is pretty much never welcome. BEWARE: IS YOUR WRITTEN NOTIFICATION FOR CONDITION CODE 44 The topic of Condition Code 44 is not new. Detailed by the Centers for Medicare & Medicaid Services (CMS) in September 2004 via MLN Matters SE 0622, titled Clarification of Medicare Payment Policy When Inpatient Admission is Determined not to be Medically Necessary, Including the Use of Condition Code 44: Inpatient Admission Changed to Outpatient, many others have also described the CMS BOOSTS PAYMENT FOR AT-HOME COVID VACCINATIONS The Biden Administration is turning its attention to the approximately 1.6 million seniors covered by Medicare who experience difficulty leaving their homes.RAC UNIVERSITY
RACmonitor Compliance Webcasts Subscription Attend unlimited webcasts through the RACmonitor Webcast Portal! We can't supply you with additional staff or provide travel expenses for off-site education, but we can provide expert training for you and your team members — at a reasonable cost — without the hassle of having to leave yourfacility.
PROFILE | RACMONITOR Subscribe to receive free RAC news and updates. Sign Up. Facebook COVID-19 WAIVERS: WHAT IT MEANS FOR IRFS COVID-19 Waivers: What It Means for IRFs. On March 13, the Centers for Medicare & Medicaid Services (CMS) issued blanket waivers that will impact Inpatient Rehabilitation Facilities (IRFs) as well as other Post-Acute Care (PAC) settings. The blanket waivers, which do not require any special request to be filed, will allow IRFs to admitpatients
ICD-10: THE AXIS OF CLASSIFICATION As a heightened awareness and acceptance of our inevitable transition to ICD-10 develops, many of you may be wondering how to approach the task of preparing your key stakeholders, coders, clinical documentation specialists and providers for the change. Certainly we all realize the need for additional education, but just where do you begin? The HIM profession typically approaches such a PROVIDER MEDICAID CONTRACT TERMINATION REVERSED IN COURT Judge’s order prevented closing of mental health clinic. Last week, I won a permanent injunction for a healthcare facility that, but for the injunction, would be closed, its 300 staff unemployed, and its 600 Medicare and Medicaid consumers without access to their mental health and substance abuse providers, their primary care physicians, and theSuboxone clinic.
MEDICAL AND SURGICAL ROOT OPERATIONS OF BODY PARTS EDITOR’S NOTE: This is the third in a series of articles addressing the definitions and differences between the Medical and Surgical Root Operations. Let's review what we covered so far. In the Medical and Surgical section (first character 0), there are 31 root operations using standardized terminology with no procedure names, diagnostic information or eponyms. You won't find an NEW FUNDING PROMPTS SDOH ACTION Actions speak louder than words. Several impactful events occurred in the arena of the social determinants of health (SDoH) over these pastfew weeks.
MEDICARE’S E&M CHANGES IMPERIL POTENTIAL LEGAL DEFENSES Medicare reimbursement is merely one of a plethora of reasons that medical record documentation is important. Last week Frank Cohen wrote an excellent article exploring how Medicare changing principles for coding evaluation and management (E&M) services was PREVENTING A BREACH, LESSONS LEARNED FROM OCR ENFORCEMENT DOWNLOAD MRO’S EBOOK Complete the form to download MRO’s eBook “Preventing a Breach: Tips and Best Practices to Safeguard your Healthcare Organization” which discusses the following: Healthcare Breach Trends Top Issues in Investigated Cases Closed with OCR Corrective Action Lessons Learned from 2017 Resolution Agreements and Civil Money Penalties Mitigating Breach Risk in Release of HOME | RACMONITORNEWSRAC UNIVERSITYMONITOR MONDAYSFREE ENEWS SIGN UPTHE SATURDAY POSTSTAY AT HOME KIDS By Ronald Hirsch, MD. Round-up of recent audit news, including UHC auditing decision on Sepsis. Lots of items to cover today. First, UnitedHealthcare (UHC) issued a notice that they are going to start performing prepayment audits on admissions for sepsis. That is certainly their right, but what a payer cannot do is MONITOR MONDAYS PODCASTS Quality Audits and Malpractice Suits: How 2021 E&M Guidelines Raise Medical/Legal Issues Monday, June 7, 2021 10-10:30 a.m. EST; 7-7:30a.m. PST
MEDICAL/LEGAL IMPACT OF 2021 E&M CHANGES Without detailed documentation, providers may face an uphill battle in defending themselves from quality audits and even malpractice issues. Up until 2021, at least for the prior two decades, coders and clinicians relied upon the established Evaluation and Management (E&M) guidelines to determine which E&M code was appropriate for eachspecific encounter.
RAC UNIVERSITY
The Social Determinants of Health: Case Management's Next Frontier The Social Determinants of Health: Case Management’s Next Frontier is designed to help case managers develop strategies to manage and intervene with the populations predisposed to the risks associatedwith SDoHs.
MAKING SENSE OF SHARED VISITS CMS has deleted official guidance on the topic but promised that new guidance is still to come. It was pure coincidence that I was going to write an article on shared visits when Ronald Hirsch, MD called my attention to the fact that the Centers for Medicare & Medicaid Services (CMS) pulled the shared visit language from the Manual on May3.
CMS RELEASES FY 2022 PROPOSED RULE FOR INPATIENT This brings the Proposed FY 2022 Standard Payment Conversion Factor to $17,273 as compared to $16,856 for FY 2021. The proposed rule also includes an adjustment to the outlier threshold to maintain outlier payments at 3.0 percent in FY 2022. The adjustment would result in a 0.3 percentage point decrease to overall outlier payments. CMS MODIFIES NCD FOR ICDS; SHARED DECISION-MAKING NOW Every patient receiving an ICD for primary prevention will be required to have an encounter for shared decision-making using an evidence-based decision tool. The Centers for Medicare & Medicaid Services (CMS) has released a final decision memo on changes to the national coverage determination (NCD) for implantable cardioverters defibrillators (ICDs). In the memo, released on Feb. 15, CMS CODING DENIALS: BACK TO BASICS Coding Denials: Back to Basics. Coding must be supported by documentation, but also by the Official Coding Guidelines. While preparing for a clinical validation presentation on acute kidney injury denials, I took inventory of the most common denials and recoveries obtained by payers. It came as no surprise that sepsis, severe malnutrition, and UTILIZATION REVIEW: IMPLEMENTING A “TIGHT” PROCESS TO The best place to start would be utilization review (UR), with the implementation of a “tight” process. This will require precise, accurate, compliant knowledge of the UR process, followed by a gap analysis. This analysis is like building a puzzle. The picture on the box reveals the intended result. The individual pieces are the partsof
PRESUMPTIVE COMPLIANCE FOR IRFS: ARE YOU FACING A DESK A formal letter from your Medicare Administrative Contractor (MAC) is rarely a welcome surprise. For inpatient rehabilitation facilities (IRFs), a letter informing the provider that they have not met IRF classification requirements related to the 60 percent rule based on “presumptive methodology” and thus will be subject to “medical review methodology” is pretty much never welcome. HOME | RACMONITORNEWSRAC UNIVERSITYMONITOR MONDAYSFREE ENEWS SIGN UPTHE SATURDAY POSTSTAY AT HOME KIDS By Ronald Hirsch, MD. Round-up of recent audit news, including UHC auditing decision on Sepsis. Lots of items to cover today. First, UnitedHealthcare (UHC) issued a notice that they are going to start performing prepayment audits on admissions for sepsis. That is certainly their right, but what a payer cannot do is MONITOR MONDAYS PODCASTS Quality Audits and Malpractice Suits: How 2021 E&M Guidelines Raise Medical/Legal Issues Monday, June 7, 2021 10-10:30 a.m. EST; 7-7:30a.m. PST
MEDICAL/LEGAL IMPACT OF 2021 E&M CHANGES Without detailed documentation, providers may face an uphill battle in defending themselves from quality audits and even malpractice issues. Up until 2021, at least for the prior two decades, coders and clinicians relied upon the established Evaluation and Management (E&M) guidelines to determine which E&M code was appropriate for eachspecific encounter.
RAC UNIVERSITY
The Social Determinants of Health: Case Management's Next Frontier The Social Determinants of Health: Case Management’s Next Frontier is designed to help case managers develop strategies to manage and intervene with the populations predisposed to the risks associatedwith SDoHs.
MAKING SENSE OF SHARED VISITS CMS has deleted official guidance on the topic but promised that new guidance is still to come. It was pure coincidence that I was going to write an article on shared visits when Ronald Hirsch, MD called my attention to the fact that the Centers for Medicare & Medicaid Services (CMS) pulled the shared visit language from the Manual on May3.
CMS RELEASES FY 2022 PROPOSED RULE FOR INPATIENT This brings the Proposed FY 2022 Standard Payment Conversion Factor to $17,273 as compared to $16,856 for FY 2021. The proposed rule also includes an adjustment to the outlier threshold to maintain outlier payments at 3.0 percent in FY 2022. The adjustment would result in a 0.3 percentage point decrease to overall outlier payments. CMS MODIFIES NCD FOR ICDS; SHARED DECISION-MAKING NOW Every patient receiving an ICD for primary prevention will be required to have an encounter for shared decision-making using an evidence-based decision tool. The Centers for Medicare & Medicaid Services (CMS) has released a final decision memo on changes to the national coverage determination (NCD) for implantable cardioverters defibrillators (ICDs). In the memo, released on Feb. 15, CMS CODING DENIALS: BACK TO BASICS Coding Denials: Back to Basics. Coding must be supported by documentation, but also by the Official Coding Guidelines. While preparing for a clinical validation presentation on acute kidney injury denials, I took inventory of the most common denials and recoveries obtained by payers. It came as no surprise that sepsis, severe malnutrition, and UTILIZATION REVIEW: IMPLEMENTING A “TIGHT” PROCESS TO The best place to start would be utilization review (UR), with the implementation of a “tight” process. This will require precise, accurate, compliant knowledge of the UR process, followed by a gap analysis. This analysis is like building a puzzle. The picture on the box reveals the intended result. The individual pieces are the partsof
PRESUMPTIVE COMPLIANCE FOR IRFS: ARE YOU FACING A DESK A formal letter from your Medicare Administrative Contractor (MAC) is rarely a welcome surprise. For inpatient rehabilitation facilities (IRFs), a letter informing the provider that they have not met IRF classification requirements related to the 60 percent rule based on “presumptive methodology” and thus will be subject to “medical review methodology” is pretty much never welcome. CMS BOOSTS PAYMENT FOR AT-HOME COVID VACCINATIONS 1 day ago · The Biden Administration is turning its attention to the approximately 1.6 million seniors covered by Medicare who experience difficulty leaving their homes. PROFILE | RACMONITOR Subscribe to receive free RAC news and updates. Sign Up. Facebook UNDERSTANDING THE RAC LETTER REQUESTS This article highlights key similarities and differences and may not include all RAC region request forms posted or not posted on their Web sites. You've Got Mail In general, there are three separate letters that hospital providers can expect to receive from RAC Region A. The logo of the Centers for Medicare & Medicaid Services (CMS) is at the top of the letter and the RAC's logo may be either ICD-10: THE AXIS OF CLASSIFICATION As a heightened awareness and acceptance of our inevitable transition to ICD-10 develops, many of you may be wondering how to approach the task of preparing your key stakeholders, coders, clinical documentation specialists and providers for the change. Certainly we all realize the need for additional education, but just where do you begin? The HIM profession typically approaches such a MEDICAL AND SURGICAL ROOT OPERATIONS OF BODY PARTS EDITOR’S NOTE: This is the third in a series of articles addressing the definitions and differences between the Medical and Surgical Root Operations. Let's review what we covered so far. In the Medical and Surgical section (first character 0), there are 31 root operations using standardized terminology with no procedure names, diagnostic information or eponyms. You won't find an CMS MODIFIES NCD FOR ICDS; SHARED DECISION-MAKING NOW Every patient receiving an ICD for primary prevention will be required to have an encounter for shared decision-making using an evidence-based decision tool. The Centers for Medicare & Medicaid Services (CMS) has released a final decision memo on changes to the national coverage determination (NCD) for implantable cardioverters defibrillators (ICDs). In the memo, released on Feb. 15, CMS DRG VALIDATION RULES: IT PAYS CHECK DRG Validation Rules: It Pays Check. On every RAC finding reported, CMS methodically goes through the specific coding issues uncovered and where providers can find guidance about them. Usually, the guidance that CMS provides is not complicated. Instead, it’s a focus on basic coding rules and examples that providers seem to have forgotten or NEW FUNDING PROMPTS SDOH ACTION 1 day ago · Actions speak louder than words. Several impactful events occurred in the arena of the social determinants of health (SDoH) over these past few weeks. PROVIDER MEDICAID CONTRACT TERMINATION REVERSED IN COURT 1 day ago · Judge’s order prevented closing of mental health clinic. Last week, I won a permanent injunction for a healthcare facility that, but for the injunction, would be closed, its 300 staff unemployed, and its 600 Medicare and Medicaid consumers without access to their mental health and substance abuse providers, their primary care physicians, and the Suboxone clinic. MEDICARE’S E&M CHANGES IMPERIL POTENTIAL LEGAL DEFENSES 1 day ago · Medicare reimbursement is merely one of a plethora of reasons that medical record documentation is important. Last week Frank Cohen wrote an excellent article exploring how Medicare changing principles for coding evaluation and management (E&M) services was HOME | RACMONITORNEWSRAC UNIVERSITYMONITOR MONDAYSFREE ENEWS SIGN UPTHE SATURDAY POSTSTAY AT HOME KIDS By Ronald Hirsch, MD. Round-up of recent audit news, including UHC auditing decision on Sepsis. Lots of items to cover today. First, UnitedHealthcare (UHC) issued a notice that they are going to start performing prepayment audits on admissions for sepsis. That is certainly their right, but what a payer cannot do is MONITOR MONDAYS PODCASTS Quality Audits and Malpractice Suits: How 2021 E&M Guidelines Raise Medical/Legal Issues Monday, June 7, 2021 10-10:30 a.m. EST; 7-7:30a.m. PST
MEDICAL/LEGAL IMPACT OF 2021 E&M CHANGES Without detailed documentation, providers may face an uphill battle in defending themselves from quality audits and even malpractice issues. Up until 2021, at least for the prior two decades, coders and clinicians relied upon the established Evaluation and Management (E&M) guidelines to determine which E&M code was appropriate for eachspecific encounter.
RAC UNIVERSITY
The Social Determinants of Health: Case Management's Next Frontier The Social Determinants of Health: Case Management’s Next Frontier is designed to help case managers develop strategies to manage and intervene with the populations predisposed to the risks associatedwith SDoHs.
MAKING SENSE OF SHARED VISITS CMS has deleted official guidance on the topic but promised that new guidance is still to come. It was pure coincidence that I was going to write an article on shared visits when Ronald Hirsch, MD called my attention to the fact that the Centers for Medicare & Medicaid Services (CMS) pulled the shared visit language from the Manual on May3.
CMS RELEASES FY 2022 PROPOSED RULE FOR INPATIENT This brings the Proposed FY 2022 Standard Payment Conversion Factor to $17,273 as compared to $16,856 for FY 2021. The proposed rule also includes an adjustment to the outlier threshold to maintain outlier payments at 3.0 percent in FY 2022. The adjustment would result in a 0.3 percentage point decrease to overall outlier payments. CMS MODIFIES NCD FOR ICDS; SHARED DECISION-MAKING NOW Every patient receiving an ICD for primary prevention will be required to have an encounter for shared decision-making using an evidence-based decision tool. The Centers for Medicare & Medicaid Services (CMS) has released a final decision memo on changes to the national coverage determination (NCD) for implantable cardioverters defibrillators (ICDs). In the memo, released on Feb. 15, CMS CODING DENIALS: BACK TO BASICS Coding Denials: Back to Basics. Coding must be supported by documentation, but also by the Official Coding Guidelines. While preparing for a clinical validation presentation on acute kidney injury denials, I took inventory of the most common denials and recoveries obtained by payers. It came as no surprise that sepsis, severe malnutrition, and UTILIZATION REVIEW: IMPLEMENTING A “TIGHT” PROCESS TO The best place to start would be utilization review (UR), with the implementation of a “tight” process. This will require precise, accurate, compliant knowledge of the UR process, followed by a gap analysis. This analysis is like building a puzzle. The picture on the box reveals the intended result. The individual pieces are the partsof
PRESUMPTIVE COMPLIANCE FOR IRFS: ARE YOU FACING A DESK A formal letter from your Medicare Administrative Contractor (MAC) is rarely a welcome surprise. For inpatient rehabilitation facilities (IRFs), a letter informing the provider that they have not met IRF classification requirements related to the 60 percent rule based on “presumptive methodology” and thus will be subject to “medical review methodology” is pretty much never welcome. HOME | RACMONITORNEWSRAC UNIVERSITYMONITOR MONDAYSFREE ENEWS SIGN UPTHE SATURDAY POSTSTAY AT HOME KIDS By Ronald Hirsch, MD. Round-up of recent audit news, including UHC auditing decision on Sepsis. Lots of items to cover today. First, UnitedHealthcare (UHC) issued a notice that they are going to start performing prepayment audits on admissions for sepsis. That is certainly their right, but what a payer cannot do is MONITOR MONDAYS PODCASTS Quality Audits and Malpractice Suits: How 2021 E&M Guidelines Raise Medical/Legal Issues Monday, June 7, 2021 10-10:30 a.m. EST; 7-7:30a.m. PST
MEDICAL/LEGAL IMPACT OF 2021 E&M CHANGES Without detailed documentation, providers may face an uphill battle in defending themselves from quality audits and even malpractice issues. Up until 2021, at least for the prior two decades, coders and clinicians relied upon the established Evaluation and Management (E&M) guidelines to determine which E&M code was appropriate for eachspecific encounter.
RAC UNIVERSITY
The Social Determinants of Health: Case Management's Next Frontier The Social Determinants of Health: Case Management’s Next Frontier is designed to help case managers develop strategies to manage and intervene with the populations predisposed to the risks associatedwith SDoHs.
MAKING SENSE OF SHARED VISITS CMS has deleted official guidance on the topic but promised that new guidance is still to come. It was pure coincidence that I was going to write an article on shared visits when Ronald Hirsch, MD called my attention to the fact that the Centers for Medicare & Medicaid Services (CMS) pulled the shared visit language from the Manual on May3.
CMS RELEASES FY 2022 PROPOSED RULE FOR INPATIENT This brings the Proposed FY 2022 Standard Payment Conversion Factor to $17,273 as compared to $16,856 for FY 2021. The proposed rule also includes an adjustment to the outlier threshold to maintain outlier payments at 3.0 percent in FY 2022. The adjustment would result in a 0.3 percentage point decrease to overall outlier payments. CMS MODIFIES NCD FOR ICDS; SHARED DECISION-MAKING NOW Every patient receiving an ICD for primary prevention will be required to have an encounter for shared decision-making using an evidence-based decision tool. The Centers for Medicare & Medicaid Services (CMS) has released a final decision memo on changes to the national coverage determination (NCD) for implantable cardioverters defibrillators (ICDs). In the memo, released on Feb. 15, CMS CODING DENIALS: BACK TO BASICS Coding Denials: Back to Basics. Coding must be supported by documentation, but also by the Official Coding Guidelines. While preparing for a clinical validation presentation on acute kidney injury denials, I took inventory of the most common denials and recoveries obtained by payers. It came as no surprise that sepsis, severe malnutrition, and UTILIZATION REVIEW: IMPLEMENTING A “TIGHT” PROCESS TO The best place to start would be utilization review (UR), with the implementation of a “tight” process. This will require precise, accurate, compliant knowledge of the UR process, followed by a gap analysis. This analysis is like building a puzzle. The picture on the box reveals the intended result. The individual pieces are the partsof
PRESUMPTIVE COMPLIANCE FOR IRFS: ARE YOU FACING A DESK A formal letter from your Medicare Administrative Contractor (MAC) is rarely a welcome surprise. For inpatient rehabilitation facilities (IRFs), a letter informing the provider that they have not met IRF classification requirements related to the 60 percent rule based on “presumptive methodology” and thus will be subject to “medical review methodology” is pretty much never welcome. CMS BOOSTS PAYMENT FOR AT-HOME COVID VACCINATIONS 1 day ago · The Biden Administration is turning its attention to the approximately 1.6 million seniors covered by Medicare who experience difficulty leaving their homes. PROFILE | RACMONITOR Subscribe to receive free RAC news and updates. Sign Up. Facebook UNDERSTANDING THE RAC LETTER REQUESTS This article highlights key similarities and differences and may not include all RAC region request forms posted or not posted on their Web sites. You've Got Mail In general, there are three separate letters that hospital providers can expect to receive from RAC Region A. The logo of the Centers for Medicare & Medicaid Services (CMS) is at the top of the letter and the RAC's logo may be either ICD-10: THE AXIS OF CLASSIFICATION As a heightened awareness and acceptance of our inevitable transition to ICD-10 develops, many of you may be wondering how to approach the task of preparing your key stakeholders, coders, clinical documentation specialists and providers for the change. Certainly we all realize the need for additional education, but just where do you begin? The HIM profession typically approaches such a MEDICAL AND SURGICAL ROOT OPERATIONS OF BODY PARTS EDITOR’S NOTE: This is the third in a series of articles addressing the definitions and differences between the Medical and Surgical Root Operations. Let's review what we covered so far. In the Medical and Surgical section (first character 0), there are 31 root operations using standardized terminology with no procedure names, diagnostic information or eponyms. You won't find an CMS MODIFIES NCD FOR ICDS; SHARED DECISION-MAKING NOW Every patient receiving an ICD for primary prevention will be required to have an encounter for shared decision-making using an evidence-based decision tool. The Centers for Medicare & Medicaid Services (CMS) has released a final decision memo on changes to the national coverage determination (NCD) for implantable cardioverters defibrillators (ICDs). In the memo, released on Feb. 15, CMS DRG VALIDATION RULES: IT PAYS CHECK DRG Validation Rules: It Pays Check. On every RAC finding reported, CMS methodically goes through the specific coding issues uncovered and where providers can find guidance about them. Usually, the guidance that CMS provides is not complicated. Instead, it’s a focus on basic coding rules and examples that providers seem to have forgotten or NEW FUNDING PROMPTS SDOH ACTION 1 day ago · Actions speak louder than words. Several impactful events occurred in the arena of the social determinants of health (SDoH) over these past few weeks. PROVIDER MEDICAID CONTRACT TERMINATION REVERSED IN COURT 1 day ago · Judge’s order prevented closing of mental health clinic. Last week, I won a permanent injunction for a healthcare facility that, but for the injunction, would be closed, its 300 staff unemployed, and its 600 Medicare and Medicaid consumers without access to their mental health and substance abuse providers, their primary care physicians, and the Suboxone clinic. MEDICARE’S E&M CHANGES IMPERIL POTENTIAL LEGAL DEFENSES 1 day ago · Medicare reimbursement is merely one of a plethora of reasons that medical record documentation is important. Last week Frank Cohen wrote an excellent article exploring how Medicare changing principles for coding evaluation and management (E&M) services was HOME | RACMONITORNEWSRAC UNIVERSITYMONITOR MONDAYSFREE ENEWS SIGN UPTHE SATURDAY POSTSTAY AT HOME KIDS Without detailed documentation, providers may face an uphill battle in defending themselves from quality audits and even malpractice issues. Up until 2021, at least for the prior two decades, coders and clinicians relied upon the established Evaluation and Management (E&M) guidelines to determine which E&M MONITOR MONDAYS PODCASTS Quality Audits and Malpractice Suits: How 2021 E&M Guidelines Raise Medical/Legal Issues Monday, June 7, 2021 10-10:30 a.m. EST; 7-7:30a.m. PST
MEDICAL/LEGAL IMPACT OF 2021 E&M CHANGES Without detailed documentation, providers may face an uphill battle in defending themselves from quality audits and even malpractice issues. Up until 2021, at least for the prior two decades, coders and clinicians relied upon the established Evaluation and Management (E&M) guidelines to determine which E&M code was appropriate for eachspecific encounter.
MAKING SENSE OF SHARED VISITS CMS has deleted official guidance on the topic but promised that new guidance is still to come. It was pure coincidence that I was going to write an article on shared visits when Ronald Hirsch, MD called my attention to the fact that the Centers for Medicare & Medicaid Services (CMS) pulled the shared visit language from the Manual on May3.
RAC UNIVERSITY
The Social Determinants of Health: Case Management's Next Frontier The Social Determinants of Health: Case Management’s Next Frontier is designed to help case managers develop strategies to manage and intervene with the populations predisposed to the risks associatedwith SDoHs.
CODING DENIALS: BACK TO BASICS Coding must be supported by documentation, but also by the Official Coding Guidelines. While preparing for a clinical validation presentation on acute kidney injury denials, I took inventory of the most common denials and recoveries obtained by payers. It came as no surprise that sepsis, severe malnutrition, and encephalopathy were atthe top of the
CMS RELEASES FY 2022 PROPOSED RULE FOR INPATIENT Proposed rule solicits comments on closing the health equity gap. The Centers for Medicare & Medicaid Services (CMS) issued a proposed rule for Inpatient Rehabilitation Facilities (IRFs) that would update payment policies for FY 2022, update IRF Quality Reporting Program (QRP) requirements for FY 2022, address Public Reporting of Quality Requirements and that seeks input CMS MODIFIES NCD FOR ICDS; SHARED DECISION-MAKING NOW Every patient receiving an ICD for primary prevention will be required to have an encounter for shared decision-making using an evidence-based decision tool. The Centers for Medicare & Medicaid Services (CMS) has released a final decision memo on changes to the national coverage determination (NCD) for implantable cardioverters defibrillators (ICDs). In the memo, released on Feb. 15, CMS UTILIZATION REVIEW: IMPLEMENTING A “TIGHT” PROCESS TO Why not prevent errors from occurring in the beginning? I recently attended a brainstorming session that was designed to focus on a clinical department and find ways to improve its function and outcomes. This brainstorming is just in the initial phase, and the moderator is non-clinical, but rather a process improvement engineer.The thought was
PRESUMPTIVE COMPLIANCE FOR IRFS: ARE YOU FACING A DESK A formal letter from your Medicare Administrative Contractor (MAC) is rarely a welcome surprise. For inpatient rehabilitation facilities (IRFs), a letter informing the provider that they have not met IRF classification requirements related to the 60 percent rule based on “presumptive methodology” and thus will be subject to “medical review methodology” is pretty much never welcome. HOME | RACMONITORNEWSRAC UNIVERSITYMONITOR MONDAYSFREE ENEWS SIGN UPTHE SATURDAY POSTSTAY AT HOME KIDS Without detailed documentation, providers may face an uphill battle in defending themselves from quality audits and even malpractice issues. Up until 2021, at least for the prior two decades, coders and clinicians relied upon the established Evaluation and Management (E&M) guidelines to determine which E&M MONITOR MONDAYS PODCASTS Quality Audits and Malpractice Suits: How 2021 E&M Guidelines Raise Medical/Legal Issues Monday, June 7, 2021 10-10:30 a.m. EST; 7-7:30a.m. PST
MEDICAL/LEGAL IMPACT OF 2021 E&M CHANGES Without detailed documentation, providers may face an uphill battle in defending themselves from quality audits and even malpractice issues. Up until 2021, at least for the prior two decades, coders and clinicians relied upon the established Evaluation and Management (E&M) guidelines to determine which E&M code was appropriate for eachspecific encounter.
MAKING SENSE OF SHARED VISITS CMS has deleted official guidance on the topic but promised that new guidance is still to come. It was pure coincidence that I was going to write an article on shared visits when Ronald Hirsch, MD called my attention to the fact that the Centers for Medicare & Medicaid Services (CMS) pulled the shared visit language from the Manual on May3.
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The Social Determinants of Health: Case Management's Next Frontier The Social Determinants of Health: Case Management’s Next Frontier is designed to help case managers develop strategies to manage and intervene with the populations predisposed to the risks associatedwith SDoHs.
CODING DENIALS: BACK TO BASICS Coding must be supported by documentation, but also by the Official Coding Guidelines. While preparing for a clinical validation presentation on acute kidney injury denials, I took inventory of the most common denials and recoveries obtained by payers. It came as no surprise that sepsis, severe malnutrition, and encephalopathy were atthe top of the
CMS RELEASES FY 2022 PROPOSED RULE FOR INPATIENT Proposed rule solicits comments on closing the health equity gap. The Centers for Medicare & Medicaid Services (CMS) issued a proposed rule for Inpatient Rehabilitation Facilities (IRFs) that would update payment policies for FY 2022, update IRF Quality Reporting Program (QRP) requirements for FY 2022, address Public Reporting of Quality Requirements and that seeks input CMS MODIFIES NCD FOR ICDS; SHARED DECISION-MAKING NOW Every patient receiving an ICD for primary prevention will be required to have an encounter for shared decision-making using an evidence-based decision tool. The Centers for Medicare & Medicaid Services (CMS) has released a final decision memo on changes to the national coverage determination (NCD) for implantable cardioverters defibrillators (ICDs). In the memo, released on Feb. 15, CMS UTILIZATION REVIEW: IMPLEMENTING A “TIGHT” PROCESS TO Why not prevent errors from occurring in the beginning? I recently attended a brainstorming session that was designed to focus on a clinical department and find ways to improve its function and outcomes. This brainstorming is just in the initial phase, and the moderator is non-clinical, but rather a process improvement engineer.The thought was
PRESUMPTIVE COMPLIANCE FOR IRFS: ARE YOU FACING A DESK A formal letter from your Medicare Administrative Contractor (MAC) is rarely a welcome surprise. For inpatient rehabilitation facilities (IRFs), a letter informing the provider that they have not met IRF classification requirements related to the 60 percent rule based on “presumptive methodology” and thus will be subject to “medical review methodology” is pretty much never welcome. CMS BOOSTS PAYMENT FOR AT-HOME COVID VACCINATIONS 1 day ago · The Biden Administration is turning its attention to the approximately 1.6 million seniors covered by Medicare who experience difficulty leaving their homes. PROFILE | RACMONITOR Subscribe to receive free RAC news and updates. Sign Up. Facebook UNDERSTANDING HOSPITAL AT HOME This is a concept introduced by CMS to address surge capacity by providing acute-care services in the home setting. Not to be confused with the Hospital to Home program for readmission prevention, the Hospital at Home waiver (aka Hospitals without Walls), introduced by the Centers for Medicare & Medicaid Services (CMS), is a conceptintroduced
ICD-10: THE AXIS OF CLASSIFICATION As a heightened awareness and acceptance of our inevitable transition to ICD-10 develops, many of you may be wondering how to approach the task of preparing your key stakeholders, coders, clinical documentation specialists and providers for the change. Certainly we all realize the need for additional education, but just where do you begin? The HIM profession typically approaches such a CODING DENIALS: BACK TO BASICS Coding must be supported by documentation, but also by the Official Coding Guidelines. While preparing for a clinical validation presentation on acute kidney injury denials, I took inventory of the most common denials and recoveries obtained by payers. It came as no surprise that sepsis, severe malnutrition, and encephalopathy were atthe top of the
MEDICAL AND SURGICAL ROOT OPERATIONS OF BODY PARTS EDITOR’S NOTE: This is the third in a series of articles addressing the definitions and differences between the Medical and Surgical Root Operations. Let's review what we covered so far. In the Medical and Surgical section (first character 0), there are 31 root operations using standardized terminology with no procedure names, diagnostic information or eponyms. You won't find an UNDERSTANDING THE RAC LETTER REQUESTS This article highlights key similarities and differences and may not include all RAC region request forms posted or not posted on their Web sites. You've Got Mail In general, there are three separate letters that hospital providers can expect to receive from RAC Region A. The logo of the Centers for Medicare & Medicaid Services (CMS) is at the top of the letter and the RAC's logo may be either PROVIDER MEDICAID CONTRACT TERMINATION REVERSED IN COURT 1 day ago · Judge’s order prevented closing of mental health clinic. Last week, I won a permanent injunction for a healthcare facility that, but for the injunction, would be closed, its 300 staff unemployed, and its 600 Medicare and Medicaid consumers without access to their mental health and substance abuse providers, their primary care physicians, and the Suboxone clinic. NEW FUNDING PROMPTS SDOH ACTION 1 day ago · Actions speak louder than words. Several impactful events occurred in the arena of the social determinants of health (SDoH) over these past few weeks. MEDICARE’S E&M CHANGES IMPERIL POTENTIAL LEGAL DEFENSES 1 day ago · Medicare reimbursement is merely one of a plethora of reasons that medical record documentation is important. Last week Frank Cohen wrote an excellent article exploring how Medicare changing principles for coding evaluation and management (E&M) services was HOME | RACMONITORNEWSRAC UNIVERSITYMONITOR MONDAYSFREE ENEWS SIGN UPTHE SATURDAY POSTSTAY AT HOME KIDS By Ronald Hirsch, MD. Round-up of recent audit news, including UHC auditing decision on Sepsis. Lots of items to cover today. First, UnitedHealthcare (UHC) issued a notice that they are going to start performing prepayment audits on admissions for sepsis. That is certainly their right, but what a payer cannot do is MONITOR MONDAYS PODCASTS Quality Audits and Malpractice Suits: How 2021 E&M Guidelines Raise Medical/Legal Issues Monday, June 7, 2021 10-10:30 a.m. EST; 7-7:30a.m. PST
MEDICAL/LEGAL IMPACT OF 2021 E&M CHANGES Medical/Legal Impact of 2021 E&M Changes. Emily Anderson. June 2, 2021. Without detailed documentation, providers may face an uphill battle in defending themselves from quality audits and even malpractice issues. Up until 2021, at least for the prior two decades, coders and clinicians relied upon the established Evaluation andManagement (E&M
MAKING SENSE OF SHARED VISITS CMS has deleted official guidance on the topic but promised that new guidance is still to come. It was pure coincidence that I was going to write an article on shared visits when Ronald Hirsch, MD called my attention to the fact that the Centers for Medicare & Medicaid Services (CMS) pulled the shared visit language from the Manual on May3.
CMS MODIFIES NCD FOR ICDS; SHARED DECISION-MAKING NOW Every patient receiving an ICD for primary prevention will be required to have an encounter for shared decision-making using an evidence-based decision tool. The Centers for Medicare & Medicaid Services (CMS) has released a final decision memo on changes to the national coverage determination (NCD) for implantable cardioverters defibrillators (ICDs). In the memo, released on Feb. 15, CMS CODING DENIALS: BACK TO BASICS Coding Denials: Back to Basics. Coding must be supported by documentation, but also by the Official Coding Guidelines. While preparing for a clinical validation presentation on acute kidney injury denials, I took inventory of the most common denials and recoveries obtained by payers. It came as no surprise that sepsis, severe malnutrition, and UTILIZATION REVIEW: IMPLEMENTING A “TIGHT” PROCESS TO The best place to start would be utilization review (UR), with the implementation of a “tight” process. This will require precise, accurate, compliant knowledge of the UR process, followed by a gap analysis. This analysis is like building a puzzle. The picture on the box reveals the intended result. The individual pieces are the partsof
UNDERSTANDING THE RAC LETTER REQUESTS This article highlights key similarities and differences and may not include all RAC region request forms posted or not posted on their Web sites. You've Got Mail In general, there are three separate letters that hospital providers can expect to receive from RAC Region A. The logo of the Centers for Medicare & Medicaid Services (CMS) is at the top of the letter and the RAC's logo may be either THE NEW SHORT-STAY EXCEPTION: READ BEFORE USING I have written a lot in the past about the two-midnight rule exception for physician judgment of the need for inpatient admission with an expectation of a stay of under two midnights. As a reminder, when the two-midnight rule was first adopted, the only approved exceptions to the two-midnight expectation were unplanned mechanical ventilation and inpatient-only surgery. (Patients who have a PRESUMPTIVE COMPLIANCE FOR IRFS: ARE YOU FACING A DESK A formal letter from your Medicare Administrative Contractor (MAC) is rarely a welcome surprise. For inpatient rehabilitation facilities (IRFs), a letter informing the provider that they have not met IRF classification requirements related to the 60 percent rule based on “presumptive methodology” and thus will be subject to “medical review methodology” is pretty much never welcome. HOME | RACMONITORNEWSRAC UNIVERSITYMONITOR MONDAYSFREE ENEWS SIGN UPTHE SATURDAY POSTSTAY AT HOME KIDS By Ronald Hirsch, MD. Round-up of recent audit news, including UHC auditing decision on Sepsis. Lots of items to cover today. First, UnitedHealthcare (UHC) issued a notice that they are going to start performing prepayment audits on admissions for sepsis. That is certainly their right, but what a payer cannot do is MONITOR MONDAYS PODCASTS Quality Audits and Malpractice Suits: How 2021 E&M Guidelines Raise Medical/Legal Issues Monday, June 7, 2021 10-10:30 a.m. EST; 7-7:30a.m. PST
MEDICAL/LEGAL IMPACT OF 2021 E&M CHANGES Medical/Legal Impact of 2021 E&M Changes. Emily Anderson. June 2, 2021. Without detailed documentation, providers may face an uphill battle in defending themselves from quality audits and even malpractice issues. Up until 2021, at least for the prior two decades, coders and clinicians relied upon the established Evaluation andManagement (E&M
MAKING SENSE OF SHARED VISITS CMS has deleted official guidance on the topic but promised that new guidance is still to come. It was pure coincidence that I was going to write an article on shared visits when Ronald Hirsch, MD called my attention to the fact that the Centers for Medicare & Medicaid Services (CMS) pulled the shared visit language from the Manual on May3.
CMS MODIFIES NCD FOR ICDS; SHARED DECISION-MAKING NOW Every patient receiving an ICD for primary prevention will be required to have an encounter for shared decision-making using an evidence-based decision tool. The Centers for Medicare & Medicaid Services (CMS) has released a final decision memo on changes to the national coverage determination (NCD) for implantable cardioverters defibrillators (ICDs). In the memo, released on Feb. 15, CMS CODING DENIALS: BACK TO BASICS Coding Denials: Back to Basics. Coding must be supported by documentation, but also by the Official Coding Guidelines. While preparing for a clinical validation presentation on acute kidney injury denials, I took inventory of the most common denials and recoveries obtained by payers. It came as no surprise that sepsis, severe malnutrition, and UTILIZATION REVIEW: IMPLEMENTING A “TIGHT” PROCESS TO The best place to start would be utilization review (UR), with the implementation of a “tight” process. This will require precise, accurate, compliant knowledge of the UR process, followed by a gap analysis. This analysis is like building a puzzle. The picture on the box reveals the intended result. The individual pieces are the partsof
UNDERSTANDING THE RAC LETTER REQUESTS This article highlights key similarities and differences and may not include all RAC region request forms posted or not posted on their Web sites. You've Got Mail In general, there are three separate letters that hospital providers can expect to receive from RAC Region A. The logo of the Centers for Medicare & Medicaid Services (CMS) is at the top of the letter and the RAC's logo may be either THE NEW SHORT-STAY EXCEPTION: READ BEFORE USING I have written a lot in the past about the two-midnight rule exception for physician judgment of the need for inpatient admission with an expectation of a stay of under two midnights. As a reminder, when the two-midnight rule was first adopted, the only approved exceptions to the two-midnight expectation were unplanned mechanical ventilation and inpatient-only surgery. (Patients who have a PRESUMPTIVE COMPLIANCE FOR IRFS: ARE YOU FACING A DESK A formal letter from your Medicare Administrative Contractor (MAC) is rarely a welcome surprise. For inpatient rehabilitation facilities (IRFs), a letter informing the provider that they have not met IRF classification requirements related to the 60 percent rule based on “presumptive methodology” and thus will be subject to “medical review methodology” is pretty much never welcome. CMS BOOSTS PAYMENT FOR AT-HOME COVID VACCINATIONS 1 day ago · The Biden Administration is turning its attention to the approximately 1.6 million seniors covered by Medicare who experience difficulty leaving their homes. PROFILE | RACMONITOR Subscribe to receive free RAC news and updates. Sign Up. Facebook CODING DENIALS: BACK TO BASICS Coding Denials: Back to Basics. Coding must be supported by documentation, but also by the Official Coding Guidelines. While preparing for a clinical validation presentation on acute kidney injury denials, I took inventory of the most common denials and recoveries obtained by payers. It came as no surprise that sepsis, severe malnutrition, and NEW FUNDING PROMPTS SDOH ACTION 1 day ago · Actions speak louder than words. Several impactful events occurred in the arena of the social determinants of health (SDoH) over these past few weeks. CMS MODIFIES NCD FOR ICDS; SHARED DECISION-MAKING NOW Every patient receiving an ICD for primary prevention will be required to have an encounter for shared decision-making using an evidence-based decision tool. The Centers for Medicare & Medicaid Services (CMS) has released a final decision memo on changes to the national coverage determination (NCD) for implantable cardioverters defibrillators (ICDs). In the memo, released on Feb. 15, CMS THE NEW SHORT-STAY EXCEPTION: READ BEFORE USING I have written a lot in the past about the two-midnight rule exception for physician judgment of the need for inpatient admission with an expectation of a stay of under two midnights. As a reminder, when the two-midnight rule was first adopted, the only approved exceptions to the two-midnight expectation were unplanned mechanical ventilation and inpatient-only surgery. (Patients who have a PROVIDER MEDICAID CONTRACT TERMINATION REVERSED IN COURT 1 day ago · Judge’s order prevented closing of mental health clinic. Last week, I won a permanent injunction for a healthcare facility that, but for the injunction, would be closed, its 300 staff unemployed, and its 600 Medicare and Medicaid consumers without access to their mental health and substance abuse providers, their primary care physicians, and the Suboxone clinic. COPYING AND PASTING: THE REAL RULES PREVAIL In my job, I wear many hats. I am an auditor, a physician educator, a consultant, an author, and an auditing instructor. In these roles, I hear a common concern regarding the use of electronic health records (EHRs): that of cloning, or copying and pasting, records. It is important first to consider the rules that exist regarding copying and pasting, as compared to the opinions of many in the MEDICARE’S E&M CHANGES IMPERIL POTENTIAL LEGAL DEFENSES 1 day ago · Medicare reimbursement is merely one of a plethora of reasons that medical record documentation is important. Last week Frank Cohen wrote an excellent article exploring how Medicare changing principles for coding evaluation and management (E&M) services was PREVENTING A BREACH, LESSONS LEARNED FROM OCR ENFORCEMENT DOWNLOAD MRO’S EBOOK Complete the form to download MRO’s eBook “Preventing a Breach: Tips and Best Practices to Safeguard your Healthcare Organization” which discusses the following: Healthcare Breach Trends Top Issues in Investigated Cases Closed with OCR Corrective Action Lessons Learned from 2017 Resolution Agreements and Civil Money Penalties Mitigating Breach Risk in Release of HOME | RACMONITORNEWSRAC UNIVERSITYMONITOR MONDAYSFREE ENEWS SIGN UPTHE SATURDAY POSTSTAY AT HOME KIDS By Ronald Hirsch, MD. Round-up of recent audit news, including UHC auditing decision on Sepsis. Lots of items to cover today. First, UnitedHealthcare (UHC) issued a notice that they are going to start performing prepayment audits on admissions for sepsis. That is certainly their right, but what a payer cannot do isNEWS | RACMONITOR
Another Pharma Company Settles False Claims Act Claims for paying Kickbacks. Mary Inman, Esq. and Max Voldman, Esq. May 26, 2021. ReadMore ».
RACMONITOR.COM
During the next live edition of Monitor Mondays, an all-star line up of audit and regulatory experts will come together in a 60-minute edition of the venerable weekly broadcast. Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will make his Monday Rounds with another installment of CMS RELEASES FY 2022 PROPOSED RULE FOR INPATIENT This brings the Proposed FY 2022 Standard Payment Conversion Factor to $17,273 as compared to $16,856 for FY 2021. The proposed rule also includes an adjustment to the outlier threshold to maintain outlier payments at 3.0 percent in FY 2022. The adjustment would result in a 0.3 percentage point decrease to overall outlier payments. COVID-19 WAIVERS: WHAT IT MEANS FOR IRFS COVID-19 Waivers: What It Means for IRFs. On March 13, the Centers for Medicare & Medicaid Services (CMS) issued blanket waivers that will impact Inpatient Rehabilitation Facilities (IRFs) as well as other Post-Acute Care (PAC) settings. The blanket waivers, which do not require any special request to be filed, will allow IRFs to admitpatients
CODING DENIALS: BACK TO BASICS Coding Denials: Back to Basics. Coding must be supported by documentation, but also by the Official Coding Guidelines. While preparing for a clinical validation presentation on acute kidney injury denials, I took inventory of the most common denials and recoveries obtained by payers. It came as no surprise that sepsis, severe malnutrition, and CMS CLARIFIES PATIENT FINANCIAL RESPONSIBILITY FOR COVID EDITOR’S NOTE: RACmonitor.com news asked Dr. Ronald Hirsch, vice president at R1 RCM, to summarize the latest from the Centers for Medicare & Medicaid Services (CMS) on covering costs for COVID-19 care. In response, Dr. Hirsch provided RACmonitor the following summary. When the first guidance on COVID-19 testing was released onMarch 13, CMS made
UNDERSTANDING THE RAC LETTER REQUESTS This article highlights key similarities and differences and may not include all RAC region request forms posted or not posted on their Web sites. You've Got Mail In general, there are three separate letters that hospital providers can expect to receive from RAC Region A. The logo of the Centers for Medicare & Medicaid Services (CMS) is at the top of the letter and the RAC's logo may be either BREAKING: UNITEDHEALTHCARE SEPSIS-3 CRITERIA NOT BEING Plan was “strongly opposed” by NY healthcare groups. The Healthcare Association of New York (HANY) told providers Tuesday that the Empire State that it will not use the UnitedHealthcare (UHC) Sepsis-3 criteria when reviewing claims to validate sepsis for payment. New York state law defines sepsis with systemic inflammatory response syndrome (SIRS) criteria, otherwise known PRESUMPTIVE COMPLIANCE FOR IRFS: ARE YOU FACING A DESK A formal letter from your Medicare Administrative Contractor (MAC) is rarely a welcome surprise. For inpatient rehabilitation facilities (IRFs), a letter informing the provider that they have not met IRF classification requirements related to the 60 percent rule based on “presumptive methodology” and thus will be subject to “medical review methodology” is pretty much never welcome. HOME | RACMONITORNEWSRAC UNIVERSITYMONITOR MONDAYSFREE ENEWS SIGN UPTHE SATURDAY POSTSTAY AT HOME KIDS By Ronald Hirsch, MD. Round-up of recent audit news, including UHC auditing decision on Sepsis. Lots of items to cover today. First, UnitedHealthcare (UHC) issued a notice that they are going to start performing prepayment audits on admissions for sepsis. That is certainly their right, but what a payer cannot do isNEWS | RACMONITOR
Another Pharma Company Settles False Claims Act Claims for paying Kickbacks. Mary Inman, Esq. and Max Voldman, Esq. May 26, 2021. ReadMore ».
RACMONITOR.COM
During the next live edition of Monitor Mondays, an all-star line up of audit and regulatory experts will come together in a 60-minute edition of the venerable weekly broadcast. Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will make his Monday Rounds with another installment of CMS RELEASES FY 2022 PROPOSED RULE FOR INPATIENT This brings the Proposed FY 2022 Standard Payment Conversion Factor to $17,273 as compared to $16,856 for FY 2021. The proposed rule also includes an adjustment to the outlier threshold to maintain outlier payments at 3.0 percent in FY 2022. The adjustment would result in a 0.3 percentage point decrease to overall outlier payments. COVID-19 WAIVERS: WHAT IT MEANS FOR IRFS COVID-19 Waivers: What It Means for IRFs. On March 13, the Centers for Medicare & Medicaid Services (CMS) issued blanket waivers that will impact Inpatient Rehabilitation Facilities (IRFs) as well as other Post-Acute Care (PAC) settings. The blanket waivers, which do not require any special request to be filed, will allow IRFs to admitpatients
CODING DENIALS: BACK TO BASICS Coding Denials: Back to Basics. Coding must be supported by documentation, but also by the Official Coding Guidelines. While preparing for a clinical validation presentation on acute kidney injury denials, I took inventory of the most common denials and recoveries obtained by payers. It came as no surprise that sepsis, severe malnutrition, and CMS CLARIFIES PATIENT FINANCIAL RESPONSIBILITY FOR COVID EDITOR’S NOTE: RACmonitor.com news asked Dr. Ronald Hirsch, vice president at R1 RCM, to summarize the latest from the Centers for Medicare & Medicaid Services (CMS) on covering costs for COVID-19 care. In response, Dr. Hirsch provided RACmonitor the following summary. When the first guidance on COVID-19 testing was released onMarch 13, CMS made
UNDERSTANDING THE RAC LETTER REQUESTS This article highlights key similarities and differences and may not include all RAC region request forms posted or not posted on their Web sites. You've Got Mail In general, there are three separate letters that hospital providers can expect to receive from RAC Region A. The logo of the Centers for Medicare & Medicaid Services (CMS) is at the top of the letter and the RAC's logo may be either BREAKING: UNITEDHEALTHCARE SEPSIS-3 CRITERIA NOT BEING Plan was “strongly opposed” by NY healthcare groups. The Healthcare Association of New York (HANY) told providers Tuesday that the Empire State that it will not use the UnitedHealthcare (UHC) Sepsis-3 criteria when reviewing claims to validate sepsis for payment. New York state law defines sepsis with systemic inflammatory response syndrome (SIRS) criteria, otherwise known PRESUMPTIVE COMPLIANCE FOR IRFS: ARE YOU FACING A DESK A formal letter from your Medicare Administrative Contractor (MAC) is rarely a welcome surprise. For inpatient rehabilitation facilities (IRFs), a letter informing the provider that they have not met IRF classification requirements related to the 60 percent rule based on “presumptive methodology” and thus will be subject to “medical review methodology” is pretty much never welcome.NEWS | RACMONITOR
Another Pharma Company Settles False Claims Act Claims for paying Kickbacks. Mary Inman, Esq. and Max Voldman, Esq. May 26, 2021. ReadMore ».
TO MASK OR NOT TO MASK? ASK OSHA The most recent CDC guidance on masks is again, just guidance. If you’re like me, you went out this past weekend to Home Depot or your favorite restaurant to find a state of near chaos in terms of people wearing masks or not – and businesses requiring themor not. OIG AUDITS GETTING BACK IN GEAR Federal contractors are paying particular attention to payment for COVID care. It’s time to revisit a prediction regarding COVID-related audits.WORD2 | RACMONITOR
An MLN Matters article published on Dec. 11 reported on a recent advisement from the Centers for Medicare & Medicaid Services (CMS) to its medical review contractors related to therapy services in Inpatient Rehabilitation Facilities (IRFs). Consistent with what we are seeing in the field, two key areas were addressed in this guidance to contractors: Therapy intensity of services Individualized BATTLING THE BACKLOG AT THE ALJ Battling the Backlog at the ALJ. Frank D. Cohen, MPA, MBB. April 21, 2021. A federal judge ordered the government to reduce the massive backlog of healthcare hearings – and if recent events are any indication, it may finally be happening. I imagine that pretty much everyone who touches on coding and billing compliance in our industryis
COVID-19 WAIVERS: WHAT IT MEANS FOR IRFS COVID-19 Waivers: What It Means for IRFs. On March 13, the Centers for Medicare & Medicaid Services (CMS) issued blanket waivers that will impact Inpatient Rehabilitation Facilities (IRFs) as well as other Post-Acute Care (PAC) settings. The blanket waivers, which do not require any special request to be filed, will allow IRFs to admitpatients
UTILIZATION REVIEW: IMPLEMENTING A “TIGHT” PROCESS TO The best place to start would be utilization review (UR), with the implementation of a “tight” process. This will require precise, accurate, compliant knowledge of the UR process, followed by a gap analysis. This analysis is like building a puzzle. The picture on the box reveals the intended result. The individual pieces are the partsof
NEWS ALERT: BFCC-QIO AUDITS POISED TO RESUME Providers would do well to prepare by taking a close look at their short stays. After a multi-year pause due to the COVID-19 pandemic and a contract dispute, it appears that the Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC-QIO) short-stay audits are poised to resume, with Livanta being the sole contactors providing audit services THE NEW SHORT-STAY EXCEPTION: READ BEFORE USING I have written a lot in the past about the two-midnight rule exception for physician judgment of the need for inpatient admission with an expectation of a stay of under two midnights. As a reminder, when the two-midnight rule was first adopted, the only approved exceptions to the two-midnight expectation were unplanned mechanical ventilation and inpatient-only surgery. (Patients who have a COPYING AND PASTING: THE REAL RULES PREVAIL In my job, I wear many hats. I am an auditor, a physician educator, a consultant, an author, and an auditing instructor. In these roles, I hear a common concern regarding the use of electronic health records (EHRs): that of cloning, or copying and pasting, records. It is important first to consider the rules that exist regarding copying and pasting, as compared to the opinions of many in the HOME | RACMONITORNEWSRAC UNIVERSITYMONITOR MONDAYSFREE ENEWS SIGN UPTHE SATURDAY POSTSTAY AT HOME KIDS By Ronald Hirsch, MD. Round-up of recent audit news, including UHC auditing decision on Sepsis. Lots of items to cover today. First, UnitedHealthcare (UHC) issued a notice that they are going to start performing prepayment audits on admissions for sepsis. That is certainly their right, but what a payer cannot do isNEWS | RACMONITOR
Another Pharma Company Settles False Claims Act Claims for paying Kickbacks. Mary Inman, Esq. and Max Voldman, Esq. May 26, 2021. ReadMore ».
RACMONITOR.COM
During the next live edition of Monitor Mondays, an all-star line up of audit and regulatory experts will come together in a 60-minute edition of the venerable weekly broadcast. Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will make his Monday Rounds with another installment of CMS RELEASES FY 2022 PROPOSED RULE FOR INPATIENT This brings the Proposed FY 2022 Standard Payment Conversion Factor to $17,273 as compared to $16,856 for FY 2021. The proposed rule also includes an adjustment to the outlier threshold to maintain outlier payments at 3.0 percent in FY 2022. The adjustment would result in a 0.3 percentage point decrease to overall outlier payments. COVID-19 WAIVERS: WHAT IT MEANS FOR IRFS COVID-19 Waivers: What It Means for IRFs. On March 13, the Centers for Medicare & Medicaid Services (CMS) issued blanket waivers that will impact Inpatient Rehabilitation Facilities (IRFs) as well as other Post-Acute Care (PAC) settings. The blanket waivers, which do not require any special request to be filed, will allow IRFs to admitpatients
CODING DENIALS: BACK TO BASICS Coding Denials: Back to Basics. Coding must be supported by documentation, but also by the Official Coding Guidelines. While preparing for a clinical validation presentation on acute kidney injury denials, I took inventory of the most common denials and recoveries obtained by payers. It came as no surprise that sepsis, severe malnutrition, and CMS CLARIFIES PATIENT FINANCIAL RESPONSIBILITY FOR COVID EDITOR’S NOTE: RACmonitor.com news asked Dr. Ronald Hirsch, vice president at R1 RCM, to summarize the latest from the Centers for Medicare & Medicaid Services (CMS) on covering costs for COVID-19 care. In response, Dr. Hirsch provided RACmonitor the following summary. When the first guidance on COVID-19 testing was released onMarch 13, CMS made
UNDERSTANDING THE RAC LETTER REQUESTS This article highlights key similarities and differences and may not include all RAC region request forms posted or not posted on their Web sites. You've Got Mail In general, there are three separate letters that hospital providers can expect to receive from RAC Region A. The logo of the Centers for Medicare & Medicaid Services (CMS) is at the top of the letter and the RAC's logo may be either BREAKING: UNITEDHEALTHCARE SEPSIS-3 CRITERIA NOT BEING Plan was “strongly opposed” by NY healthcare groups. The Healthcare Association of New York (HANY) told providers Tuesday that the Empire State that it will not use the UnitedHealthcare (UHC) Sepsis-3 criteria when reviewing claims to validate sepsis for payment. New York state law defines sepsis with systemic inflammatory response syndrome (SIRS) criteria, otherwise known PRESUMPTIVE COMPLIANCE FOR IRFS: ARE YOU FACING A DESK A formal letter from your Medicare Administrative Contractor (MAC) is rarely a welcome surprise. For inpatient rehabilitation facilities (IRFs), a letter informing the provider that they have not met IRF classification requirements related to the 60 percent rule based on “presumptive methodology” and thus will be subject to “medical review methodology” is pretty much never welcome. HOME | RACMONITORNEWSRAC UNIVERSITYMONITOR MONDAYSFREE ENEWS SIGN UPTHE SATURDAY POSTSTAY AT HOME KIDS By Ronald Hirsch, MD. Round-up of recent audit news, including UHC auditing decision on Sepsis. Lots of items to cover today. First, UnitedHealthcare (UHC) issued a notice that they are going to start performing prepayment audits on admissions for sepsis. That is certainly their right, but what a payer cannot do isNEWS | RACMONITOR
Another Pharma Company Settles False Claims Act Claims for paying Kickbacks. Mary Inman, Esq. and Max Voldman, Esq. May 26, 2021. ReadMore ».
RACMONITOR.COM
During the next live edition of Monitor Mondays, an all-star line up of audit and regulatory experts will come together in a 60-minute edition of the venerable weekly broadcast. Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will make his Monday Rounds with another installment of CMS RELEASES FY 2022 PROPOSED RULE FOR INPATIENT This brings the Proposed FY 2022 Standard Payment Conversion Factor to $17,273 as compared to $16,856 for FY 2021. The proposed rule also includes an adjustment to the outlier threshold to maintain outlier payments at 3.0 percent in FY 2022. The adjustment would result in a 0.3 percentage point decrease to overall outlier payments. COVID-19 WAIVERS: WHAT IT MEANS FOR IRFS COVID-19 Waivers: What It Means for IRFs. On March 13, the Centers for Medicare & Medicaid Services (CMS) issued blanket waivers that will impact Inpatient Rehabilitation Facilities (IRFs) as well as other Post-Acute Care (PAC) settings. The blanket waivers, which do not require any special request to be filed, will allow IRFs to admitpatients
CODING DENIALS: BACK TO BASICS Coding Denials: Back to Basics. Coding must be supported by documentation, but also by the Official Coding Guidelines. While preparing for a clinical validation presentation on acute kidney injury denials, I took inventory of the most common denials and recoveries obtained by payers. It came as no surprise that sepsis, severe malnutrition, and CMS CLARIFIES PATIENT FINANCIAL RESPONSIBILITY FOR COVID EDITOR’S NOTE: RACmonitor.com news asked Dr. Ronald Hirsch, vice president at R1 RCM, to summarize the latest from the Centers for Medicare & Medicaid Services (CMS) on covering costs for COVID-19 care. In response, Dr. Hirsch provided RACmonitor the following summary. When the first guidance on COVID-19 testing was released onMarch 13, CMS made
UNDERSTANDING THE RAC LETTER REQUESTS This article highlights key similarities and differences and may not include all RAC region request forms posted or not posted on their Web sites. You've Got Mail In general, there are three separate letters that hospital providers can expect to receive from RAC Region A. The logo of the Centers for Medicare & Medicaid Services (CMS) is at the top of the letter and the RAC's logo may be either BREAKING: UNITEDHEALTHCARE SEPSIS-3 CRITERIA NOT BEING Plan was “strongly opposed” by NY healthcare groups. The Healthcare Association of New York (HANY) told providers Tuesday that the Empire State that it will not use the UnitedHealthcare (UHC) Sepsis-3 criteria when reviewing claims to validate sepsis for payment. New York state law defines sepsis with systemic inflammatory response syndrome (SIRS) criteria, otherwise known PRESUMPTIVE COMPLIANCE FOR IRFS: ARE YOU FACING A DESK A formal letter from your Medicare Administrative Contractor (MAC) is rarely a welcome surprise. For inpatient rehabilitation facilities (IRFs), a letter informing the provider that they have not met IRF classification requirements related to the 60 percent rule based on “presumptive methodology” and thus will be subject to “medical review methodology” is pretty much never welcome.NEWS | RACMONITOR
Another Pharma Company Settles False Claims Act Claims for paying Kickbacks. Mary Inman, Esq. and Max Voldman, Esq. May 26, 2021. ReadMore ».
TO MASK OR NOT TO MASK? ASK OSHA The most recent CDC guidance on masks is again, just guidance. If you’re like me, you went out this past weekend to Home Depot or your favorite restaurant to find a state of near chaos in terms of people wearing masks or not – and businesses requiring themor not. OIG AUDITS GETTING BACK IN GEAR Federal contractors are paying particular attention to payment for COVID care. It’s time to revisit a prediction regarding COVID-related audits.WORD2 | RACMONITOR
An MLN Matters article published on Dec. 11 reported on a recent advisement from the Centers for Medicare & Medicaid Services (CMS) to its medical review contractors related to therapy services in Inpatient Rehabilitation Facilities (IRFs). Consistent with what we are seeing in the field, two key areas were addressed in this guidance to contractors: Therapy intensity of services Individualized BATTLING THE BACKLOG AT THE ALJ Battling the Backlog at the ALJ. Frank D. Cohen, MPA, MBB. April 21, 2021. A federal judge ordered the government to reduce the massive backlog of healthcare hearings – and if recent events are any indication, it may finally be happening. I imagine that pretty much everyone who touches on coding and billing compliance in our industryis
COVID-19 WAIVERS: WHAT IT MEANS FOR IRFS COVID-19 Waivers: What It Means for IRFs. On March 13, the Centers for Medicare & Medicaid Services (CMS) issued blanket waivers that will impact Inpatient Rehabilitation Facilities (IRFs) as well as other Post-Acute Care (PAC) settings. The blanket waivers, which do not require any special request to be filed, will allow IRFs to admitpatients
UTILIZATION REVIEW: IMPLEMENTING A “TIGHT” PROCESS TO The best place to start would be utilization review (UR), with the implementation of a “tight” process. This will require precise, accurate, compliant knowledge of the UR process, followed by a gap analysis. This analysis is like building a puzzle. The picture on the box reveals the intended result. The individual pieces are the partsof
NEWS ALERT: BFCC-QIO AUDITS POISED TO RESUME Providers would do well to prepare by taking a close look at their short stays. After a multi-year pause due to the COVID-19 pandemic and a contract dispute, it appears that the Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC-QIO) short-stay audits are poised to resume, with Livanta being the sole contactors providing audit services THE NEW SHORT-STAY EXCEPTION: READ BEFORE USING I have written a lot in the past about the two-midnight rule exception for physician judgment of the need for inpatient admission with an expectation of a stay of under two midnights. As a reminder, when the two-midnight rule was first adopted, the only approved exceptions to the two-midnight expectation were unplanned mechanical ventilation and inpatient-only surgery. (Patients who have a COPYING AND PASTING: THE REAL RULES PREVAIL In my job, I wear many hats. I am an auditor, a physician educator, a consultant, an author, and an auditing instructor. In these roles, I hear a common concern regarding the use of electronic health records (EHRs): that of cloning, or copying and pasting, records. It is important first to consider the rules that exist regarding copying and pasting, as compared to the opinions of many in the* Home
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THE FUTURE OF TELEHEALTH: A LESS ROSY OUTLOOK By Ronald Hirsch, MD The future of telehealth is too uncertain. It is clearly too early to speculate about life after the COVID-19 pandemic. But one question that many are seeking to answer is this: what is the future of telehealth, once the public health emergency has ended? While Seema Verma, the Centers for ...Read More
COVID-19 FUNDING FOR PROVIDERS IN CARES 2.0: NEW MONEY AND MOREGUIDANCE
By Matthew Albright
More money to offset the impact of COVID-19. EDITOR’S NOTE: During recent weeks, the Centers for Medicare & Medicaid Services (CMS) has been announcing revisions to its regulatory requirements on a near-daily basis to ease administrative and logistical burdens on providers amid the ongoing ...Read More
INTERSECTION OF COVID-19 AND SDOH By Ellen Fink-Samnick MSW, ACSW, LCSW, CCM, CRP Employment security, health insurance, and mental health are issues that are dominating care management. The dramatic rise in unemployment has received considerable focus across the country, with so many experiencing challenges with health insurance, access to care, and added numbers of persons at ...Read More
EXPANSION OF TELEHEALTH A POTENTIAL SAVIOR FOR PROVIDERS REELING FINANCIALLY FROM PANDEMIC By David M. Glaser, Esq. Reimbursement for such services has grown during recent weeks. Many healthcare entities are facing tough economic times. There is a possible solution that benefits patients while also providing revenue that may help healthcare organizations survive. Send something to all patients explaining that ...Read More
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REPLACEMENT NAMED FOR HHS OIG CHIEF WHO HIGHLIGHTED HOSPITAL STRUGGLES AMID PANDEMICBy Mark Spivey
The ousting of Christi A. Grimm comes amid a series of OIG removals, developments that are concerning lawmakers and editorial boards alike. “The first messenger that gave notice of Lucullus’s coming was so far from pleasing Tigranes, that he had his head cut off for his pains; and no man daring ...Read More
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