On a Monitor Mondays broadcast in July, I reported that The Center for Medicare Advocacy had received half a million dollars from the John A. Hartford Foundation to “raise awareness” of the negative consequences of what they call “observation status” (observation is service provided to patients whose status is listed as outpatient, but I will refer to it simply as “status” in this article). Details about the first result of that …Read more
The good thing about compliance is that there is always a roadmap to rely upon and guidance from the enforcement authorities on where to focus your compliance efforts. The “go-to” document issued each year is the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) Work Plan. The OIG released its 2017 Work Plan in November, and there is a lot that can be learned by reviewing …Read more
EDITOR’S NOTE: Here is the second installment by the author. Part I appeared in the Nov. 17, 2016 edition of the RACmonitor eNews. Earlier we discussed the approach and reasoning for audits, and how that should drive the findings to separate “this will do” from “this is compliant documentation.” It’s hard to know if a third-party auditing firm is going to provide this type of review for you. I was working …Read more
Perhaps the biggest news out of the 2017 Outpatient Prospective Payment System (OPPS) final rule is something that didn’t happen. The proposed rule was going to prevent off-campus, provider-based entities from offering any new services that were not within a clinical family furnished and billed as of Nov. 2, 2015. the Centers for Medicare & Medicaid Services (CMS) opted not...Read more
There are two sections of the Federal Register entry of the 2017 Outpatient Prospective Payment System final rule that address the implementation of Section 603 of the Bipartisan Budget Act (BiBA) of 2015. This involves congressionally mandated payment changes for off-campus, provider-based clinics and operations. Interestingly enough, the provider-based rule (PBR) found at 42 CFR §413.65 is not materially changed. The...Read more
The Centers for Medicare & Medicaid Services (CMS) last month posted responses to questions submitted at the time of the August federal inpatient rehabilitation facility (IRF) training for quality measures. The entire document can be found on the IRF quality reporting training website here: (Q&A). Based on the questions and responses in that document, one thing is clear: the who, how,...Read more
I recently received an email from a case manager who was questioning something I had said at a conference about condition code 44. She wrote, “We continue to have problems with our billing department that insists on ‘stop billing’ accounts where a compliant Condition Code 44 process was done but the order for observation was not signed until after the...Read more
The official 2017 Coding and Reporting Guidelines are creating one of the biggest frustrations for hospital audit and denial teams in recent memory. Payers are rapidly downgrading DRGs due to a lack of clinical evidence even though the documentation by clinicians is sufficient for a coder to code the diagnoses correctly. Ronald Hirsch, MD will provide valuable insight as a physician and as a nationally recognized physician advisor on how to arrive at a compliant solution for one of the most insidious attacks this year on DRG clinical validation.
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