NEWS RELEASE

FOR IMMEDIATE RELEASE

Tampa, Fla. – [December 11, 2024] – Florida State University has announced its 2025 Seminole 100 list, an annual recognition of the fastest-growing businesses owned or led by FSU alumni. Brundage Group, a leading provider of innovative healthcare solutions, is proud to be included in this prestigious group, which celebrates entrepreneurial excellence and industry leadership.

Brundage Group is honored to have multiple FSU alums on its leadership team, including Chief Culture Officer Patty Brundage, Vice President of Business Development Taylor Smith, and Jason Coffing, Managing Partner of Brundage Workforce Solutions. Their leadership, rooted in the values of innovation and excellence, has been instrumental in driving the company’s growth and success.

“It is an incredible honor for Brundage Group to be recognized on the Seminole 100 list,” said Dr. Tim Brundage, CEO. “This recognition reflects the team’s hard work and innovative spirit. I am particularly proud to share this milestone with Patty, Taylor, and Jason, whose contributions exemplify the excellence instilled during their time at Florida State University.”

Brundage Group is grateful to Florida State University for this recognition and congratulates the other honorees.

Brundage Group is the trusted choice of hospital systems for revenue cycle management solutions. We support hospitals nationwide with customized solutions that include a full suite of physician advisory services, staff augmentation/workforce solutions, proprietary level of care analytics, and physician-led documentation education to relay high-quality care. Our programs help hospital organizations break down departmental silos by unifying all departments in the mid-revenue cycle. Our dedicated staffing division provides seasoned, veteran RN case managers, utilization review nurses, and appeals/denials professionals, all backed by our team of expert physician advisors and documentation and coding experts.

Media Contact

Lacey Thompson
Brundage Group
Email: lthompson@brundagegroup.com
https://brundagegroup.com/

Despite the Two-Midnight Rule passing its 11-year mark, there’s still confusion about when to place an inpatient order for patients initially placed in outpatient status with observation.

I see the same case reviewed by multiple Physician Advisors, with different outcomes. The American College of Physician Advisors (ACPA) publishes an observation case in its monthly newsletter. There is always nuance in how the Two-Midnight Rule should be applied, which can result in differing opinions. This year, much of the conversation revolves around how Medicare Advantage (MA) plans should respect the rule, but from what I’ve seen, compliance is still inconsistent.

However, I’d like to refocus on the basics – and possibly provide a different perspective. While the differing opinions can be academic, hospitals have real cases, real audits, and real revenue, so it is kind of a big deal. This has major implications for both original Medicare and Medicare Advantage, especially as we work to hold MA plans accountable.

Regardless of the payer, all Medicare beneficiaries should be managed consistently, so our rationale and perspective from which we make decisions must remain uniform.

Let’s consider the same patient presenting to three hospitals with chest pain. Initial and repeat troponins are negative, but due to risk factors, the ED physician calls the hospitalist, who places an order for observation.

Should an inpatient order be placed for any of these patients? Two of the three are suspected to have passed a second midnight in the hospital.

Let’s review the relevant regulation found at 42 CFR 412.3, starting in paragraph (D)(1):

“Except as specified in paragraphs (d)(2) and (3) of this section, an inpatient admission is generally appropriate for payment under Medicare Part A when the admitting physician expects the patient to require hospital care that crosses two midnights.

• The expectation of the physician should be based on such complex medical factors as patient history and comorbidities, the severity of signs and symptoms, current medical needs, and the risk of an adverse event. The factors that lead to a particular clinical expectation must be documented in the medical record in order to be granted consideration.”

I frequently hear that American Medical Association (AMA) definitions of discharge, death, or rapid improvement are referred to as exceptions. As the chair of the ACPA Certification Committee and Exam, I have received complaints regarding a question that addresses this issue (hint: this is on the exam). This is a misunderstanding of the Two-Midnight Rule.

Unforeseen circumstances are not exceptions. The rule is about expectation. Patients with unforeseen circumstances still must have a two-midnight expectation when the order is placed, and the documentation must support that expectation. This same principle is vital in deciding who should be upgraded to inpatient status. The rule hinges on the expectation of a two-midnight stay, which must be documented. Conversely, an observation order identifies that the physician does not expect the patient to require greater than two midnights of hospital care. This is absolutely critical.

Another helpful quote can be found in the Two-Midnight Rule itself, Rule 1599-F. It states:

“The crux of the medical decision is the choice to keep the beneficiary at the hospital in order to receive services or reduce risk or discharge the beneficiary home because they may be safely treated through intermittent outpatient visits or some other care.”

Let’s apply this to our scenarios, recognizing that the “admitting” physician did not expect the patient to require hospital care that crossed two midnights when he/she placed an order for observation:

So, what does this all mean, and how can it be applied to reviewing cases and educating physicians on documentation? First, when reviewing observation cases, focus on clinical changes. Observation is intended to extend the workup time and determine if the patient needs ongoing hospital care or can be safely treated with intermittent visits or other care.

A lack of clinical changes or specific documentation to alter the expectation of a stay of fewer than two midnights likely means inpatient status is not warranted.

Physicians must be educated on the importance of documentation on hospital day 2. It is not enough to continue the initial plan, as that plan expected fewer than two midnights. When an inpatient order is placed, that day’s progress note becomes the admission note, and needs to support the expectation of a stay beyond two midnights. The regulation states,

“The factors that lead to a particular clinical expectation must be documented in the medical record in order to be granted consideration.”

I recommend physicians specifically document why the patient requires hospital care, including why the same care could not be safely provided via intermittent outpatient visits or some other care. When done correctly, denials are reduced, and peer-to-peer overturn rates improve.

Above all, you will be confident that your facility is compliant – and receiving the revenue it rightfully deserves.

By Tim Brundage, MD CCDS

Health systems face pressure in today’s margin-compressed environment. Department heads are routinely called to justify their budgets, ensure costs are contained, and deliver on metrics prioritizing immediate departmental financial health. Yet, while hospitals excel at scrutinizing expenses, few have mastered connecting those expenses to the returns they generate—particularly when those returns show up in different parts of financial statements.

Hospitals may focus on short-term savings but unintentionally miss out on significant long-term value, sometimes to the extent that maintaining or even increasing investment could lead to better financial outcomes.

The result? Hospitals risk being “penny wise and pound foolish.”

Utilization Management (UM) and Utilization Review (UR) leaders are rewarded for keeping staffing costs under budget or maintaining low utilization percentages.  These department-level metrics, while important, often come with unintended consequences:

A clear, enterprise-level understanding of costs and benefits empowers hospitals to avoid unintended decisions that could negatively affect their financial health.

Well-implemented Physician Advisor services frequently deliver a 10:1 (or even better) ROI. For every dollar spent on Physician Advisor resources, hospitals can capture or retain $10 in compliant net revenue.  For instance:

Investing $100,000 monthly in Physician Advisor services could yield $1 million in monthly incremental net profit by reducing denials and facilitating compliant observations to inpatient conversions; these services typically offer higher reimbursement rates for equivalent care.

However, the 10:1 ratio can flex up or down as it is heavily impacted by the skill and experience of the Physician Advisors being utilized; in upcoming blog posts, we will dive deeper into the full economics of Physician Advisor programs to explore how hospitals can optimize Physician Advisor support.

Unfortunately, too many hospitals focus solely on the expense side of the equation, treating Physician Advisor services as a cost center rather than an essential component of the revenue cycle needed to ensure appropriate reimbursement. This perspective ignores the financial ripple effect of suboptimal or insufficient Physician Advisor utilization, including:

• Missed opportunities to overturn denials.
• Incorrect status determination leading to revenue loss and increased denials.
• Delays in identifying medical necessity issues that impact reimbursement.

At Brundage Group, we work closely with our hospital partners to factor both costs and benefits at an enterprise level- not just department silos. Our mission is clear: to empower hospitals to remain financially viable while continuing to serve their communities.

If you are evaluating your approach to Physician Advisor services- whether considering internal programs, third-party support, or a combination- ask yourself these critical questions:

Making decisions about Physician Advisor services is not just about managing costs—it’s about understanding the complete financial picture of the clinical revenue cycle and ensuring your hospital maximizes compliant revenue opportunities. As a trusted advisor, Brundage Group provides the expertise and tools needed to navigate these decisions competently and confidently.

A few weeks ago, during the weekly Monitor Monday broadcast, healthcare attorney David Glaser presented a great segment that simplified the two-midnight rule into two essential parts: first, that a patient must require hospital care, and second, that the need for that care must be expected to span two midnights.

Yet despite the clarity of these conditions, why does conflict persist between payers and hospitals on how this rule is applied?

One main issue is that some payers still need to fully recognize the rule despite clear regulations. However, a more significant challenge stems from differences in defining and understanding what constitutes hospital care.

This leads to an important question: What exactly is hospital care? Is it simply any skilled service provided within the hospital walls? Alternatively, is it a restrictive definition used by many Medicare Advantage companies, where a patient must meet strict third-party criteria to qualify?

What does it mean for a patient to require hospital care? For insight, we look at Rule 1599F—the two-midnight rule—which clarifies that “The crux of the medical decision is the choice to keep the beneficiary at the hospital in order to receive services or reduce risk or discharge the beneficiary because they may be safely treated through intermittent outpatient visits or some other care.“

If the required care could be delivered safely outside the hospital or in a less intensive setting, it should not count toward the two-midnight benchmark. Notably, the decision should be evidence-based rather than it be convenient for the patient or physician, and external, third-party criteria should not dictate it.

In my most recent segment during the Monitor Monday broadcast, I discussed how an order for observation services indicates that the physician cannot confidently predict a patient will need hospital care for over two midnights. Per the guidance above, on day two of the hospital stay, the patient must be discharged, or documentation to substantiate the need for ongoing hospital care must be present.

Based on the above guidance from the two-midnight rule, this documentation should expressly state or make obvious why the same care cannot safely be provided elsewhere or through periodic outpatient visits. Unfortunately, in our busy healthcare environment, physicians often rely on templated language that needs more specifics on patient acuity or the unique need for ongoing hospital care.

For example, I was able to overturn a denial on peer-to-peer review for a patient with chronic obstructive pulmonary disease (COPD) on room air when the physician documented persistent shortness of breath, tachypnea, and the need for IV steroids. However, despite similar presentations, a patient whose chart stated they had “improved since admission” and whose exam appeared as a generic template was denied because the documentation did not support the need for hospital care.

Both required hospital care, but only one was paid as an inpatient.

At my previous organization, we piloted an initiative to address documentation gaps. Adding a dedicated section to the physician’s note template prompted hospitalists to include one concise statement, based on their medical judgment, explaining why the patient required hospital care and could not be discharged. The documentation was to be based solely on the medical rationale and proposed or required treatment and not consider social or other discharge barriers outside the physician’s control.

We wanted them to tell us when the patient was medically cleared and, if not medically cleared, why not. As you can imagine, implementing this required substantial engagement and education and did not happen overnight. Physicians struggled to distill this information into a statement other non-physicians can understand. They are taught to list diagnoses and the appropriate treatment for that diagnosis.

No text or handbook provided in residency teaches young physicians when patients should be discharged. These practice patterns are institutional and passed down from attendings to residents.

However, in implementing this process, I found that many young hospitalists assumed that someone had determined they needed to be in the hospital because the patient was there. Many didn’t even realize people were looking to them to help with these decisions. I won’t lie; getting this to change takes some heavy lifting, but it ultimately streamlined the status process, reduced denials, and increased overturn rates during peer-to-peer reviews. It also improved communication and participation in multidisciplinary rounds, which helped the care management team organize discharge plans for skilled nursing facilities, home health, and other services.

Instead of the discharge process being worked “in series,” where the care management team would have to wait until the physician cleared the patient to start working on placement, our goal was to have parallel processes that lined up at the same time, thus reducing unnecessary delays waiting for acceptance, authorization, supplies, etc. This proactive coordination significantly decreased avoidable hospital days and length of stay, benefiting both patients and the hospital.

In sum, the two-midnight rule is evident in its intent, but clarity in documentation supporting the ongoing need for hospital care is the third essential step in reducing denials and preventing audit takebacks.  Collaboration between the Physician Advisor and hospitalist medical director is required to provide physician education and promote engagement and buy-in.

However, the reality is we overcomplicate the two-midnight rule. The rule is clear. It’s often the documentation and rationale that is missing. If you can get that part in order, it is as easy as one, two, three.

In today’s complex healthcare landscape, regulatory compliance, revenue optimization, and operational efficiency are critical for success. Certus Radar is designed to tackle these challenges head-on. Our innovative proprietary platform, built with direct input from seasoned Physician Advisors and revenue cycle experts, ensures that hospitals stay compliant while maximizing their revenue and operational potential.

Here’s how Certus Radar achieves these goals:

Certus Radar was built by Physician Advisors and revenue cycle experts who understand the intricacies of clinical and regulatory standards. Our expert team has decades of experience interpreting regulations and supporting compliant revenue cycle practices.

Hospitals never sleep, and neither does Certus Radar. The platform is designed to function continuously, even during off-hours, holidays, and staff downtime. This ensures that utilization management processes remain optimized all the time, preventing costly delays, maintaining operational efficiency and fully capturing earned revenue.

Revenue capture can be a complex and challenging process, but Certus Radar simplifies it by combining expertly designed case automation with the clinical expertise of Brundage Group Physician Advisors. The platform monitors patients admitted to the hospital to optimize patient status verification by accurately determining which accounts need to be escalated to a Physician Advisor as well as determining the optimal time for the review to occur. Allowing UM staff to focus on the right patients at the right time, preventing revenue opportunities from slipping through the cracks. Accurately determining patient status as early as possible reduces revenue leakage and optimizes the use of hospital resources.

In healthcare, timely and actionable data is essential. Metrics that reflect the accuracy and efficiency of utilization review efforts are often overlooked but play a vital role in the financial health of a hospital. Certus Radar provides real-time analytics through key performance indicator (KPIs) dashboards that impact a hospital’s financial health. From optimizing staff schedules to improving overall operational efficiency, the platform’s real-time insights allow hospital leadership to make data-driven decisions that positively impact financial health and operating margins.

By Tim Brundage, MD, CCDS

A recent study by Kodiak analyzed claims data from 1,900 hospitals. Significant insights emerged regarding compliance with the Medicare Two-Midnight Rule among various payers, including commercial managed care plans, Medicare Advantage (MA) plans, and traditional Medicare. The findings underscore a critical issue that hospitals face today: payers often apply their criteria for inpatient admissions rather than adhering to the Two-Midnight Rule for all Medicare beneficiaries.

The Centers for Medicare and Medicaid (CMS) mandated use of the Two-Midnight Rule when determining the medical necessity of inpatient services by MA plans effective January 1, 2024.  Although Medicare Advantage beneficiaries are entitled to the same covered services as those with traditional Medicare, they have historically experienced lower inpatient rates due to stricter medical necessity criteria. Implementation of the Two-Midnight Rule was supposed to eliminate that discrepancy.

Despite the new Medicare Advantage coverage changes, the data suggest widespread non-compliance, which poses a financial risk to hospitals.

The study reveals that Medicare Advantage plans have yet to fully comply with the Two-Midnight Rule, leading not only to revenue loss but unnecessary expenses for hospitals when appealing these noncompliant denials. This trend highlights the urgent need for hospitals to be vigilant in monitoring MA plan medical necessity denials.

At Brundage Group, we understand the complexities of navigating this landscape. Our expertise in overturning medical necessity denials is more crucial than ever in this environment of payer non-compliance. Our team challenges inappropriate denials, making sure hospitals capture appropriate revenue for the care delivered to MA plan beneficiaries in good faith.

The findings from Kodiak’s study remind Brundage Group of our critical role in safeguarding our hospitals’ interests. Our compliant approach to medical necessity denials helps to ensure admissions are accurately classified according to established guidelines.

By partnering with Brundage Group, you gain access to a team knowledgeable about the Two-Midnight Rule and adept at leveraging data-driven insights to strengthen your case against payer denials. We actively monitor trends by payer, provide expert guidance, and share valuable information to enhance your organization’s ability to navigate these challenges.

The data from Kodiak’s study highlights the pressing need for healthcare systems to be proactive with their utilization review strategies. With Brundage Group, you will be prepared to challenge unjust denials and benefit from our extensive knowledge of payer behaviors and regulatory requirements.

In an increasingly complex compliance landscape, Brundage Group’s expertise in overturning medical necessity denials is a key resource for healthcare systems. Our expertise, combined with insights from proprietary analytics platform, equips hospitals to navigate the nuances of payer behaviors confidently.

NEWS RELEASE

FOR IMMEDIATE RELEASE

Tampa, Fla. – [October 22, 2024] – Brundage Group is excited to announce a partnership with Iodine Software, bringing our Physician Advisors into the AwareUM platform. This collaboration enables seamless integration of Brundage Group Physician Advisors with hospital utilization management (UM) teams, creating new opportunities for optimized decision-making, workflow efficiency, and improved patient outcomes.

Taylor Smith, Vice President of Business Development at Brundage Group, shared his excitement for the partnership:

“This collaboration enhances support for hospitals in managing utilization and revenue cycles. By integrating our Physician Advisors into the AwareUM platform, we combine real-time expertise with innovative technology, empowering hospitals to make informed decisions and capture their earned revenue.”

Brundage Group’s Physician Advisors manage over 4,000 peer-to-peer calls monthly across major payers, including Medicare Advantage and Commercial payers such as UnitedHealthCare, Aetna, Cigna, Humana, Blue Cross Blue Shield, WellCare, and more. Now, with the integration of AwareUM, our Physician Advisors can offer hospitals even greater efficiency in real-time case management, patient status determination, and denials management.

Brundage Group’s Physician Advisors specialize in reviewing medical necessity and documentation, bridging clinical and business aspects of medicine, and ensuring accurate patient statuses based on medical necessity.

Brundage Group’s expert team of Physician Advisors and denial management specialists meticulously analyze and resolve denials, identifying trends and root causes to develop targeted prevention strategies, ensuring accurate reimbursement for hospitals.

Our revenue integrity analytics platform provides data-driven insights to identify trends, improve utilization, and make revenue-positive decisions.

Brundage Group is the trusted choice of hospital systems for revenue cycle management solutions. We support hospitals nationwide with customized solutions that include a full suite of Physician Advisory services, staff augmentation/workforce solutions, proprietary level of care analytics, and physician-led documentation education to relay high-quality care. Our programs help hospital organizations break down departmental silos by unifying all departments in the mid-revenue cycle. Our dedicated staffing division provides seasoned, veteran RN case managers, utilization review nurses, and appeals/denials professionals, all backed by our team of expert Physician Advisors and documentation and coding experts.

Lacey Thompson
Brundage Group
Email: lthompson@brundagegroup.com
https://brundagegroup.com/

As we celebrate Case Management Week, let’s explore how case management has evolved and recognize Physician Advisors’ vital role in supporting this essential function. Here’s a look at the evolution of case management and the value Physician Advisors bring:

As case management has evolved, Physician Advisors have become indispensable in helping case management teams navigate today’s complex healthcare landscape.

Here’s how they contribute:

• Physician Advisors provide real-time clinical guidance to support accurate patient status decisions and efficient resource utilization.
• By leveraging analytics and benchmark data, Physician Advisors offer insights that improve care coordination and help uncover revenue opportunities.
• Physician Advisors collaborate with case managers to ensure timely discharge planning, which reduces lengths of stay.

Brundage Group is proud to announce that Keith Fulmer, Chief Technology and Innovation Officer (CTIO), has been recognized by Becker’s Hospital Review in their prestigious 2024 edition of “Health IT and Revenue Cycle Up-and-Comers.”

This list highlights rising stars who drive expansion, transformation, and financial success across hospitals, health systems, and healthcare companies. These leaders are shaping the future of healthcare by optimizing operations through health IT and revenue cycle management. Fulmer’s innovative leadership and dedication to advancing Brundage Group’s services and technology infrastructure have earned him a place among these visionary professionals.

Keith Fulmer’s expertise has been pivotal to Brundage Group’s growth. He helps the company navigate the evolving healthcare landscape and ensures that our clients benefit from cutting-edge technology solutions. His leadership has been instrumental in advancing revenue cycle management initiatives that enable healthcare organizations to improve efficiency and achieve financial success.

The Becker’s Hospital Review editorial team selected this list from a pool of nominations, highlighting individuals demonstrating remarkable contributions to healthcare IT and revenue cycle operations. Fulmer’s inclusion on the list reflects his exceptional commitment to Brundage Group’s mission of delivering innovative solutions that enhance healthcare performance and patient outcomes.

For more information and to view the complete list, visit Becker’s Hospital Review.

Brundage Group is the trusted choice of hospital systems for revenue cycle management solutions. We support hospitals nationwide with customized solutions that include a full suite of physician advisory services, staff augmentation/workforce solutions, proprietary level of care analytics, and physician-led documentation education to relay high-quality care. Our programs help hospital organizations break down departmental silos by unifying all departments in the mid-revenue cycle. Our dedicated staffing division provides seasoned, veteran RN case managers, utilization review nurses, and appeals/denials professionals, all backed by our team of expert physician advisors and documentation and coding experts.

• Lacey Thompson
• Email: lthompson@brundagegroup.com
• https://brundagegroup.com/

By Tim Brundage, MD CCDS

As hospitals look to reduce costs, bringing Physician Advisor (PA) services in-house often emerges as an attractive solution. After all, eliminating external PA contracts is an immediate way to save money. But is this approach as financially sound as it appears? Before making the transition, there are several critical factors worth considering.

Many hospitals view PA services as an expense rather than an opportunity for revenue growth. But is this perception causing you to overlook the actual financial impact of a well-supported PA program? With their specialized expertise and resources, external PA services often generate significant returns for hospitals by identifying revenue opportunities that might otherwise be missed. Are you confident that transitioning in-house will maintain or enhance these returns?

While an internal PA program may appear more cost-effective on the surface, have you considered whether it can fully meet the demands of your hospital? Physician guidance, including evenings, weekends, and holidays, is needed at all hours. Can your in-house staff consistently cover these needs without burnout or gaps in service? What about the additional administrative and operational burdens of managing a PA program internally? Is your hospital prepared to handle these complexities without sacrificing the quality and availability of PA guidance?

External PA services often come with the advantage of a robust support network, giving your hospital access to a broader range of expertise. This network can enhance the effectiveness of your PA program through shared insights, industry best practices, and collaborative problem-solving. By moving in-house, are you potentially isolating your PA team from these valuable resources?

One of the strengths of working with an external PA service is access to industry benchmark data and advanced analytics. This data provides insights into how your hospital’s revenue cycle performance compares to other hospitals nationwide. Are you confident that transitioning to an internal program will offer the same level of data-driven decision-making?

As you evaluate your operational capabilities, consider whether you have a work management platform that equips your teams with the right data when needed.

Effective workflows improve visibility and help teams locate patient, clinical, and payer data quickly. With predefined, customizable workflows, users can navigate complex information more efficiently, reducing delays and improving accuracy. This approach enhances coordination among departments and optimizes revenue capture and compliance, all while boosting operational efficiency. Are you confident your current system can meet the demands of your evolving healthcare environment?

Transitioning to an internal PA program may seem straightforward and cost-saving, but the reality is often more complex. Have you thoroughly evaluated the potential trade-offs, including missed revenue opportunities, reduced access to expertise, and the potential for increased operational strain? Before leaping, it’s crucial to consider whether an internal program will genuinely deliver the financial and operational benefits your hospital needs.

From my experience, DRG validation is about more than just billing. Ultimately, it’s about ensuring the patient’s clinical story is adequately reflected in the documentation and codes. This alignment is critical for several reasons:

• Accurate Reimbursement: As physicians, we know that the complexity of our patient’s conditions is only sometimes fully captured in the initial coding. Additionally, hospitals can lose substantial revenue when documentation doesn’t reflect the actual severity of illness.
• Reducing Denials: Denied claims place a significant administrative burden on hospitals and clinicians. Validating DRGs ensures that the documented and coded are clinically valid and aligned with coding guidelines, reducing the risk of costly denials.
• Compliance and Audit Readiness: Physicians are held to high standards of care and documentation. A robust DRG validation process helps ensure compliance with coding guidelines, reducing the likelihood of audits and penalties related to high-risk DRGs.
• Quality Measure Performance: Many hospital quality measures such as those within the Center for Medicare and Medicaid Services (CMS) value-based purchasing measures are based entirely on the coded record rather than clinical outcomes. However, this discordance can result in low quality measure performance if the coded record is not an accurate and complete picture of the patient’s conditions and course. 

The most successful DRG validation efforts involve collaboration between multiple teams. CDI specialists, coding professionals, and Physician Advisors each play a vital role:

• CDI Specialists: With their clinical expertise, CDI teams help ensure documentation accuracy and clinical validity. They often identify documentation gaps that can be corrected before coding occurs.
• Coding Experts: Coding professionals ensure the codes applied are accurate and in line with current regulations. They bridge the gap between clinical documentation and the billing process, ensuring that the hospital is reimbursed appropriately. 
• Physician Advisors: Provide additional clinical insight, and a unique perspective needed to ensure that the DRGs accurately reflect the patient’s clinical condition. Our involvement often helps resolve clinical documentation discrepancies, improve queries, and provide necessary education to achieve more accurate coding and improved compliance.

CDIs and coders review cases concurrently, but an additional second-level review may be valuable for certain DRGs. Analogous to clinical workflows, redundancy through collaborative efforts—such as two nurses verifying a high-risk medication dose—helps reduce clinical errors. Although multiple checks within CDI and coding are not always feasible, applying this concept can reduce revenue leakage and improve compliance by ensuring that the coding and documentation in certain cases are accurately reflected in the claim codes

At Brundage Group, I’ve been proud to be a part of a team of CDI, coding professionals and Physician Advisors that have delivered exceptional results through our DRG Validation Reviews:

For Physician Advisors like me, being actively involved in DRG validation has allowed me to bridge the gap between clinical care and the administrative side of healthcare. Moreover, it’s not just about ensuring the hospital gets paid; it’s about ensuring that the patient’s story is accurately documented and that we, as clinicians, are correctly credited for the complexity of the care we deliver. 

If you’re a Physician Advisor or hospital leader, I strongly urge you to participate actively in DRG validation. The impact goes beyond finances—it ensures compliance, reduces denials, and improves the overall quality of care.

By Cheryl Ericson, RN, MS, CCDS, CDIP

Gone are the days when Clinical Documentation Integrity (CDI) was referred to as a “program.” Today, CDI Departments have become mainstream. They are no longer a supplemental business function as hospitals without a robust CDI department cannot keep up with their peers. As an integral part of the revenue cycle, CDI activities must be tied to organizational metrics in meaningful ways that identify success and improvement opportunities.

Traditionally, when hospitals faced economic hardships, they would set goals to either grow revenue or cut costs. A favorite metric of hospital leadership when tracking revenue expectations within the inpatient population has been case mix index (CMI). Often leadership would set year-over-year goals of increasing the CMI. In the early days of CDI, there was a lot of opportunity and CDI departments would be credited with “finding” millions of dollars of incremental revenue through an increasing CMI even though there are many factors that impact CMI beyond CDI activities.

Fast-forward to the COVID pandemic, when CMIs peaked because only the sickest patients could access inpatient care. But there was also an important lesson to be learned during COVID regarding CMI. A high CMI was no guarantee of profitability. MS-DRGs are a classification scheme comprised of clinically similar patients as determined by the principal diagnosis, who are expected to consistently use similar amounts of hospital resources. It was designed to cover routine costs like room and board, nursing care, diagnostics, treatment, and ancillary services. Patients who need additional healthcare resources are identified through secondary diagnoses classified as complications/comorbidities (CC) and major complications/comorbidities (MCC). When a CC or MCC is present on a claim and not designed by the Centers for Medicare and Medicaid (CMS) as a Hospital Acquired Condition (HAC), the hospital gets paid a higher rate because the patient requires more hospital resources.

The Medicare Severity Diagnostic Related Group (MS-DRG) reimbursement methodology is a prospective payment system. The significance of this should not be overlooked. Hospitals provide services in good faith under the MS-DRG system expecting future payment that reflects the billed MS-DRG. Astute hospitals have always tracked both the billed CMI as well as the adjusted CMI. The adjusted CMI is based upon payments received rather than what was billed. The importance of monitoring the adjusted CMI cannot be overstated in today’s healthcare environment where payer denials are ever increasing.

CDI activities affect not only the billed CMI but also the adjusted CMI. As hospitals look to maximize revenue opportunities there may be additional pressure on CDI departments to increase CC and MCC capture rates and CMI, but this only tells half the story. However, a better way to monitor the effectiveness of CDI efforts is to examine how CDI efforts contribute to the adjusted CMI. This is where revenue leakage is occurring. The goal has always been for CDI activities to support accurate billing that reflects the acuity of the patient population. Though all denials are not justifiable even on appeal, the result is still an inaccurate bill. The hospital is “losing” expected revenue. Tracking the adjusted CMI helps an organization create more of a realistic expectation of incremental revenue opportunities, especially when there is no guarantee that CMI will continue to increase.

Tracking the right metrics allows hospital leadership to better measure the success and shortcomings of CDI efforts. One of the metrics that hospitals should track is the percentage of cases reviewed by CDI staff that results in a denial, especially when a clinical validation denial affects a diagnosis added by a CDI query. Because submitting “accurate” bills can reduce revenue leakage and the administrative costs associated with appeals, it is in every hospital’s financial interest to track the impact of CDI and Coding activities on the billing process. This is not to imply that individual CDI and Coding professionals should be reprimanded when a denial occurs on a claim they worked; however, it is important for CDI and Coding professionals to receive direct feedback about how their work is affecting the overall financial health of the organization so adjustments can be made as needed to minimize lost revenue.

Because the lifecycle of a claim can be so long, it can be beneficial to use a proxy to audit inpatient claims prior to their submission. Many organizations have a second level review process or internal audit process, but it is often more effective to have an objective third party conduct these second level reviews and provide constructive feedback on problematic trends. When considering a vendor to perform these prebill audits, it is best to consider one who has experience in appealing DRG and clinical validation denials because they are more likely to understand industry trends that contribute to revenue leakage even if it has yet to reach your health system.

Though it is unrealistic to expect 100% accuracy- as some payers may have unreasonable expectations – improvement is always possible. Tracking “clean claims” has always been a metric in the outpatient setting and a measure of success for registration, insurance verification, and other early revenue cycle departments.

As we celebrate Clinical Documentation Integrity (CDI) Week September 16 – 20, it’s the perfect time to spotlight CDI’s vital role in healthcare. CDI is not just about accurate documentation; it’s about assuring that hospitals are appropriately reimbursed for their care, reducing compliance risks, and supporting high-quality patient care. One of the most critical areas that CDI professional impact is Diagnosis-Related Group (DRG) assignment. Want to learn how CDI and DRG validation work together to compliantly capture earned revenue?

CDI departments are the backbone of accurate clinical documentation, ensuring that the medical record fully captures the clinical scenario in terms that accurately reflect patient acuity within ICD-10 nomenclature. This accuracy is essential for correct DRG assignment, as DRGs categorize patients for billing purposes. Incomplete or imprecise documentation can lead to incorrect DRG assignments, potentially affecting hospital reimbursement and financial health.

CDI specialists help optimize DRG assignments by identifying clinical indicators associated with undocumented diagnoses, ensuring hospitals receive appropriate reimbursement for care delivered. This optimization prevents the pitfalls of under coding, which can lead to lost revenue, and over coding, which can result in compliance risks. Accurate DRG assignment is critical to aligning hospitals’ reimbursements with the quality of care delivered, ensuring the financial sustainability of healthcare organizations.

One of CDI’s core functions involves working closely with physicians to clarify vague, incomplete, or ambiguous diagnoses. This clarification ensures that all relevant conditions, including comorbidities, are accurately documented. Proper documentation of these details is crucial for DRG assignment, as the billed DRGs is often determined by secondary diagnoses that reflect the complexity of care. This process helps ensure that hospitals are reimbursed appropriately based on the resources used to treat the patient.

CDI isn’t just about financial outcomes—it’s also about compliance. Clinical validation has become a critical activity performed by CDI professionals.  Performing clinical validation reviews minimizes the risk of DRG downgrades during audits and helps prevent claim denials. Proper CDI practices ensure that the documentation can withstand scrutiny from payers and regulatory agencies, reducing compliance risks and supporting a seamless revenue cycle.

Effective CDI practices lead to comprehensive clinical documentation, directly influencing accurate DRG assignments, optimizing reimbursement, and ensuring compliance. A strong CDI department supports accurate code assignment, which in turn, leads to accurate DRG assignment that minimizes financial losses and maximizes performance on outcome quality measures.

NEWS RELEASE

FOR IMMEDIATE RELEASE

Tampa, Fla. – [July 20, 2024] – Brundage Group, a leading healthcare consulting organization, proudly announces its recognition as one of the Best Places to Work in Tampa Bay 2024 in the Large Company category. This prestigious honor highlights Brundage Group’s ongoing commitment to its employees and the core values that guide its business daily.

“At Brundage Group, our journey is fueled by passion, purpose, and a shared commitment to excellence,” said Tim Brundage, MD, CEO of Brundage Group. “This recognition is a testament to our team’s dedication, leadership’s vision, and the values that inspire us daily. We are incredibly proud of what we’ve built and even more excited about the future.”

Participation in the Best Places to Work program was about more than just winning an award. It was a chance for Brundage Group to reflect on how it prioritizes its people—creating an empowering environment where team members feel valued, motivated, and supported to bring their best every day. The company prides itself on fostering a workplace that feels like a community where everyone’s voice is heard, and collaboration thrives.

Key performance metrics, including employee engagement, satisfaction, and overall well-being, were integral to this recognition. Brundage Group achieved an impressive score of 97/100 and a 95.65% employee engagement rate, demonstrating its deep connection with its workforce. These scores reflect Brundage Group’s unwavering commitment to building a workplace where people are energized and appreciated.

“What’s most meaningful is hearing how our employees describe our workplace,” added Brundage. “The word ‘fun’ came up often, which speaks volumes. From team-building events to celebrating each other’s successes, we’ve created an atmosphere where collaboration, respect, and enjoyment are part of our daily culture.”

Brundage Group remains dedicated to investing in the growth and development of its people, understanding that its team is its greatest asset. The company continues to evolve and elevate its workplace culture, always striving to create an environment where every team member can thrive.

Brundage Group is the trusted choice of hospital systems for revenue cycle management solutions. We support hospitals nationwide with customized solutions that include a full suite of physician advisory services, staff augmentation/workforce solutions, proprietary level of care analytics, and physician-led documentation education to relay high-quality care. Our programs help hospital organizations break down departmental silos by unifying all departments in the mid-revenue cycle. Our dedicated staffing division provides seasoned, veteran RN case managers, utilization review nurses, and appeals/denials professionals, all backed by our team of expert physician advisors and documentation and coding experts.

Lacey Thompson

Brundage Group

Email: lthompson@brundagegroup.com

https://brundagegroup.com/

In today’s healthcare landscape, where operating margins are tightening and administrative burdens are increasing, hospitals face the critical challenge of ensuring they capture every dollar of earned revenue. While front-end revenue cycle activities like patient registration and back-end activities like billing and collections are often well-monitored, the mid-revenue cycle—a crucial phase that includes utilization management, clinical documentation integrity (CDI), and denials management—is frequently overlooked.

Optimizing the mid-revenue cycle is essential for preventing revenue leakage and maximizing reimbursement. At Brundage Group, we understand the complexities of this critical stage and offer specialized services to help hospitals streamline their processes and capture the revenue they deserve.

The mid-revenue cycle is the keystone connecting clinical care delivery with the financial processes that follow. It involves ensuring that patient care is accurately documented, appropriately coded, and compliant with payer regulations while managing the utilization of hospital resources. This stage directly impacts the accuracy of billing, the effectiveness of denial management, and, ultimately, the hospital’s financial health. 

However, mid-revenue cycle departments often operate in silos, leading to inefficiencies and missed opportunities for accurate claim submission. For hospitals to optimize this phase, collaboration across departments is crucial. This is where Brundage Group’s Physician Advisors play a pivotal role.

Hospitals need a dedicated Physician Advisor for each core area of responsibility: utilization management, clinical documentation integrity, and denials management to effectively bridge the gaps between the various mid-revenue cycle departments. These Physician Advisors act as “quarterbacks,” promoting collaboration across departments that are often working in isolation.

A dedicated Physician Advisor in utilization management ensures that patient status is correctly assigned, resources are used efficiently, and care is delivered in compliance with payer requirements. This prevents costly denials and ensures that hospitals are reimbursed appropriately for the care provided.

Accurate and comprehensive clinical documentation is the foundation of proper coding and billing. A Physician Advisor focused on CDI and coding works closely with physicians, CDI, and coding staff to ensure that the documentation reflects the complexity of care delivered. This supports accurate reimbursement and mitigates the risk of audits and penalties.

Denials are a significant source of revenue leakage for hospitals. A Physician Advisor dedicated to denials management can proactively identify trends, address root causes, support creation of appeal letters, and lead peer-to-peer discussions with payers to overturn denials. This reduces the burden on clinical staff while improving hospital finances

At Brundage Group, our team of seasoned Physician Advisors brings a wealth of expertise in mid-revenue cycle optimization. Our holistic approach focuses on utilization management, CDI, and denials management to ensure that hospitals capture every dollar of earned revenue.

In a time when every dollar counts, optimizing the mid-revenue cycle is essential for hospitals to remain financially viable. Hospitals can significantly reduce revenue leakage and maximize reimbursement retention by ensuring collaboration across utilization management, clinical documentation integrity, and denials management.  

Brundage Group’s dedicated Physician Advisors are the key to unlocking this potential, serving as the “quarterbacks” who drive collaboration and efficiency across the mid-revenue cycle. With our support, hospitals can capture their earned revenue and strengthen their financial health in a challenging healthcare environment.

**FOR IMMEDIATE RELEASE**

Nationwide revenue cycle solutions provider is committed to foundational cybersecurity controls and information risk management for healthcare information security with support from Marcum LLP and 24By7Security, Inc.

July 17, 2024 – Brundage Group, a leading provider of physician advisory services and revenue cycle analytics, achieves HITRUST e1 Certification status by HITRUST for foundational cybersecurity.

This certification provides assurance to Brundage Group’s hospital partners that the company has adequate security and privacy controls in place to help manage and mitigate cybersecurity threats and comply with ever-changing industry regulations.

This certification highlights Brundage Group’s commitment to protecting patient and hospital data and upholding essential cybersecurity hygiene standards of healthcare information security. Marcum LLP, a top national accounting and advisory firm, conducted the rigorous third-party assessment, ensuring Brundage Group met all HITRUST e1 requirements.

Additionally, 24By7Security, Inc., a leader in cybersecurity and compliance solutions, provided essential support to Brundage Group in navigating the complexities of ensuring data security.

“In today’s cyber risk landscape, securing HITRUST certification is critical to our position as an industry-leading partner to hospital systems,” said Keith Fulmer, Chief Technology Information Officer, Brundage Group. “With the support of Marcum LLP and 24By7Security, Inc., we demonstrate our commitment to maintaining the highest levels of security, privacy, and regulatory compliance, giving peace of mind to clients knowing their data is secured and protected.”

“Brundage Group has demonstrated commitment to elevated cybersecurity and compliance posture in order to protect against cyber incidents and to comply with various regulations,” said Sanjay Deo, Virtual CISO for the Brundage Group.

Brundage Group is the trusted choice of hospital systems for revenue cycle management solutions. We support hospitals nationwide with customized solutions, including a full suite of physician advisory services, staffing solutions, proprietary level of care analytics, and physician-led education to relay high-quality care. Our programs help hospital organizations break down departmental silos by unifying all departments in the mid-revenue cycle. Our dedicated staffing division provides seasoned RN case managers, utilization review nurses, and appeals/denials professionals, all backed by our team of expert physician advisors and documentation and coding experts. Learn more at brundagegroup.com.

marketing@brundagegroup.com

**FOR IMMEDIATE RELEASE**

Strategic partnership combines expertise and services from both industry leaders to offer comprehensive, integrated solutions for hospital systems nationwide.

Strategic partnership combines expertise and services from both industry leaders to offer comprehensive, integrated solutions for hospital systems nationwide.

July 15, 2024 — Brundage Group, a leading provider of Physician Advisory services, revenue cycle analytics, and staffing solutions, announces its partnership with Phoenix Medical Management, a renowned consulting firm specializing in clinical documentation improvement (CDI), utilization review (UR), and case management (CM). The clinical revenue cycle industry leaders will deliver unparalleled services and support to healthcare organizations across the nation.

The collaboration between Brundage Group and Phoenix Medical Management represents a powerful synergy in healthcare consulting and advisory services. Combining Brundage Group’s expertise in Physician Advisor services, revenue cycle and UR analytics, and staffing solutions, with Phoenix Medical Management’s proficiency in CDI, UR, CM, and denials/appeals management, the partnership offers comprehensive, integrated solutions that address the complex challenges of healthcare organizations.

“We are committed to progressing our service and product offerings through innovation and partnerships that keep us at the forefront of the healthcare industry,” said Timothy Brundage, MD, CCDS, CEO, Brundage Group. “Our strategic collaboration with Phoenix Medical Management is an opportunity to deliver specialized expertise and services to further enhance the performance of our hospital partners nationwide.”

“At Phoenix we are focused on making sure our hospital clinical revenue cycle clients can deliver ROI back to their organization. In doing so, it is important to make sure we meet their needs with partners that help deliver the same high-level expertise we strive to provide. Brundage is a great partner in providing that support from a staffing and Physician Advisor perspective.” Tiffany Ferguson, LMSW, CMAC, ACM, CEO of Phoenix Medical Management.

Brundage Group is the trusted choice of hospital systems for revenue cycle management solutions. We support hospitals nationwide with customized solutions, including a full suite of Physician Advisory services, staffing solutions, proprietary level of care analytics, and physician-led education to relay high-quality care. Our programs help hospital organizations break down departmental silos by unifying all departments in the mid-revenue cycle. Our dedicated staffing division provides seasoned RN case managers, utilization review nurses, and appeals/denials professionals, all backed by our team of expert Physician Advisors and documentation and coding experts. Learn more at brundagegroup.com.

Phoenix Medical Management is a leading healthcare consulting firm specializing in clinical documentation improvement, utilization review, case management, and denials/appeal prevention. Their mission is to support healthcare providers in delivering high-quality care while optimizing financial and operational outcomes through standout not standard solutions. Learn more at phoenixmed.net.

For more information, please contact:

marketing@brundagegroup.com

Dr. Hassan Rao, MD, CCS, CPC

Dr. Hassan Rao is a Hospitalist and Executive Physician Advisor renowned for his clinical documentation, coding, quality, and utilization management expertise. With extensive experience in clinical documentation improvement (CDI) audits, quality metrics (including PSIs and mortalities), denials management (covering both clinical validation and coding denials), and DRG reviews, Dr. Rao brings invaluable insights to the table.

Robin Sewell, CDIP, CCDS-O, CCS, CPC, CIC

Robin Sewell is a veteran coder with a comprehensive background in CDI and coding. She validates coding errors and second-level reviews of high-dollar accounts and DRGs. Robin’s expertise lies in identifying CDI and coding opportunities through data analytics and comprehensive DRG reviews.

At Brundage Group, we leverage our Physician Advisor and coding expertise to provide robust CDI audits and education, ensuring the highest quality and revenue management standards. Each review involves veteran coders and Physician Advisors, guaranteeing accuracy and reliability.

• Pre-Bill DRG Reviews: Learn the critical value of pre-bill documentation and coding reviews to ensure accurate claims data. Our tailored approach uncovers trends, addresses query and coding opportunities, validates coding for hospital quality, and reduces revenue leakage.
• DRG Validation Misconceptions: We demystify the term “DRG validation” and clarify its scope and significance. Thorough validation processes are essential for optimal revenue cycle management.
• Denial Prevention and Compliance: Accurate claims are crucial for reducing denials and ensuring compliance, directly impacting the hospital revenue cycle.

• Uncover Trends and Areas for Improvement: Ongoing monitoring and tracking of critical metrics reveal opportunities for enhancement.
• Minimize Bill Holds: Quick turnaround of DRG reviews reduces bill holds and expedites revenue flow.
• Integrated Analytics: Integrating analytics allows for dynamic claims adjustment, focusing on DRGs.
• Improve DRG Accuracy: Minimal impact on DNFB while enhancing DRG accuracy and reviewing quality measures.

This webinar is a must-attend for healthcare professionals dedicated to optimizing their hospital’s revenue cycle. Gain valuable insights from seasoned experts, learn practical strategies, and take your hospital’s revenue integrity to the next level.

Register now and ensure your spot for this transformative webinar. Join us on Thursday, July 18, 2024, at 1:00 PM ET, and empower your hospital with the knowledge and tools to excel in clinical revenue cycle management.

Optimize your hospital’s revenue cycle with expert insights and practical strategies. Join us for this impactful webinar and stay ahead in the healthcare industry!

Hospital inpatient utilization management (UM) is crucial in the healthcare industry, ensuring hospital resources are used appropriately and efficiently. UM involves assessing the necessity and efficiency of the care provided to patients impacting healthcare costs for the patient and the hospital. Effective utilization management processes can significantly impact hospital operations and financial health in several ways. Ensuring compliance with payer requirements contributes to better cash flow when payments are made promptly. Reducing claim denials also promotes better cash flow but, more importantly, it reduces administrative and financial burdens associated with the appeals process.

Hospital utilization management strategies involve systematically evaluating and managing hospital resources. Key activities include pre-admission screening, concurrent review during hospital stays, and retrospective review after discharge. These activities help ensure that medically necessary care is delivered in the most appropriate setting.

The goals of utilization management include:

• Ensuring appropriate use of hospital inpatient resources and services.
• Reducing unnecessary hospital admissions and lengths of stay.
• Enhancing hospital compliance with payer requirements and regulatory standards.
• Minimizing financial losses due to claim denials and revenue leakage.

UR is a critical component of hospital UM functions, involving the evaluation of the medical necessity, appropriateness, and efficiency of healthcare services. UR processes include assessing admission criteria, reviewing ongoing patient care, and verifying when a patient has met discharge criteria.

The Medicare Two-Midnight Rule is a critical regulation in UR, stipulating that inpatient admissions are generally appropriate if the physician expects the patient to require hospital care spanning at least two midnights. This rule, codified for Medicare Advantage Programs (Medicare Part C), guides hospitals in determining the appropriate patient status.

Education is essential for both hospital UR staff and admitting providers. Education and training for UR staff are vital to ensure they can effectively evaluate medical necessity. Skilled UR staff can make informed decisions that align with payer requirements, reducing the risk of claim denials and ensuring compliance. Training providers to understand UR protocols helps ensure that patient admissions and services meet medical necessity criteria, reducing the likelihood of claim denials.

Ineffective UR processes can lead to significant revenue leakage for hospitals. UR staff need to review the right patient at the right time, which varies by setting and payer. Failure to complete a timely review can result in claim denials and financial losses. Proper workflows are essential to prevent these issues.

Medical necessity is a critical factor in accurately determining patient status. Hospitals must ensure UR staff have the skills and knowledge to assess medical necessity effectively and appropriately by payer. This includes understanding clinical guidelines and applying appropriate screening criteria.

Hospital UR staff benefit from the support of a Physician Advisor. Physician Advisors provide expert medical judgment beyond standard screening criteria. This collaboration enhances the accuracy of patient status determinations and reduces the risk of claim denials.

At Brundage Group, we offer comprehensive services to support hospital inpatient utilization review activities to minimize and prevent revenue leakage. Brundage Group can support your UR department every step of the way. Our unique approach allows our Physician Advisors to seamlessly integrate into the UR workflow where we provide expert guidance, ensuring accurate patient status determinations that comply with payer requirements. Due to the importance of getting a patient in the right admission status as quickly as possible, we also offer utilization review education to enhance the skills of your admitting physicians. Lastly, if a denial is received from the payer, Brundage Group can represent the hospital during the peer-to-peer process and assist with post-discharge appeals.

Contact Brundage Group today to learn how we can help your hospital capture earned revenue and optimize utilization management processes.

Effective inpatient clinical revenue cycle management (RCM) is crucial for hospitals aiming to maintain financial health and operational efficiency. Key components such as Utilization Review (UR), Clinical Documentation Integrity (CDI), and inpatient coding play pivotal roles in ensuring accurate billing, reducing denials, and capturing earned revenue.

Revenue leakages in the context of the hospital inpatient clinical revenue cycle management refer to financial losses that occur due to inefficiencies and errors within the revenue cycle. These leakages often arise from departmental silos where communication breakdowns lead to discrepancies in patient documentation and billing. Consequences include denied claims, underpayments, and increased administrative costs, all of which strain hospital finances and disrupt inpatient operations. Early identification and resolution of these issues through a robust appeals process are essential to minimizing financial losses and ensuring the hospital’s revenue integrity. Further, preventing denials before they occur is ideal by optimizing utilization review processes and CDI processes streamlining the physician advisor review process and educating admitting providers how to document to support the medical necessity and acuity of inpatient admissions.

1. Patient Status Errors: Misclassification of patient status, such as incorrect assignment to inpatient or observation services, can result in significant revenue loss.
2. Inadequate Clinical Documentation: Lack of thorough and accurate clinical documentation impedes proper coding and billing, leading to claim denials and delayed reimbursements.
3. MS-DRG Coding and Sequencing Errors: Errors in MS-DRG (Medicare Severity Diagnosis Related Group) coding or sequencing can affect reimbursement rates and increase the likelihood of audits and denials.

Utilizing revenue cycle analytics can help identify trends and patterns contributing to revenue loss, allowing hospitals to address these issues proactively.

1. Effective Utilization Review (UR): Ensuring appropriate and timely patient status assignment is critical. UR staff should be well-trained to evaluate the accuracy of the ordered patient status based on clinical criteria and payer guidelines.
2. Physician-Led DRG Validation: Engaging physician advisors in the DRG validation process helps ensure coding accuracy, reduces denials, and enhances overall compliance. Our physician advisors’ clinical expertise combined with coding knowledge leads to more precise and defensible claims.

Brundage Group offers specialized services designed to enhance hospital inpatient revenue cycle management:

1. Revenue Cycle Analytics: Our analytics services provide data-driven insights that identify revenue leakage trends and patterns, allowing hospitals to make informed decisions and implement effective corrective actions.
2. Physician-Led DRG Validation: Our team of experienced physicians and coders work collaboratively to validate DRG assignments, ensuring accuracy and compliance. This approach helps reduce denials, capture earned revenue, and improve overall financial performance.

By focusing on effective inpatient clinical revenue cycle management, hospitals can minimize revenue leakage and enhance financial stability. With the support of Brundage Group’s comprehensive services, healthcare systems can achieve greater accuracy in coding, improve patient status assignment, and secure the revenue they deserve.

Ready to capture earned revenue and enhance your hospital’s financial stability? Contact Brundage Group today to learn how our expert services in revenue cycle analytics and physician-led DRG validation can help your facility achieve optimal revenue cycle management.

Explore Dr. Hassan Rao’s transformative journey from hospitalist to certified coder, as an Executive Physician Advisor at Brundage Group. In “Physician Advisor Turned Coder: How I Learned to Tackle the Practical Challenges of Clinical Documentation,” Dr. Rao shares his journey from practicing hospitalist to delving into the complexities of clinical documentation and coding. Discover how he collaborates with Robin Sewell, a veteran coder and Clinical Coding Analyst at Brundage Group, to bridge the physician-coding gap and leads the physician-led DRG validation service line.

Hassan Rao, MD, CCS, CPC, possesses extensive expertise in clinical documentation, coding, quality, and utilization management. Leading the DRG validation service line, Dr. Rao advises clients in coding charts with high fidelity to ensure compliance, minimize denials, and maximize earned revenue. Additionally, Dr. Rao provides education on clinical and complex coding topics to providers, CDIs and coders.

Reducing the length of stay holds much significance for both patients and hospitals. Shorter stays contribute to improved patient well-being, minimize exposure to potential hazards like infections, and lower costs significantly. Longer durations can strain hospital resources as well, potentially compromising the quality of health services provided by these institutions.

Hence, reducing the time spent in hospitals is key to not only ensuring optimal patient recovery but also fostering efficient functioning within our healthcare systems.

When you’re admitted to a hospital, your end goal is getting better. However, staying in for longer than necessary can impact the quality of care received and overall well-being. Even subtle shifts can enhance patient flow through acute care hospitals, which underscores our main focus here: reducing length of stay (LOS).

Lengthy stays not only wear on patients physically but also emotionally, causing undue stress that could potentially hinder recovery processes. Shortened LOS means less strain for staff, too; they can direct resources more effectively towards providing exceptional treatment. Data from hospitals worldwide indicate that strategies to reduce Length of Stay (LOS) can be effectively implemented without sacrificing patient safety or the quality of healthcare outcomes.

Following suit isn’t easy; it takes planning plus commitment. Applying proven techniques such as FOCUS-PDSA, a method for organizing data collection, can help an organization determine how to refine discharge procedures to lower the average LOS. Reduction in the average LOS translates into amplified benefits across the healthcare system, including higher bed availability, partly addressing another significant challenge faced by most healthcare institutions.

Reducing the length of stay has a direct association with decreased healthcare costs. It’s vital for hospitals to deliver expedited care without sacrificing treatment quality. Shorter visits empower hospitals to manage their resources more efficiently while concurrently offering optimum care services.

These cost savings don’t merely provide financial relief but enhance overall sector efficiency, too! More funds become available for other essential areas, like preventative health initiatives and research efforts, when less cash is spent on lengthy inpatient admissions. Hospital administration makes crucial decisions based on these aspects, formulating strategies that rally around best practices that reduce patient days logged in bed swiftly and safely.

This approach creates an environment where everyone prospers: patients experience quicker recoveries coupled with lower out-of-pocket expenses, while hospitals streamline operational procedures, thus solidifying trust between both parties and concentrating on collective well-being outcomes.

Boosting staff efficiency and productivity is a crucial aspect of minimizing hospital stays. Optimizing operations not only allows medical personnel to handle their responsibilities more proficiently, but it also accelerates the treatment processes essential for patient wellbeing. By implementing strategies like care coordination or early mobility programs, professionals can streamline healthcare service delivery, resulting in less waiting time between procedures and faster recovery times for patients during their stay.

Moreover, employing solutions such as multidisciplinary teams fosters collaboration among different units within the facility, potentially enhancing problem-solving capabilities and lowering the chances of discharge delays attributable to decision-making bottlenecks. Remember that your staff’s effectiveness directly impacts how long a patient remains in your institution before receiving clearance for homebound recovery. Therefore, taking steps towards optimizing employee performance goes hand-in-hand with efforts aimed at reducing the length of stay, ultimately benefiting both patients’ wellness and hospital resource allocation.

Maximizing bed availability in hospitals is always a struggle, especially when demand surges unexpectedly. When patient flow improves, and length of stay decreases, more patients can promptly access the care they need. Remember that every moment counts in acute case scenarios.

More available beds mean fewer cancellations for elective procedures as well. Imagine how grateful you would be if your long-awaited surgery didn’t face postponement due to lack of space. Furthermore, efficient use of resources reduces overcrowding pressures on healthcare workers by spreading out their workload evenly over time.

Moreover, an increased bed turnover rate offers opportunities for sanitation practices between admissions. This ensures hygienic standards are maintained at all times to keep infections under control within hospital premises. Thus, overly lengthy stays don’t only affect individual patients; they impinge significantly upon entire system efficiencies, too!

So let’s work together towards reducing delays where we can so everyone can benefit from the ripple effects.

Successfully navigating the intricate maze of healthcare revenue cycle management demands a sharp comprehension and a well-thought-out strategy. As you seek to optimize your hospital’s financial performance, remember that maintaining compliance is just as critical. This guide provides clear insights into achieving revenue integrity, enabling you to establish robust processes in place for billing accuracy and operational efficiency.

Discover comprehensive solutions designed specifically for the complex world of healthcare finances, ensuring every charge is captured correctly without compromising on regulatory requirements, a balancing act crucial for sustainability in today’s ever-evolving medical landscape.

To secure your healthcare facility’s financial health, it’s vital to zero in on revenue integrity. This means you need a keen eye for detail when examining billing practices and compliance. Make sure medical codes match delivered patient services. Errors could lead to underbilling or overbilling.

For compliance, review claims regularly, pinpoint coding mistakes quickly, and fix them right away. Remember, solid checks prevent lost revenue. It upholds not just cash flow but also patients’ trust in the quality of your care.

Transparency rises as financial records reflect true service values through precise audits, a must-do for sound decisions and resource distribution.

Check your revenue process often. Make sure you find and fix mistakes in billing or coding to avoid revenue leakage. Perform prebill audits to catch errors early. That way, you keep funds flowing without having to deal with costly appeals.

Train your team on revenue cycle management to tackle errors that hurt hospital finances. Consistent education on best practices can help staff spot coding mistakes, avoiding both underbilling and overbilling. With solid training, they’ll ensure bills reflect true services rendered, protecting against fraud, too.

Regular audits keep everyone sharp. Compliance becomes second nature, upholding a strong financial foundation.

You need to revamp your coding setup. Each patient service must be coded accurately for correct billing. Slip-ups lead to lost revenue, denials, or even legal trouble. Audit regularly, update processes often, and train staff well.

This tightens compliance with laws like HIPAA while you get paid properly, which is key for financial health. Remember, precise coding equals accurate bills, which means stable revenue to allow the hospital to continue its mission.

Optimizing healthcare revenue while maintaining compliance is key for your hospital’s financial health. You need a robust strategy that aligns billing processes, complies with regulations, and ultimately safeguards revenue integrity. Brundage Group offers expertise to streamline these operations effectively.

By leveraging our knowledge of clinical documentation and coding practices, you ensure accurate reimbursements for services rendered. Trust us to enhance your financial performance without compromising on adherence to ever-evolving healthcare standards.

By Cheryl Ericson, RN, MS, CCDS, CDIP

Director, CDI, UM/CM, Brundage Group

Hospitals require a physician order to guide hospital care. The patient status order (often referred to as “admission order”) determines if hospital care will be delivered as an outpatient or inpatient service. This is basically a billing determination as it does not affect your ability to order additional services; however, it does impact hospital reimbursement and patient financial responsibilities. It’s best to use the term “hospitalize” rather than “admit” when letting a patient know they will be staying in the hospital overnight.

Did you know the hospital is required by Medicare to officially notify patients of their hospital status? Leave it to the utilization review experts to have that conversation with the patient.

• The Medicare Outpatient Observation Notice (MOON) is provided to Medicare patients who receive observation services as outpatients for more than 24 hours.
• The purpose of the MOON is to ensure patients who spend a night in the hospital receiving observation services understand that they are not currently inpatients and will be responsible for co-pays associated with their Medicare Part B benefits.
• Additionally, patients receiving observation services will not meet the three-day inpatient admission requirement for Medicare Skilled Nursing Facility coverage.

Providers who treat Medicare beneficiaries have an obligation to deliver medically reasonable and necessary care. Services are considered medically necessary if they meet the standards of good medical practice and are:

• Proper and needed for the diagnosis or treatment of the beneficiary’s medical condition;
• Furnished for the diagnosis, direct care and treatment of the beneficiary’s medical condition; and
• Not mainly for the convenience of the beneficiary or provider.

Medicare expects a provider to order the appropriate type of hospital service, which is validated by hospital utilization review staff.  Unfortunately, the patent cannot request a particular patient status. The ordered hospital status must be rooted in documentation that specifies the patient’s acuity, comorbidities, specific risk if care is not provided in the hospital setting and associated treatment plan.

Providers should not automatically default to observation services for patients who qualify for inpatient services to avoid patient frustration and the associated hospital administrative burden.  According to Medicare, “Observation care is a well-defined set of specific, clinically appropriate services, which include ongoing short-term treatment, assessment, and reassessment before a decision can be made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital. Observation services are commonly ordered for patients who present to the emergency department and who then require a significant period of treatment or monitoring in order to make a decision concerning their admission or discharge.”

“When a physician orders that a patient receive observation care, the patient’s status is that of an outpatient. The purpose of observation is to determine the need for further treatment or inpatient admission. Thus, a patient receiving observation services may improve and be released or be admitted as an inpatient.”

Observation services may be appropriate when:

• Active care or further observation is needed following emergency room care to determine if the patient is stabilized.
• Intense physician or nursing care is expected to be necessary for less than 2 midnights.
• Further diagnostic testing and/or observation is needed to make a diagnosis and establish appropriate treatment.

Although a patient can be upgraded from observation status to inpatient status, if a provider expects the patient will need two or more nights of hospital services or their acuity is such that they need an intense level of hospital services, e.g., mechanical ventilation, intensive care service, etc., it is appropriate to order inpatient status.

You’re a hospital administrator faced with the complex task of dealing with insurance reimbursements. How does this process work? Essentially, your organization provides medical care to policyholders who make payments through their premiums.

The critical step in getting funds from insurers back into the healthcare system is quite complicated but crucial for maintaining financial health and stability within your institution. This guide aims to demystify that convoluted journey, unraveling how hospitals receive reimbursement from insurance companies.

In the context of hospital operations, submitting claims for reimbursement is a key operational task. You must navigate this complex process with care to avoid any setbacks. Remember that each claim must contain accurate patient information: name, medical history, diagnosis, and treatment codes. This data directly affects your ability to receive the correct reimbursements from insurance providers. Your staff should understand how to correctly assign diagnosis codes following standard requirements (like ICD-10), and, if they also code hospital outpatient services they will need knowledge about Current Procedural Terminology (CPT) coding used in billing.

The electronic submission of these coded claims is the next vital step, which occurs through specialized software systems designated by respective insurers or payers. Staff should be monitoring payer correspondence and remittance to promptly identify payment issues, facilitating quick action for resubmission without delay. Remember, time plays an essential role here, fast resolution equals faster cash flow into your system!

Hospitals often receive less payment than the amount listed on their chargemaster. This happens due to negotiated discounts known as “contractual adjustments.” Payment rates vary significantly among payers. Additionally, the chargemaster assigns a price to every individual hospital service, but most payers offer a bundled payment rate for hospital inpatient services. This may be a per day rate or a per admission rate.  The per admission rate is the most common inpatient payment methodology. 

Take Medicare, for example, a federally run healthcare program that sets specific service payments. Hospital charges could amount to $37,000 for a three-day inpatient admission, but Medicare’s inpatient payment mechanism is the Medicare Severity Diagnostic Related Group (MS-DRG), a per admission rate payment.  If the associated MS-DRG has a payment rate of $10,000, that is all Medicare is required to pay! 

Although it may appear that the hospital is losing money when payers reimburse admission services at a rate lower than total charges, it is unusual for anyone to pay the total of hospital charges.  Even for patients without insurance benefits, referred to as self-pay, are usually offered a discount off the total charges. 

Educating your team about denial management processes can give them a winning edge. Regular workshops, webinars, and classroom-style teaching sessions work wonders in this regard. These educational activities keep the staff informed of any changes or updates within the healthcare sector and also provide insights into best practices in revenue cycle compliance regulations that could decrease claim denials.

Additionally, data analytics play an instrumental role, as it helps recognize patterns causing repeated payment rejections. Advanced revenue cycle systems generate insightful reports on trends and highlight improvement areas for consideration by hospital administration to significantly reduce future instances of denied claims.

To maximize hospital reimbursements, focus on patient outcomes. By shifting attention to what patients need rather than the volume of services provided, increases in efficiency are possible. You’re not just supplying medical care but delivering high-value treatment with a significant impact on your revenue cycle.

In short, put patient needs first, streamline service delivery based on those needs, and prioritize quality over quantity, all while aiming for overall system improvement. Reimbursements naturally follow suit when these steps intertwine, ideally within any healthcare organization looking to maximize its potential financial gains.

Navigating insurance reimbursement can be tough. With Brundage Group‘s expertise, such complexities are streamlined for a smooth process on your end. We work diligently to handle denials, following up rigorously with payers and mitigating future issues by analyzing trends in denial causes.

Trust us. We’ll advocate passionately for the financial health of your hospital.

In amplifying a hospital’s financial health, medical billing and coding play pivotal roles. Medical billing ensures rightful compensation for services rendered by hospitals from insurance providers or government programs. This robust flow of funds guarantees continued operation.

A cornerstone in systematic record-keeping is medical coding, which translates diagnoses, procedures, and treatments into universal codes – a language that insurers comprehend to process payments accurately. The World Health Organization’s ICD-10 serves as today’s prevalent reference book, guiding this crucial translation process. Both processes together facilitate smoother communication between the various parties involved, with efficient data transfer acting like the backbone, holding everything upright and streamlined within our busy healthcare system.

Accuracy in coding is pivotal for submitting clean claims, which speeds up reimbursements. Remember that your hospital’s financial sustainability largely depends on payments from patients or their insurance providers. Correct codes submitted with initial claims expedite this process while avoiding costly delays or revenue loss due to inaccuracies that you could avoid easily. Be mindful of ever-changing healthcare regulations; lack of compliance could result in denied claims and impede cash flow significantly.

Moreover, general coding may overlook details crucial for additional revenue collection, besides increasing the chances of claim denial. To bolster efficiency and precision during medical billing, consider utilizing advanced tools designed specifically for these tasks, as they simplify the process considerably, even amidst a busy work environment. Regular auditing helps proactively identify issues for immediate resolution.

Evolving technologies can simplify complex tasks while minimizing human error rates significantly. Advanced software platforms can automate manual, time-consuming processes swiftly, paving the way to efficient communication between hospitals and insurance firms. Learn more about what Brundage Group has to offer to help your healthcare organization.

Accurate hospital claims are crucial. It ensures seamless insurance reimbursements, promoting financial health within hospitals. Moreover, Clinical Documentation Integrity (CDI) plays a pivotal role in maintaining this accuracy, as CDI specialists undergo rigorous education to validate and enhance clinical documentation excellence.

In the precision-driven world of healthcare, CDI stands as a pillar. The process involves thoroughly scrutinizing medical record documentation to ensure completeness and accuracy. Think of CDI specialists as gatekeepers who monitor data correctness within hospital systems; they hold pivotal roles in preserving system-wide harmony. Adherence to strong CDI practices can improve coding accuracy, mitigate compliance issues, and reduce future denials.

Crucial to the claims process, accurate hospital medical coding ensures hospitals receive their due compensation. When healthcare professionals provide services within the hospital setting, appropriate ICD-10 codes that are primarily assigned based on provider documentation must correlate with patient conditions and procedures performed. As providers feel more and more rushed when documenting patient encounters, they may omit significant details that impact accurate code assignment.

Coding is a very exact discipline that is based on a dictionary. If appropriate terminology that corresponds to a diagnosis code is not documented, that condition will not be accurately represented on the hospital claim. Coders can only assign code based on what is explicitly documented. They cannot make inferences. CDI professionals help bridge this communication gap.

Additionally, coder performance is measured through productivity and how many records they can code each day. Pressure to reach a particular volume of completed records can lead to missed opportunities. When coders do identify opportunities, it is often difficult to obtain provider cooperation because coding is a post-discharge activity, so the provider may not recall the issue in question. CDI professionals review the health record concurrently while the patient is in the hospital. Therefore, identified opportunities can be reconciled while the provider is still caring for the patient, which improves their level of cooperation.

Notably, it contributes to data analysis for improved health policies and outcomes. However, simple human error can lead to mistakes that significantly impact claim results through rejections or audits, leading to penalties, decreased revenue, and potentially damaging reputations. Robust quality assurance programs should be instituted to monitor outcome performance. Automation tools should be employed, where possible, to minimize risks and enhance accuracy. Clear communication should be fostered amongst all stakeholders, including doctors and other relevant personnel involved throughout documentation until the final coding stages.

The CDI specialist plays a pivotal role in improving financial outcomes for healthcare organizations. Their work involves enhancing the accuracy and specificity of clinical documentation, which directly influences hospital coding and billing processes. When document details are crystal clear and in a language that corresponds to coding lexicons, the complexity of patient conditions is accurately represented, resulting in appropriate reimbursement rather than an underpayment due to ambiguous or insufficient information.

Moreover, their keen eye may uncover overlooked opportunities and instances where rightful reimbursement was missed initially but is rightfully deserved after review. Comprehensive notes lessen the risk of claim denials while ensuring smoother revenue cycle management operations, helping drive fiscal health within hospitals.

Appropriate reimbursement hinges on the precision of hospital medical coding. When hospitals use correct codes, they outline an accurate picture of a patient’s clinical scenario. These snapshots are critical for insurance companies to decipher patient acuity as well as what services have been provided. Errors in this process can cause significant disruptions to hospital cash flow. Moreover, coding based on inaccurate documentation could lead to claims denial from insurance companies.

This implies that hospitals might not receive any compensation for the high-quality services they render, a situation both unfavorable and avoidable through precise documentation that supports code assignment. Thus, maintaining accuracy throughout the entire documentation process is something hospitals should make sure happens consistently within your facility. It assures timely payment without interruptions impacting revenue stream stability.

Inaccuracies in hospital coding can lead to severe consequences. If errors creep into the system, these mistakes could jeopardize your healthcare organization’s financial well-being. One must maintain vigilance at every stage while dealing with the intricate details involved in accurate hospital coding and claims submission.

Coding accuracy in hospital claims streamlines the medical billing process. This crucial step prevents unnecessary delays or denials, promoting efficient revenue cycle management for healthcare institutions. Therefore, Brundage Group’s commitment to precision cannot be understated; it compliantly optimizes financial outcomes and reduces payer denials.

When scouting for a stellar CDI specialist, you seek someone who will drive excellent patient outcomes. This critical role requires specific skill sets: unmatched expertise in clinical documentation integrity (CDI) and a continuous commitment to learning.

The right candidate can transform your hospital by improving accuracy and efficiency, which is essential to keeping pace in today’s rapidly changing medical field.

When seeking a CDI Specialist, assess qualifications and certifications closely. Strong candidates often hold the Certified Clinical Documentation Specialist (CCDS) credential offered by the Association for Clinical Documentation Integrity Specialists (ACDIS) or the Certified Documentation Integrity Practitioner from the American Health Information Management Association (AHIMA). These credentials illustrate knowledge in areas such as medical terminology, anatomy, pharmacology, chronic condition management, and coding guidelines. A nursing degree isn’t universally required, but it may be favored by some hospitals.

Remember that potential hires should manage their workload independently while communicating effectively via virtual channels when required to do so. Qualities demonstrating adequate adaptability are key within dynamic roles such as those found within healthcare recruiting firms specializing in sourcing skilled personnel for hospitals. Coexisting harmoniously alongside physicians/colleagues is necessary, considering they’re integral partners in your mission towards efficient documentation that supports hospital revenue.

When looking for a CDI professional, consider their experience. How well they navigate the complexities of clinical documentation shows expertise and understanding. You want someone who can work with multiple personalities across different medical disciplines without any significant problems.

A potential hire should exhibit fluency in managing both data algorithms and provider reimbursement issues, areas highly critical to your operations’ efficiency. One crucial aspect you need to focus on is whether candidates have an acquaintance or are familiar with working with “CDI physician champions.” Their role revolves around improving documentation, which is important as it bridges the gap between other physicians and colleagues within an organization.

Finally, observe how effectively they communicate virtually; this indicates their ability to function independently when needed without much supervision from higher-ups while maintaining professional decorum at all times, even under pressure-filled circumstances.

Remember: You’re not only hiring them because of their competence but also due to their being a team player, so choose wisely!

When hiring a CDI professional, understanding hospital practices and procedures is crucial. Deep knowledge of revenue cycle processes goes beyond the textbook; it’s about practical application. You rely on this professional to decode medical records to support accurate coding that can impact both performance on quality-of-care indicators and hospital reimbursement.

The CDI professional need proficiency in determining when a diagnosis can be reported on a claim as well as interpreting provider documentation into accurate diagnosis codes. This role should comprehend various diagnoses thoroughly; identifying subtle nuances between general conditions versus more specific ones when translating them into precise codes is paramount.

Moreover, they must exhibit adeptness at using critical thinking skills to pinpoint gaps in documentation that might demand clarification; a pivotal skill set indeed! The ability to facilitate seamless connections among patients’ health status records further underlines their competency level; the evidence of excellent collaboration capabilities is undeniably vital here.

When seeking a CDI specialist, professionalism ranks high on the list. This trait encompasses an individual’s attitude towards their work, showing respect for hospital policies and adhering to industry standards. Reliability is another critical factor; you need someone you can count on to consistently deliver excellent results.

A reliable worker won’t offer excuses but solutions; instead, they’ll tackle challenges head-on while upholding quality. Availability shouldn’t be overlooked either; the healthcare landscape shifts continuously, sometimes by the minute! So, it helps if your chosen professional has flexible hours that complement this demand-driven sector.

Remember these three attributes: professionalism, reliability, and availability as you navigate through your hiring process for a new CDI specialist.

In your search for a CDI specialist, consider their adaptability. The work environment of healthcare is ever-changing, often requiring quick and on-the-spot adjustments to different situations. An ideal candidate should possess the agility to swiftly decipher complex medical data and translate it into reportable diagnoses.

Their capacity for flexibility can greatly impact their efficiency when facing novel circumstances brought about by rapidly evolving health scenarios or technology updates. Encourage candidates to share instances where they’ve had to adjust strategies quickly without compromising accuracy or quality during interviews.

Remember that coping with unpredicted changes is not only crucial but intrinsic within this role, as it aligns directly with the interplay between patient documentation and code assignment, a critical connection point overseen by all successful CDI specialists.

Establishing a robust network within the CDI community plays an integral role in hiring quality personnel. Embrace frequent participation at industry events, seminars, and conferences to forge valuable connections. Having your presence felt among this circle not only enhances your reputation but also gives you direct access to a pool of potential candidates.

Consider actively involving yourself on online platforms dedicated to CDI professionals. You can gain insights into the latest trends or participate in engaging discussions that might open doors for talent acquisition. Moreover, these networks are often treasure troves when it comes to spotting professionals demonstrating a keen interest and deep knowledge about various facets of CDI.

Lastly, having regular communication with educational institutions offering specialized courses directly or tangentially related to CDIs can help you scout fresh talent right from academia itself. In sum, understanding its significance is mandatory as networking isn’t merely gathering contacts; it’s all about establishing relationships conducive to recruiting ideal individuals best positioned for success.

Evaluating a potential CDI specialist is more than just reviewing credentials. Examine their comprehension of clinical matters, regulatory policies, and coding expertise. Assess their communication skills as well; they will be interacting extensively with the healthcare team at your organization.

Reducing denied claims and underpayments is a vital part of Revenue Cycle Management (RCM). The leadership of most hospitals knows just how essential Clinical Documentation Integrity (CDI) is to the clinical revenue cycle. A robust CDI department ensures hospital inpatient services are appropriately reflected in the health record so they can be accurately coded and billed.

The quality of clinical documentation can impact both hospital revenue and performance on quality measures. Encouraging providers to document a detailed and precise description of the clinical scenario can ensure the medical claim correctly reflects the gravity and complexity of cases being treated, paving a path towards legitimate higher reimbursements. Clinical Documentation Integrity (CDI) departments can lead to a more accurate representation of case mix indices. These numbers represent average illness severity amongst your patients: high indices are an indicator of complex cases that should rightfully earn higher reimbursement.  Enhancing Clinical Documentation Integrity (CDI) is vital for your revenue cycle.

Clinical validation involves confirming diagnoses by using evidence from a patient’s medical record. Clinical validation is typically performed by those with a clinical background or those who are familiar with disease processes.  Clinical validation can be part of the routine Clinical Documentation Integrity (CDI) workflow or a separate second level review process.  Clinical validation denials can lead to DRG payment reductions. They are difficult to refute if the payer is not transparent with the clinical criteria used to deny the condition since many diagnoses do not have universally accepted criteria among medical professionals.

Clinical Validation is a clinical review of information within the health record, unusually by a physician or nurse, to ensure reported diagnoses that impact billing can be objectively verified. In this case, objectively verified only means there is clinical evidence in the record to support the diagnosis (e.g., patient presentation, symptoms, diagnostic findings, etc.); however, the quality of the clinical evidence and quantity of clinical evidence a reviewer requires to substantiate a diagnosis is very subjective.

Clinical validation denials are a relatively new type of denial introduced in 2011 in the Centers for Medicare and Medicaid Scope of Work (SOW) for Recovery Auditors that has subsequently been adopted by commercial payers.  Within the SOW clinical validation was described as a review process separate from the DRG validation process and beyond the scope of DRG validation and the skills of a certified coder. Interestingly, these types of reviews are no longer within the SOW for Recovery Auditors. The SOW for Region 1 Recovery Auditors dated March 26, 2021, states “clinical validation is prohibited in all RAC reviews.1”

Differentiating clinical validations from DRG validations, as well as the role of coding professionals, has been addressed through ICD-10-CM Official Coding Guidelines for Coding and Reporting. Professional medical coders are allowed to report a documented condition on the claims form if it meets Uniform Hospital Discharge Data Requirements for the reporting of a secondary (other) diagnosis.  Regarding clinical validation, ICD-10-CM Official Coding Guidelines for Coding and Reporting states that 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.” Consequently, clinical validation reviews are a process outside of coding practices and are usually performed by those with a clinical background.

A common strategy used by hospitals in hopes of limiting clinical validation denials is developing organizational definitions for conditions that are frequently challenged by payers like sepsis, malnutrition, acute respiratory failure, and acute kidney injury. This strategy may promote consistency when making a diagnosis within an organization, but these definitions cannot be imposed on payers unless through contractual obligation.

Accurately diagnosing medical conditions can improve communication within the treating medical team and across different healthcare settings. Additionally, it can improve performance on healthcare quality measures by ensuring evidence-based care is delivered accordingly. For example, understanding how sepsis is defined in the CMS Severe Sepsis Bundle, the role of coding in identifying the measure population, and what treatment is required under the quality measure can improve patient outcomes as well as the organization’s quality scores.

Clinical validation denials can be a source of revenue leakage for healthcare systems when upheld by the payer.  The impact of a clinical validation denial is similar to that of a DRG denial as either the principal diagnosis or a secondary classified by Medicare as a Complication/Comorbidity (CC) or Major Complication/Comorbidity (MCC) is removed from the claim resulting in a lower payment than billed by the hospital. A robust clinical validation process can proactively query providers when a diagnosis appears to be based on limited or contradictory clinical evidence to see if the diagnosis was ruled out and should not be reported on the claim.

Clinical validation entails a thorough assessment of patient records to confirm documented conditions. When executing this process, the clinical professional verifies whether there is sufficient clinical data to support a documented diagnosis. A good rule of thumb is to determine if other providers would come to the same conclusion based on the same clinical information. When a patient presents with atypical symptoms or does not meet expected abnormal thresholds, the provider should document why the diagnosis applies to this particular patient.

Although coding expertise is not required to perform clinical validation reviews, it can be more efficient if audits are performed by CDI professionals with both clinical and coding expertise. It is also beneficial to have an escalation process when disputes occur over the adequacy of clinical information to support a documented diagnosis. The arbiter of these types of situations is often a Physician Advisor.

1 SOW For RAC Region! (cms.gov) accessed on January 24, 2024

In healthcare, claim denials represent a formidable challenge for hospitals. The impact of claim denials is significant, affecting the financial stability and operations of these institutions. Mastering this aspect ensures smooth cash flow, fosters patient satisfaction, and maintains business health and viability.

Let’s delve into how hospitals can avoid the five frequent mistakes leading to claim denials.

Accurate coding plays a significant role in avoiding claim denials. As you navigate the labyrinth of medical billing, recall that payers meticulously scrutinize every detail on your claims submission; an overlooked modifier or prior authorization will not escape their notice. This underscores the need for proper and complete filling out of all necessary fields within claim forms by your team members handling this task.

Make it second nature to them: check those commonly skipped areas like patient subscriber numbers. Correct any errors they spot before sending off these crucial documents. Keeping track of each payer’s receipt ensures no deadlines slip past unnoticed, which could lead to frustrating timely filing denials.

Establish open lines of communication between coders and billers so nothing gets missed. Accidentally truncated codes can be flagged early enough to avoid denials later down the line.

In essence, meticulousness and precision are key to maintaining high standards; even more stringent insurers won’t fault complaints resulting in denied claims.

Now, let’s talk about one crucial step: double-checking patient insurance eligibility verification. When entering data like birth dates or subscriber numbers, ensure correctness to prevent delays in claims. Make it a habit to confirm active coverage before providing treatments.

Often, with non-emergency services such as radiology procedures, you need prior authorization from insurers, so always get the green light first! Be aware of commonly excluded coverages in many health insurance plans, too. When dealing with complex healthcare plans demanding medical records for claim justification, don’t hesitate to share those details promptly!

Avoid misinformation issues prevalent today by keeping payers informed of every bit related to additional primary insurances and paid co-payments through an Explanation of Benefits (EOB). Lastly, be meticulous when encoding billing codes because simple errors can lead straight down the denial lane!

Focus on addressing upfront payment discrepancies. Always remember to review your claims carefully before submitting them. Untidy or unreadable paper forms can cause issues with payers who scan documents into their systems upon receipt.

Make sure the printer aligns well with your claim form, and always check readability. Moreover, be vigilant about including all necessary information in a claim submission. Any omissions might lead to an insurance denial due to incomplete data entry points that require filling out, such as patient subscriber numbers among others.

Don’t overlook truncated codes, either! Sometimes, diagnosis codes aren’t complete; they’re missing digits, which could result in the rejection of these entries by some insurers’ stringent standards. Regular engagement between billers and coders will allow both parties to learn from each other’s areas of expertise!

Lastly, don’t let deadlines slip away unnoticed. Timely filing prevents unnecessary rejections from the insurer’s end just because you missed their schedule window.

Certain claim errors can wreak havoc on your billing process, causing significant delays in reimbursement and failing to maintain legible claims. While the digital world dominates today’s business sphere, some insurance providers still require old-fashioned paper submissions.

Misaligned printers might distort these forms and lead to denials when insurers struggle with deciphering them. Furthermore, avoid truncated codes by expanding diagnosis documentation up to its maximum level of detail. An extra digit could make all the difference between approval or denial!

Equip your team members handling this task with coding knowledge so they can spot possible error triggers sooner rather than later. Missing information is another potential pitfall that may yield undesired results. Seemingly insignificant omissions can catch keen-eyed payers who won’t hesitate to deny incomplete applications.

Conformity stands as a vital principle: Understand individual requirements set by different insurance companies you work with regularly for ease in adherence, hence facilitating smoother transactions ahead. Lastly, don’t fall victim to tardiness. Every payer sets their unique filing deadlines, which should be honored consistently, thus saving time dealing with related complications due to late filings.

Stay vigilant about shifts in policies and regulations to sidestep cash flow roadblocks from claim denials. Payers often modify their filing schedules, leaving you prone to miss a deadline if you are not watchful.

Make use of tracking tools for each payer’s submission receipts whenever feasible. Often, unfair timely filing denials occur, even when you’ve met deadlines, but insurers deny receipt before theirs lapses. Don’t let them off!

Hold them responsible for on-schedule acknowledgments. Coded diagnoses need supreme specificity: omit a digit on that seven-digit code and expect denial as your reward! Promote open discussion among billers and codifiers, ensuring they identify truncated codes early enough, averting claim disapprovals because no diagnosis is too detailed!

Navigating handwritten claims can be dicey, with some payers sticking fiercely by paper submissions despite digital ones becoming commonplace today. Messy printouts risk rejection simply due to illegibility issues, so ensure meticulous confirmation takes place prior to dispatching any request for reimbursement against treatments offered.

Data analysis and coding accuracy checks can make navigating the pitfalls of claims denials becomes easier. Diligence in documentation management ensures correct patient information.

By having an eye for detail on procedure codes, you can avoid mismatched service claims, too. Consider embracing technology to streamline your process, offer real-time claim status updates, and aid in early error detection.

For healthcare organizations, big data analytics is a great asset. It offers the capacity to collect vast amounts of medical-related information and analyze it for patterns, trends, correlations, and predictions that can improve decision-making processes – leading to improved utilization rates in patient care outcomes. Through deep analysis of health records with this toolset, hospitals are better able to optimize resources based on actionable insights, which will maximize efficiency at every level.

Predictive analytics play a key role in patient care planning. They provide insights on the likelihood of certain events before occurrence, enabling prevention over treatment. Nearly 60% of healthcare organizations employ this technology and have seen improved satisfaction rates among patients by up to 42%.

Not only that, about 39% reported cost savings. The potential for predictive algorithms extends beyond individual cases; they’re adept at tackling administrative challenges as well. A crucial area where such high-tech aid proves invaluable is within ICUs.

Frequently strained by demand due to aging populations or surgical complexity, these units can use data-driven alerts triggered by subtle changes in vital signs that warrant immediate medical intervention, potentially saving lives! It’s all part of an evolving technological landscape designed not just for hospital settings but also for home-based applications like remote health monitoring. This proactive approach ensures at-risk individuals receive timely preventative measures after being discharged from hospitals, thus reducing readmissions significantly.

You may wonder how clinical data mining plays a part in the healthcare setting. This process refers to using computing power and algorithms to sift through massive amounts of patient information. The goal isn’t merely managing the abundance but extracting genuine insights for more informed decision-making.

Just imagine looking at years’ worth of hospital admissions records with time series analysis techniques. This could reveal patterns that help predict future admission rates! Consequently, such analyses not only strengthen resource allocation planning by predicting patient load but also enhance overall care quality.

You’re likely familiar with the concept of Big Data Analytics. When harnessed correctly, BDA can lead to increased patient utilization rates. But there’s more beyond that horizon!

Key improvements have been observed when real-time monitoring enters the scene. This up-to-the-minute analysis can play a pivotal role in treatment effectiveness. By tracking patient data continually, adjustments happen swiftly if required conditions change or new patterns emerge.

This fast response time reduces potential complications and enhances outcomes for patients. Certainly, this process necessitates harnessing both organized information (structured data) and less conventional types, which are harder to analyze (unstructured data), such as input from wearables like heart rate monitors and glucose sensors. Remember, increasing your use of unstructured data doesn’t come without its challenges.

Extracting critical insights from unconventional sources may seem daunting at first due to their unpredictable nature. With appropriate techniques and technology tools at your disposal, infused into every step of care delivery, you will add immense value by utilizing unstructured datasets effectively alongside traditional ones in no time.

Imagine harnessing the power of Artificial Intelligence to manage scheduling intelligently. This tool swiftly processes large amounts of data to predict patient utilization rates with more accuracy. Such an application could analyze current trends, past records and other relevant statistics all at once while providing insights into future appointment demands for different departments or practitioners within minutes rather than hours!

Now consider how much time staff members might save on tedious manual adjustments when this process gets automated through the use of such technology! More efficient resource allocation which ultimately leads to improved services delivered by your facility as well as an increased level of satisfaction amongst patients who no longer have to bear long waits due to poor management schedules. There’s always room for optimization even in busy healthcare environments where time feels scant.

Our professional responsibilities should not become burdensome just because we’re dealing with the complexities and intricacies of the sector. The challenge here lies in finding suitable solutions to mitigate these issues. One innovative response to this advancement is the integration of Artificial Intelligence, which would certainly aid us in achieving our goal of harmonizing daily operational activities, especially in the area of task planning.

Thanks to AI-enhanced systems, it’s now possible to adjust requirements accordingly without subjecting undue stress and workload to team members. Indeed, it’s a practical and meaningful approach to embracing these emerging technologies and transforming the way we conduct business today in the medical arena. The ongoing evolution is only expected to continue its progress over the course of the years.

Be sure to watch out for further enhancements and developments unfolding on the near horizon. Get ready to reap the benefits of the digital revolution that has ushered in a new era of healthcare service delivery. Welcome the change and be equipped to counter the challenges effectively.

In the medical field, improved patient utilization rates often tie into effective referral strategies. Using big data analyses can greatly transform current methods. By identifying patterns and trends from extensive datasets, it’s possible to enhance healthcare referrals.

An efficient strategy involves scrutinizing past records of referred patients. With this information at hand, one is able to understand better why certain services are preferred over others or what factors influence a specialist choice within networks. With these insights gleaned from large-scale analysis, adjustments in referral streams become easier to manage.

Furthermore, big data allows us to gather structured data. This data allows us to create prediction models that accurately match supply with demand in different areas and settings within health systems. These models help speed up patient care delivery processes.

At the same time, they maintain the quality of care expected by both patients and providers. By harnessing the power of big data analytics, you can significantly boost patient utilization rates. It’s a remarkable tool that offers insights into patterns and trends in the usage of healthcare services. Through accurate predictions, it enhances strategic planning while fostering efficient resource allocation for hospitals, driving improvements not just in patient engagement but ultimately leading to superior health outcomes as well.

Are you facing challenges with the health of your revenue cycle? The following tips will guide you in refining processes, streamlining workflows in claim cycles, improving hospital revenue management methodologies, and keeping patient satisfaction at heart.

Understanding the significance of claims management and reimbursement in the healthcare revenue cycle is vital. Managing this process precisely helps maintain healthy operating margins for hospitals. Undoubtedly, effective administration encourages better financial health within these institutions.

Additionally, it adds to patient satisfaction by minimizing billing errors or delays and ensuring smooth transactions between patients, providers, and insurance companies, all contributing to an optimized healthcare system.

Hospitals and private practices approach revenue cycle management differently. Hospitals tend to have larger teams and intricate procedures while juggling multiple insurance carriers. Private clinics usually manage simpler cases with fewer resources available.

Each has unique challenges in achieving an efficient claims processing operation that enhances the flow of reimbursements without compromising patient care quality.

Healthcare Revenue Cycle Management faces numerous challenges, including complex and evolving regulations, billing and coding errors, variations among payers, slow payment processing, data security concerns, and rising patient financial responsibility.

Additionally, denial management, revenue leakage, manual processes, staff turnover, patient education, technology integration, and market competition contribute to the complexity of RCM. Addressing these challenges requires a multifaceted approach that includes process improvement, technology adoption, staff training, and compliance commitment to ensure the financial health of healthcare providers.

To enhance claims management, first analyze your current status. This requires examining three key aspects: the financial, technical, and operational sides of your organization. Understanding reimbursement metrics, evaluating systems involved in patient interactions, and assessing staffing and vendor relationships are all vital steps in formulating an effective remediation roadmap.

The first step involves patient registration and insurance verification. You confirm not only patients’ identities but also their coverages during this phase. Gaps here may lead you down the wrong paths later on.

Additionally, ensure accurate coding at every stage of service delivery. Using incorrect codes will likely delay payments or cause denials from insurers altogether. Submission speed is another critical factor when trying to collect quicker reimbursements.

Submitting your documents promptly often results in quicker returns. Taking the time now to ensure everything is accurate will help minimize any future claim issues and maximize your facility’s revenues. Ultimately, this will improve financial health for healthcare organizations like yours.

To enhance your data analytics capabilities, focus first on accurate data input. Remember that you can’t get precise insights from fuzzy details. Invest in advanced systems for patient registration and information collection to gather complete, accurate records at the source.

Next, train all team members thoroughly in coding accurately. This step will prevent misclassifications of diagnoses or treatments, often leading to claim denials.

Staying on top of your analytical software upgrades for optimal performance is important. Updating your software will help you predict trends more effectively by analyzing past patterns and improving accuracy in submissions. This proactive approach helps ensure long-term positive results.

To streamline your healthcare revenue cycle, consider implementing automated reimbursement solutions. They automate the billing process and can significantly reduce manual errors resulting in denied claims. Apart from reducing human error, this also frees up valuable time for staff to focus on more strategic tasks such as patient care.

Modern technology aids improved accuracy by flagging potential issues before claim submission. Simply put, effective automation means fewer obstacles when you seek compensation for services provided. Furthermore, automated tools yield real-time analytics, providing actionable insights into payment trends or discrepancies within your system.

Focus on precisely refining coding practices. Remember that accuracy is key in healthcare billing codes; any error can lead to denials or delays in payment. Invest time and resources to continuously train your coders to remain current with ever-changing medical terminologies, rules, and regulations.

Adopting a proactive approach ensures correct patient data input from the start, reducing rework significantly. Audit regularly for quality and efficiency; it’s necessary to spot flaws early while ensuring streamlined operations.

Utilizing technology to monitor payment postings is vital in refining your revenue cycle. When you harness tech tools, they can offer accurate tracking of payments, be it from private payers or public health programs like Medicare and Medicaid, effectively minimizing the instances of overlooked reimbursements.

Using digital platforms offers a major benefit: the capacity for real-time updates. This means no changes can slip through unnoticed; you’ll be aware of any alterations as soon as they occur. Furthermore, tools such as advanced billing software will instantly flag discrepancies, identifying any irregularities before they worsen.

To optimize revenue cycle outcomes, organizations need a solid grasp of analytics. Data-driven insights help identify trends and utilization opportunities. By understanding attending physician activities, diagnosis codes, or DRG tendencies, healthcare entities can make informed decisions.

This helps capture earned revenue compliantly while maintaining excellent care standards for patients.

Recent trends in healthcare claims management and reimbursement encompass several key areas. Automation and artificial intelligence are on the rise, with healthcare providers increasingly using these tools to expedite claims processing, reduce errors, and enhance overall efficiency. Additionally, the integration of telehealth into revenue cycle management processes is becoming commonplace, reflecting the shift toward virtual care.

This helps capture earned revenue compliantly while maintaining excellent care standards for patients.Value-based care models continue to gain traction, emphasizing outcomes-based reimbursement rather than fee-for-service, while improved data interoperability facilitates seamless claims management. Staying compliant with evolving billing regulations is a continued focus, alongside adopting predictive analytics to foresee and prevent claim denials.

These trends collectively aim to improve the efficiency and accuracy of revenue cycle management, aligning it with the evolving healthcare landscape and ensuring both healthcare providers and patients benefit from more streamlined processes and better financial outcomes.

At Brundage Group, we offer the technology to aid in revenue cycle management. Our expertise helps minimize denials and ease financial operations in revenue cycle management, a must-have solution for any medical facility aiming to enhance efficiency while delivering superior patient care.

In the ever-evolving landscape of healthcare, effective revenue cycle management (RCM) stands as a vital cog. As you navigate this complex field, understanding RCM’s paramount benefits can foster optimal financial health for your institution.

These five advantages underscore why adept implementation matters in today’s dynamic healthcare climate, from streamlining administrative tasks to enhancing patient satisfaction.

Revenue Cycle Management (RCM) is of paramount importance to healthcare providers, especially hospitals and healthcare organizations, for several reasons:

• Financial Stability: RCM ensures providers can cover operational costs, invest in growth, and maintain financial viability.
• Cash Flow: It provides a steady cash flow, enabling consistent operations and the ability to meet financial obligations.
• Resource Allocation: Efficient RCM helps providers allocate resources wisely, enhancing patient care and infrastructure.
• Cost Control: RCM identifies areas to reduce costs and billing errors, improving efficiency.
• Compliance: It ensures adherence to complex healthcare regulations, reducing audit risks and legal issues.
• Patient Experience: Transparent billing and accurate communication enhance the patient experience.
• Data-Driven Decisions: RCM generates data for informed decision-making and strategic planning.
• Strategic Planning: Providers can assess profitability, evaluate contracts, and plan for the future based on RCM insights.
• Competitive Advantage: Efficient RCM attracts patients and referring physicians, giving a competitive edge.
• Quality of Care: RCM supports high-quality care by providing resources for staff, equipment, and research.

Quick and accurate payments are essential to any healthcare facility’s financial well-being. Your team needs to utilize such a system to ensure an efficient process that handles claims swiftly yet accurately.

This saves considerable time and reduces the error rate significantly, leading to fewer denials of payouts from insurance companies due to incorrect data entry or mismatched codes.

By improving efficiency through automation and accuracy, you’re all geared up for fast collections with more money entering your organization on time, a critical driving factor behind successful hospital revenue cycle management.

Streamlined financial reporting serves as another significant advantage of revenue cycle management. When you implement RCM, your healthcare practice gains the ability to consolidate disparate data into clear, understandable reports.

You can better understand your cash flow by utilizing these informative summaries. Besides, this approach helps reduce mistakes that usually result from manual entries in traditional bookkeeping processes, which can lead to potential inaccuracies and discrepancies.

With automation’s role within RCM mechanics, making sure all recorded transactions are precise is easier achieved by computer algorithms than by human intervention alone.

Streamlined reporting promotes transparency within an organization. Each transaction regarding patients’ payments is systematically logged, making it easier to identify bottlenecks and irregularities. This helps to increase efficiency and reduce risks of possible financial mismanagement issues. Not only does it aid internal tracking efforts, but it also assists during external audits.

This enables smoother compliance processes and helps ensure adherence to prevailing regulations. This fosters trust among stakeholders about fiscal responsibility exhibited by the provider entity concerned. Ultimately, this benefits both parties involved.

Automation serves as a driving force in enhancing coding and billing processes. Integrating AI-powered software into your revenue cycle will pave the way for precise claims submissions.

This modern technology can analyze patient data, medical codes, and insurance details quickly and effectively. Machine learning algorithms are essential for helping gather insights from claim patterns over time. This can help identify potential errors or discrepancies that could hold up payments if not detected quickly.

Furthermore, linking Revenue Cycle Management systems with Electronic Health Records (EHRs) promotes real-time updates regarding patients’ treatment plans and billing status, fostering seamless communication between various healthcare aspects involved in improving financial productivity within your organization.

In essence, merging technology within RCM workflows helps improve accuracy while reducing administrative strain, thus allowing more focus on delivering optimal patient care.

By leveraging revenue cycle management, you pave the way for elevated patient care quality and satisfaction levels. Imagine a scenario where patients encounter no delays or mistakes in billing processes—an environment that RCM fosters by focusing on precision. With every procedure coded correctly without error, there’s ease in processing insurance claims.

Streamlining this aspect allows healthcare providers to focus more on ensuring excellent service delivery and spending more productive time interacting with their patients.

Happier relationships ensue between provider and patient when frustrations stemming from faulty billings are eradicated completely. Furthermore, alleviating any financial distress can significantly boost overall client contentment during what could be stressful medical experiences.

A key advantage is increased transparency. Accurate coding conveys the exact procedures performed and the costs of services rendered.

This means there is no confusion about what charges are included on bills processed quickly due to streamlined operations enabled by a proper RCM implementation. This creates a heightened level of trust between clients, as they can easily understand all expenses incurred.

Enhanced revenue-capturing strategies, a benefit of revenue cycle management, can be transformative. By leveraging technology like AI and analytics in the billing process, you can significantly reduce errors in manual work. This leads to more correct claims being submitted initially, thus lowering denial rates and enhancing capture of potential earnings.

Optimized strategies also call for consistent monitoring, which ensures no billable service gets overlooked or lost over time. Such attention to detail boosts financial stability, as every bit earned is accurately tracked.

Another aspect of this process involves intricate patient data analysis using advanced algorithms. This type of analysis can be used to proactively identify any underpayments or missed payments so that any potential oversight can be swiftly rectified. This improves the earning prospects considerably.

By professionally integrating with other systems, such as EHRs, it is possible for seamless information flow on treatment plans and updated billing statuses to occur. This increases accuracy and prevents administrative issues, ultimately improving overall efficiency.

To wrap it up, managing your revenue cycle brings clear benefits. It enhances cash flow while reducing payment delays, which is vital to maintaining a healthy business in healthcare.

At Brundage Group, quality assurance is of the utmost importance. We strive to provide refined processes that help reduce denials and administrative costs. This way, patients do not have to worry about financial discrepancies, allowing them to be much more satisfied with their overall experience. This is the silver lining of an effectively managed revenue cycle.

It plays an essential role in maintaining cash flow stability, which is quite significant when success hinges on healthy finances.

As an integral part of medical billing, denial management unlocks and resolves issues causing claim denials. This approach isn’t about merely identifying errors; it aims to lessen the chances of future rejections.

By keeping an eye on evolving trends, they spot possible inconsistencies within patient registration, billing cycles, and medical coding—all factors contributing largely to denied claims. Appropriate scrutiny into individual payers’ payment patterns offers clarity over any deviations from standard procedures—a crucial aspect warranting careful attention under effective health administration standards.

Guarantee successful appeals for your future claims by mitigating potential pitfalls today! With ever-increasing denials (around a 20% increase industry-wide in recent years), adopting proactive strategies is imperative.

In exploring the denial management process, understanding various types of claim denials is vital. These refusals can originate from diverse areas, clinical or administrative. At times, they arise due to deemed unnecessary procedures by unqualified physicians from a medical standpoint.

On other occasions, office mismanagement leads to these rejections. Claim denials also cause delays in cash inflow and lost labor hours. In the worst cases, they even include uncompensated care provision!

Notably, there has been an alarming 20% increase across industries within five years, necessitating proactive positioning and effective strategy formulation for financial sustainability. A smart refusal administration approach helps decipher the underlying reasons behind rejected claims, enabling rectifying steps that might eradicate future occurrences.

So, engaging HIPAA-compliant tools while implementing systematic processes proves crucial for managing insurance plea turndowns effectively.

Stellar denial management in healthcare dictates faster reimbursement, which is vital for any practice’s financial health. You run the risk of slowed-down cash flow without a robust system to tackle claim denials. Identifying repeat instances of denial codes can offer insights into the areas that need improvement.

Monitoring these patterns helps uncover issues with medical coding or patient registration hindering successful claims appeals.

Moreover, keeping an eye on individual payers’ payment trends allows for easier identification when they deviate from normal behavior. Addressing clinical-related claim denials, such as non-essential procedures and unqualified physicians, also comes under this crucial process’ purview.

By proactively tackling such scenarios, you’re not just mitigating immediate losses but ensuring smoother operations in future billing cycles. In summary, integrating effective tools into your strategy facilitates revenue cycle challenges reduction by learning about the high-denial-rate root causes and contributing factors.

Thus, it shines a light upon why keen attention toward thoroughgoing denial management remains indispensable in today’s healthcare landscape.

To optimize your denial management process in medical billing, certain key components must be functional. A robust system for tracking denials is pivotal; this tool should monitor the date and type of each claim rejection, among other crucial figures, to pinpoint recurring issues.

Secondly, an efficient appeals procedure is vital to ensure successful appeal results and, as a result, quicker payment from insurers. Swift corrective measures can be implemented to facilitate this process. Automation can play an important role by handling paperwork and reducing the workload of staff members involved in claims processing.

Training also makes another essential element; well-geared teams at different stages handle their roles competently, cutting down on errors that could result in future rejections.

Implementing preventive strategies such as routinely revising processes or adjusting workflows can reduce potential setbacks, improving cash flow. Careful planning into these aspects helps to ensure smoother operations within healthcare facilities. This fosters stronger relationships between providers and payers, minimizing future denials significantly.

Firstly, you should scrutinize denials without delay to evaluate recurring patterns or reasons for rejection. This timely evaluation can prevent future claim rejections and significantly improve your revenue cycle outcomes.

Secondly, ensure you know each payer’s protocols, as they differ extensively. Insights into these guidelines will help assure adherence, reducing chances of denial. It is also essential to provide ongoing training to staff on coding updates and billing standards. An error in this area may cause a declined claim.

Finally, constant communication within all sectors involved, like insurance representatives, aids understanding and minimizes errors leading to rejections.

Remember that even minor improvements made through adhering diligently to these key strategies improve collections while ensuring quicker payments from payers, thus enhancing overall financial health!

By partnering with Brundage Group, you position your healthcare organization for success. Our expertise lies in revenue cycle management analytics, which enables us to offer actionable insights vital for optimizing financial operations. We adopt a data-focused approach that empowers hospitals like yours to successfully navigate the intricate landscape of revenue cycles.

We also provide customized solutions catering precisely to your needs and objectives related to revenue cycle managing tasks. A notable trait is our unique knack for identifying negative trends before these can crucially affect critical aspects such as Medicare Advantage payers.

Moreover, our commitment to excellence is clear: we provide high-quality service while ensuring compliance throughout all processes. This demonstrates that excellence isn’t simply rhetoric but true action.

Remember that an efficient denial management process can make or break your practice. Harnessing competent personnel, investing in technology, and ensuring stringent follow-ups are key steps on the journey towards reducing denials.

Dive in deeper to understand this integral component further.

Let’s delve deeper into the significance of utilization management in healthcare. UM is vital in maintaining quality, managing risks, and ensuring cost-effective care provision. This is the main focus of this healthcare practice, which strives to improve patient outcomes. Early intervention tactics and preventive care measures are applied to prevent serious complications before they arise. Ultimately, this results in reduced costs for hospitals and health systems over extended periods of time.

Regular check-ups facilitate the timely detection of potential diseases, resulting in prevention rather than cure scenarios, which is always beneficial.

Concurrent review procedures allow effective monitoring of treatments throughout the medical facility’s duration of stay. This emphasizes a focus on the optimum length of stay and initial discharge planning initiatives. Additionally, post-discharge retrospective reviews provide valuable insights that can be used for continuous improvement. These reviews evaluate the appropriateness of services that were provided in the respective settings.

Moreover, ensure that professional guidance from experienced clinicians supervises these processes, as they bring forth critical thinking abilities aiding informed clinical decisions.

Lastly, remember that good UM programs aren’t just financially driven and prioritize improved patient-centric results.

The most effective utilization management strategies focus on four core components: risk minimization, quality assurance, patient education, and in-depth review. In managing risks, the goal centers around reversing disease processes through early intervention and preventive health measures. This not only enhances overall population health but also keeps costs low.

Quality assurance involves regular audits to ensure regulatory compliance and appropriate use of medical necessity guidelines. An emphasis is placed on this for creating actionable data from audit results.

Reviews of patients take place at different stages: prospective reviews occur before treatment begins, concurrent reviews happen during treatment, and retrospective reviews happen after discharge. These reviews help to determine if various parameters, such as length of stay or discharge plan execution, were appropriate.

In the utilization review process, careful checks take place. An initial evaluation occurs when a patient is admitted to a healthcare facility. This assessment revolves around medical necessity and justifiable care levels suitable for the individual’s case. This can help save significant costs in the long run. Furthermore, it involves monitoring any potential delays in care and evaluating how well progressive treatment is advancing for that individual. These evaluations occur while your loved one resides in either acute or post-acute settings within such facilities.

After these treatments are carried out, retrospective reviews are conducted. Coverage audits are then carried out after the respective therapies have been given to ensure maximum transparency. Additionally, don’t forget about precertification; this is part of a complete utilization review, assuring that scheduled services are done accurately from before admission until all necessary actions have been completed.

Thus, woven into its core practices is effective cost containment without compromising on quality health outcomes, making Utilization Management truly key when optimizing healthcare service delivery!

You need to define processes clearly to make your utilization management program deliver optimal results. Show each team member’s role and responsibility in a concise manner. This step ensures high-quality outcomes that can be repeated with ease.

Appoint an experienced Physician Advisor to oversee the process of UM reviews. Their deep understanding of healthcare policies and standards is invaluable in guiding nursing staff on best practices.

A robust quality improvement plan is essential for any successful utilization management initiative. It ensures regulatory compliance and helps ensure effective medical necessity guideline usage. Audit findings can be used to inform strategic action, such as revising training materials or refining workflows based on feedback from the audits.

Consistency across all these components paves the way toward an improved patient care journey. This should remain at the heart of every measure taken within your UM framework.

Choosing a reliable UM Physician Advisor requires careful consideration. You should carefully scrutinize potential partners for their proven track record in the industry.

Remember to ask about compliance standards, too! A first-rate utilization management firm always educates physicians on compliant documentation while reviewing each case.

Moreover, understanding how quickly they respond when peer-to-peer reviews are requested speaks volumes about their competence. In conclusion, choosing a proficient UM service provider isn’t just smart business; it’s central to ensuring accurate compensation from insurance carriers while maintaining stellar healthcare standards.

In your journey to enhance utilization management, you may find it beneficial to team up with a specialized provider. But how do you choose? Begin by assessing their industry experience and success stories; these are crucial indicators of competence.

Verify if they can deliver scalable solutions, as this shows adaptability in adjusting strategies according to changing needs or growth plans.

Next, evaluate the technical capabilities since automation is vital for efficient processes today. An ideal partner should offer cutting-edge tools along with expert human support. Also, scrutinize the quality monitoring system; an exhaustive audit mechanism suggests more reliable services. Lastly, consider communication practices; regular updates keep everyone on the same page, driving effectiveness.

By leveraging technology, Brundage Group optimizes utilization management. Our expertise ensures compliance with healthcare regulations and delivers top-notch patient care. With our solutions, you can see reduced costs and a more efficient system overall, as well as real-time consultation and data analysis for long-term strategy.

With specialized education in this field, clinical documentation specialists play an integral role. They’ll ensure integrity by bridging communication gaps between providers and coders. Let’s delve into how CDI revolutionizes healthcare organizations and its educational requirements.

CDI ensures accuracy in medical records and increases the speed and efficiency of coding. This is a process that can significantly reduce denials. The current changes in reimbursement are causing an increased focus on outpatient settings, prompting facilities to think about employing remote support solutions. To make sure that these new professionals meet the clinical requirements related to classification systems such as MS-DRG assignments, it is essential to have a thorough understanding of them.

Additionally, they need to be able to analyze patient documentation critically to ensure an accurate representation of the patient’s severity or risk profile. These are part-and-parcel skills that are required by those who strive for nothing less than excellence.

To maximize reimbursement, you must focus on clinical documentation improvement. Poorly noted provider entries can lead to value-based penalties.

Take Medicare, for example. It has been promoting better clinical notes among fee-for-service payments via instruments like MS-DRGs since 2007. The goal is a shift towards reimbursing hospitals more if they treat high-risk patients.

Failing to document MS-DRG and support codes can dent your revenue. This error often arises from staff not fully grasping robust documentation practices, an issue reported by two-thirds of CDI specialists in a recent survey. But how does good CDI bring about clear benefits?

According to Black Book Market Research’s findings in 2016, a majority of hospitals that employed solid Clinical Documentation Improvement (CDI) programs saw their revenues increase substantially. Some healthcare institutions increased their revenue by as much as $1.5 million.

The success of these CDI measures is attributed to the successful execution of case mix index improvements, which was confirmed by many healthcare finance heads from various institutions across the United States who participated in this research study.

The optimal recording of diagnoses, procedures, or comorbid conditions can profoundly affect care delivery and financial outcomes. The CDI specialist acts as an expert advisor to help ensure staff adhere to essential best practices for clinical documentation.

By properly documenting clinical information, accuracy is maintained, and errors are prevented that could potentially put patient safety at risk or lead to undesired legal action. Their deep knowledge of chart review tactics and coding skills will be instrumental for success.

The CDI specialist doesn’t just work alone. Collaboration is essential to their success. They need to have ongoing conversations with CFOs and other leaders to form clear goals from the beginning. Later, they can use performance indicators such as severity of illness scores and mortality risk to measure the progress.

In healthcare, you can’t overlook advanced analytics’ role in decision-making. Better decisions are possible with clear data insights presented by this technology. Remember, your clinical documentation holds significant potential. Over time, it can become a gold mine for data analysis.

Advanced analytics provides an effective way to extract useful information from large amounts of accumulated patient records. This can help you discover new insights that can be used to increase operational efficiency in your organization, something key in today’s rapidly evolving medical landscape.

Using these tools effectively might seem daunting at first due to the complex datasets involved and varying input data formats, ranging from lab reports to radiology images.

However, don’t let the complexities of large volumes of structured or unstructured health records be a barrier. Powerful algorithms make navigating them efficient and cost-effective. Predictive analytics allow us to forecast future trends based on historical patterns, while prescriptive measures uncover new strategies. There is also potential to explore untapped areas through discovery techniques.

CDI plays a critical role in this management process by ensuring complete and accurate documentation of patient care details. The benefits derived from hiring CDI professionals are plentiful. Such professionals review medical records to gauge severity, acuity, or risk, which helps to optimize revenue streams for improved financial health.

Furthermore, a Black Book Market Research report shows that almost 90% of larger hospitals experienced significant gains once they implemented this invigorated approach toward clinical documentation.

The introduction of remote support positions has the potential to scale up these practices beyond IP facilities. This could encompass outpatient settings as well. This adaptation has become increasingly important in light of recent changes in reimbursement procedures. These procedures emphasize optimal performance across all sectors, such as emergency departments and hospital clinics.

Expanding horizons also means educating staff about thriving documentation guidelines, blending efficiency with quality assurance measures, and robustly catering to rising complexities involved with chronic illness treatments today. Remember, investing time now in managing risks borne out through inaccuracies will help mold safer paths ahead for all stakeholders involved within your system’s ecosystem.

CDI can significantly elevate that aspect. Picture this: CDI bridges gaps between clinical practice and its documentation. Through it, clarity emerges in written medical records about the exact treatment given to patients.

This clear record assists other clinicians when they take over or continue patient care later on. Moreover, by gaining detailed insight into each unique case, proper diagnoses become more precise with less room for error. This is an integral factor, especially under current health reimbursement models focusing on service quality rather than quantity.

This shows how implementing proactive steps like integrating CDI into routine processes can indirectly enhance patient-centered service delivery, which is essential considering today’s competitive healthcare landscape dominated by value-based approaches.

Your healthcare organization thrives when all team members speak a shared language. This unity enables accurate, swift action to help patients in need. Think about introducing regular interdepartmental meetings for better information flow between staff departments or teams working together.

That way, everyone stays on the same page, and medical records become more precise because everybody knows what terminology means across various disciplines. Moreover, consider using digital platforms for record keeping and sharing clinical documentation updates within your institution.

It speeds up processes and reduces the chances of errors! Regular protocol training sessions are also key: they ensure each person understands their role clearly, along with the necessary guidelines applicable to them.

Clinical documentation integrity and improvement, a key service Brundage Group offers, greatly benefits healthcare organizations. It enhances patient care quality and bolsters the financial position of facilities while ensuring compliance with regulatory standards. CDI presents an opportunity for growth; it’s about better understanding your data to facilitate optimal real-time decision-making.

Stepping up your Clinical Documentation Integrity education? Here’s how Brundage Group can help: With a focus on education, our team of expert physician advisors engages physicians in comprehensive training programs for CDI competencies.

This results in higher-quality documentation that accurately reflects patient conditions. As you participate fully, you will gain the skills needed to precisely capture and document patient diagnoses and treatment plans. Such precision is beneficial as it facilitates effective communication among healthcare professionals, substantially improving care coordination.

Moreover, your newly verified knowledge will boost clinical decision-making while diminishing medical errors and enhancing overall patient safety measures and outcomes under your excellent care. Clearer documentation also aids hospitals by allowing accurate measuring and reporting of quality metrics and streamlining performance improvement initiatives for better health service delivery.

Whether you’re a seasoned practitioner or a new clinician exploring this terrain, a specialist like yourself can gain much from improved CDI strategies through dedicated learning experiences.

You’re well aware that our healthcare landscape has many rules, regulations, and compliance requirements. It’s crucial for your practice to stay on top of these ever-evolving standards while delivering quality patient care. Our team can guide you through the complex world of regulatory compliance like seasoned pathfinders with medical backgrounds. We know where potential pitfalls reside! We offer targeted advice designed specifically for those working directly within the sphere responsible for strictly adhering to policy directives from governing bodies such as CMS or private insurers.

We help ensure precise documentation supporting proper coding accurately reflects patients’ complexity levels. This assists in maintaining adherence to pressures from regulators and mitigating audit risks that could potentially damage reputations and negatively impact providers financially. So yes, understanding regulatory compliance isn’t just ticking off checklist boxes; it has real-life implications that touch every aspect of your professional career, even extending beyond financial stability and personal risk management domains.

Brundage Group applies a systematic approach to spot incomplete documentation issues. Our skilled advisors use advanced tools and techniques to thoroughly scrutinize your data and identify gaps in information or inaccuracies that can harm the integrity of records, such as ambiguous diagnoses, insufficiently documented procedures, and missing etiology. Incomplete data disrupts communication between healthcare providers and can also affect billing codes, leading to denied claims or penalties for non-compliance with regulatory standards.

Brundage Group’s consultants possess unmatched expertise on how clinical events should be accurately reflected on paper, enabling better coordination of care while enhancing quality and compliance efforts. We work closely with you to ensure each medical record is complete before being put into the coding workflow. This creates the transparency needed for accurate reimbursement and quality outcome reporting across all departments. Our team helps professionals like yourself understand what they need to look out for when reviewing documents, empowering them through targeted training sessions about proper practices so every detail gets recorded correctly from day one!

As you strive to make the most of clinical coding resources, guidance from an expert can be invaluable. Brundage Group fills that role with technology and education customized to your unique needs. We offer advanced tools designed to track documentation accuracy effectively.

Alongside leveraging this cutting-edge tech platform, we provide detailed insights into utilizing these resources efficiently. Our team delivers specific training sessions directly tailored to physicians’ requirements as well as general ones beneficial for broader hospital staff groups.

With our progressive approach combining human expertise and modern-day solutions harmoniously, achieving improved operational efficiency becomes achievable even amidst evolving regulatory landscapes or emerging healthcare delivery challenges facing today’s hospitals.

Brundage Group utilizes a direct engagement methodology to help enhance the overall understanding of clinical coding best practices. This improved comprehension aids communication between doctors and individuals responsible for accurately recording patient-critical health information, not just meeting compliance mandates. By doing this, the quality of care delivered to patients is improved.

Documentation integrity plays a pivotal role. Brundage Group contributes considerably to this scenario with the help of seasoned physician advisors. We aid you in grasping how thorough and precise clinical documents can boost performance metrics.

Focus here on chronic conditions deserves special mention, as they significantly affect facility-level evaluations like HCC scores or MIPS adjustments. During training sessions, our professionals focus on making physicians familiar with appropriate documenting practices and emphasize their significance related to patient care outcomes and facility revenue perspectives. We take action to improve the accuracy of risk adjustment methodologies—a component crucial for optimized reimbursement patterns—for every complex case that healthcare providers handle.

To enrich the dialogue between physicians and coders, Brundage Group provides interactive training sessions designed to improve mutual understanding of coding rules, link clinical findings with appropriate codes, and capture patients’ illness severity more accurately. Extensive efforts go into simplifying coding language for doctors while giving a deeper insight into medical practice standards for coders, resulting in a shared vocabulary that bridges gaps across different health roles. We believe robust interaction supports accurate documentation, improving patient care quality.

With common ground established through these trainings, communication barriers dissolve, leading to effective cooperation among team members. Remember this: good conversation is powerful; it fosters unity within your team and positively impacts essential aspects like financial stability and compliance adherence.

When you choose Brundage Group, you’re signing up for expert guidance in Clinical Documentation Integrity. Our experienced team provides insightful education to improve clinical outcomes. We also ensure accurate reimbursement while minimizing compliance risks through rigorous auditing procedures.

Therefore, if achieving a gold standard in healthcare services is your aim, let Brundage Group assist you on this quality improvement journey.

Discover what these stages entail and how solutions can guide you step-by-step to ensure optimal efficiency.

In the revenue cycle for hospitals and healthcare systems, patient intake and scheduling are the initial touchpoints. These stages play a pivotal role in shaping the overall patient experience. They go beyond administrative procedures, prese­nting a significant opportunity to foster trust and build rapport with patients.

During the initial stage, healthcare providers gather extensive data, e­ncompassing patient demographics, insurance de­tails, and appointment prefere­nces. By utilizing sophisticated scheduling software­, hospitals can streamline this data collection process and optimize appointment scheduling—this re­sults in reduced inefficie­ncies and capture earned reve­nue.

Impleme­nting a strategic approach to intake and scheduling is crucial for minimizing gaps between appointments, maximizing the utilization of each time slot, and optimizing daily income. The goal is not just to generate reve­nue but also to provide a seamless and patient-ce­ntric experience.

Insurance ve­rification and authorization are crucial steps in a hospital’s re­venue cycle. These processes go beyond financial considerations; they aim to ensure patients receive the necessary care without unnecessary delays.

Before a patient’s visit, hospitals must carefully check their insurance coverage. This involves verifying the validity of insurance policie­s and understanding the details of cove­rage, such as which services are­ covered and any co-payment requirements. It’s crucial to obtain authorization for specific medical procedures to avoid payment denials from insurers.

Hospitals can improve the efficiency of their re­venue cycle and ensure compliance with insurance re­gulations by prioritizing accurate data collection and authorization processes. This involves finding a balance between delivering quality care and maintaining financial sustainability.

The third stage, clinical documentation, and coding, is crucial for quality patient care and re­venue integrity within hospitals and healthcare systems.

Clinical staff carefully docume­nt every service­ provided to patients, creating a de­tailed record of each e­ncounter. These records are crucial for accurate billing procedures. In addition to supporting high-quality care, accurate and detaile­d documentation ensures that coding is done correctly by providing the necessary information.

Medical coding, performed by skilled professionals, translates medical services into standardized alphanumeric codes. These codes are vital for insurance companies when determining reimbursements. Accurate clinical documentation and precise coding are non-negotiables for hospitals that strive to avoid claim denials or underpayments.

Essentially, this stage is about aligning clinical excellence with financial responsibility, where quality and compliance go hand in hand.

Medical billing submission is the bridge between patient care and financial reimbursement. It’s a stage where hospitals and healthcare systems must ensure that every claim is accurate and complete.

Prior to submission, a thorough review of each claim is essential. Compliance with standard coding protocols and attention to detail are paramount. Even minor errors at this stage can lead to delays or denials, impacting the flow of revenue.

Hospitals can leverage specialized software solutions for medical billing and electronic claim submission. These tools streamline the process and reduce the margin for errors.

Efficiency in billing submission translates to a smoother revenue cycle and, most importantly, allows healthcare providers to allocate more resources to patient care.

Payment processing and posting represent the financial heart of the revenue cycle for hospitals and healthcare systems. It’s where revenue earned through patient care is captured and managed.

Accurate recording and application of payments to individual medical records are essential. Receipt dates are critical indicators for assessing the organization’s cash-flow performance and resource allocation. Efficient monitoring of partial or missed payments is equally crucial, ensuring that outstanding balances are promptly addressed.

This stage is a testament to the importance of meticulous financial management in healthcare. Hospitals must remember that every payment contributes to their financial sustainability, allowing them to continue delivering high-quality care.

The final stage, accounts receivable follow-up, is the guardianship of earned revenue. It’s the stage where hospitals and healthcare systems ensure they receive payment for their services.

However, this process is not just about chasing payments; it’s about maintaining a delicate balance between financial stewardship and patient satisfaction. Effective communication with insurance providers is key to securing timely payments. Rushing through this phase risks missed payments and lost revenues.

Advanced technology tools like Revenue Cycle Management software are essential for managing the complexities of this stage. Skilled professionals who understand financial nuances and individual patient scenarios’ unique intricacies are indispensable.

Ultimately, mastering these six stages of the healthcare revenue cycle is a journey that hospitals and healthcare systems embark upon to optimize their financial operations while upholding the highest standards of quality care and compliance. It’s a delicate dance where financial sustainability and patient well-being are intricately intertwined, reflecting the essence of modern healthcare management.

At Brundage Group, we offer expertise in revenue cycle solutions to assist healthcare organizations in capturing their earned revenue. Our approach, driven by Physician Advisor expertise and proprietary technology tools, plus a commitment to excellence, empower hospitals to navigate the complexities of the revenue cycle while ensuring compliance and quality care.

Through our proprietary technology platform, Certus Beacon, we provide data aggregation, advanced analytics, actionable insights, and customized solutions tailored to the unique needs of each healthcare organization. Our services help healthcare providers extract valuable insights from their revenue cycle data, make informed decisions, and enhance financial performance while delivering top-tier patient care.

Think of them as large categories bundling similar diseases or procedures designed to standardize payments for healthcare services.

Diagnosis Related Groups (DRGs) play a significant role in shaping the financial landscape of healthcare institutions, particularly hospitals, within the context of Medicare reimbursement. Each patient’s care is categorized under specific DRGs based on their diagnosis and required treatment during their hospitalization.

This system operates under the Inpatient Prospective Payment System (IPPS), where payment amounts are intricately tied to the assigned DRG. Beyond IPPS, a distinct approach comes into play when patients require long-term acute care – the Long-Term Care Hospital Prospective Payment System (LTCH-PPS). The LTCH-PPS relies on various categories of MS-LTC-DRGs, offering a more nuanced evaluation of patient needs and treatment requirements.

Now, envision the scenario of a patient being discharged after receiving healthcare services at a hospital. Medicare employs a complex methodology to assign specific DRGs based on primary and secondary diagnoses. These DRG assignments directly impact the overall costs of the patient’s stay, subsequently determining the predetermined reimbursement amount allocated to the healthcare facility.

Harnessing Diagnosis Related Groups (DRGs) carries various benefits within the healthcare system. One such advantage is cost predictability, with healthcare facilities receiving a predetermined amount per medical case categorized under DRG. This reimbursement system also encourages efficiency by promoting shorter hospital stays without compromising the quality of care provided.

However, employing DRGs within the healthcare system isn’t without its challenges. In certain instances, the fixed payment might not adequately cover the costs associated with patients requiring additional or complex medical services beyond the standard provisions covered by their assigned group rate. This can result in a financial deficit for healthcare facilities that treat these patients.

Another critique revolves around potential hasty discharges driven by the fiscal constraints of this model, potentially jeopardizing the well-being and recovery outcomes of individuals in favor of faster turnover rates for hospital beds.

DRGs play a vital role in healthcare, particularly through the Inpatient Prospective Payment System (IPPS). When patients are discharged, Medicare assigns a specific DRG based on their diagnoses, impacting the level of care and hospital reimbursement.

However, patient uniqueness and case complexity can complicate this system, as similar diagnoses may require different treatments. For instance, two individuals with similar diagnostic codes may require different treatment approaches due to variations in the complexity of their cases. This complexity is where the concept of case-mix complexity comes into play. Case-mix complexity takes into account additional factors, such as complications or comorbidities (CCs), which can significantly affect healthcare costs. Furthermore, it accommodates regional differences, such as variances in labor costs between metropolitan cities and more remote areas.

The Centers for Medicare & Medicaid Services (CMS) conducts regular reviews and recalculations to maintain fairness and accuracy within the system. This ongoing assessment ensures that base rates align with the latest healthcare data trends and evolving patient needs.

As a DRG Validation Specialist, your primary responsibility is ensuring the accuracy of inpatient medical records coding, which adheres to the ICD-10-CM/PCS standards. Your meticulous scrutiny is essential to guarantee medical codes’ correct usage and identify any potentially overlooked diagnoses or procedures.

Your expertise is pivotal in identifying discrepancies within assigned DRGs before the billing process begins. Should any discrepancies surface, you are also entrusted with initiating physician queries to rectify them.

These queries enhance the overall integrity of documentation, leading to precise code assignment that supports well-documented medical conditions or diagnoses. Additionally, collaborating closely with coders is an integral aspect of your role. This collaboration involves reviewing their queries and providing constructive feedback when necessary to ensure code accuracy.

Furthermore, it’s crucial to emphasize the importance of maintaining strong interdepartmental relationships in this role. Fostering a robust partnership with Clinical Documentation Quality Integrity staff is vital. They play a pivotal role in reconciling discrepancies between diagnostic groups, such as DRGs and APR-DRGs, ensuring the accuracy and consistency of data.

Let’s delve into the challenges they pose for the hospital and healthcare system. A recurring issue arises from inconsistent and ambiguous medical documentation, which can lead to a lack of clarity when assigning appropriate codes. Another hurdle is keeping up to date with frequent changes in healthcare regulations and coding guidelines, which is integral to maintaining efficient patient care delivery and effective hospital administration.

Even slight errors or omissions during data entry may cause significant misclassification problems later on. Limited resources, such as time constraints or a shortage of adequately trained personnel, often make it more difficult to maintain accuracy while handling various responsibilities. In cases where multiple conditions exist simultaneously within one patient (comorbidity), determining which condition influences resource use most presents another challenge.

It is worth noting how complex the Diagnosis-Related Group (DRG) system can be. This complexity can lead to potential errors for those unfamiliar with its intricacies. These classification systems must be correctly applied to ensure successful healthcare management.

Managing this complexity can be monumental, confirming the need for a high level of expertise and meticulous attention to detail.

DRGs offer a consistent method for categorizing medical cases into manageable groups, which enhances the overall organization within hospitals and healthcare facilities. Through the implementation of DRGs, healthcare providers can effectively compare treatment outcomes across various institutions.

One prominent example of this classification system is the Medicare Severity-Diagnosis Related Group (MS-DRG), which is pivotal in predicting healthcare costs based on patient-specific circumstances. Additionally, MS-DRG aids Medicare insurers in determining appropriate reimbursement amounts for healthcare facilities. Embracing DRGs fosters financial predictability and incentivizes healthcare providers to deliver cost-effective care while maintaining high-quality standards. The clear categorization of cases into Major Diagnostic Categories (MDCs) further facilitates tracking public health trends over time.

In summary, adopting systems like MS-DRGs has far-reaching benefits, contributing to efficient financial planning and enhancing overall patient management strategies. This, in turn, leads to improved service delivery within our healthcare institutions.

Brundage Group is dedicated to assisting healthcare systems in optimizing DRGs, ensuring accurate reimbursement, and delivering high-quality care while maintaining compliance and revenue integrity. Our blend of clinical expertise and data-driven insights positions us as a trusted partner in your journey toward excellence in healthcare management.

Denial management centers around navigating and resolving unpaid medical claims. Often, denials occur for various reasons. Firstly, gaps in data can cause claim refusal, with a whopping 42% of denial write-offs resulting from missing information; just one unfilled required field might lead to such an outcome.

Secondly, duplicate submissions are a common cause of denials. This occurs when the same service provider registers identical details for the same patient procedure or service item on the same day. This is especially true for Medicare B, which has an occurrence rate of over 32%.

Then there’s adjudication-related rejection, which occurs when payment benefits from another pre-settled procedure or service cover specific services offered, resulting in a denial. Further along are non-covered procedures, where if any process falls outside coverage within your current benefits plan, you face the potential risk of claim repudiation.

Lastly comes submission deadline-related exclusions; missed timelines could counteract successful filing, leading to a denied case scenario.

Despite our best efforts, human error does happen. Typos or incorrect data entries are common culprits. Leveraging modern technology like automated software can make all the difference at this denial management strategy implementation stage.

Software tools perform thorough checks against set parameters on every single piece of information within a claim form to ensure its validity. These parameters include patient demographics, insurance policy numbers, and codes related to procedures conducted or medications prescribed—just about anything you’d see on an insurance company’s radar while examining healthcare claims. You also need expert hands who will step in wherever automation fails!

Continual professional development plays a significant role here, enabling staff with evolving industry standards and guidance around recent policy changes from insurers, paving the way towards improved success rates! Remember, prevention outweighs cure when it comes to denied medical claims!

Understanding the pattern of denials plays a key role in managing earned revenues effectively. You must delve deep into your denial reports, pinpointing specific causes leading to most claim refusals. Typically, you’ll find a small fraction of issues causing the bulk of your difficulties, confirming the 80/20 rule.

Address this problem by studying these recurrent patterns vigilantly and focusing on reducing them one at a time. This method allows for gradual yet impactful change within your operations while boosting staff morale as they witness tangible improvements resulting from their efforts. Enhancing patient-facing administration with periodic training can help counter frequent errors too.

Since accurate billing commences with the first patient contact, assuring top-notch data collection upfront translates into immense downstream benefits. As schedulers obtain or confirm insurance details during calls, an integral responsibility, verifying eligibility prior to or post-appointment, is wise too! Keen analysis and focused action create powerful changes, improving reimbursement rates and overall stability.

As you delve deeper into denial management, another vital step is refiling appeals with supporting evidence. This process ensures that no claim goes unpaid due to a lack of proper backing data and documentation. Medical coding systems can be complicated, leading to errors and issues that slip through unnoticed.

When a payer denies your claim on grounds such as insufficient proof or incorrect code usage, don’t give up right away! Gather all relevant documentation, such as diagnosis records, course of treatment details, or doctor’s notes showcasing medical necessity for the services rendered. Once compiled and reviewed by an in-house team or an outsourced billing service provider, refile those denied claims immediately!

Clear communication is paramount between care providers, billers, coders, and payers. Addressing denials effectively shows clear signs toward financial wellness in the long run of hospital system operations across the U.S. today!

Once your appeal has been lodged, keeping track of its progress is vital. Don’t let open cases fall by the wayside. Regularly check up on each one’s status with your payer contacts.

With this consistent oversight, you can uncover if any information or action from you might speed things along. Moreover, ensure proper documentation for every case under review. Not only does it justify an appeal, but it also guides future steps should a denial occur again in similar scenarios.

Lastly, consider using specialized software that aids in overseeing and managing these tasks more effectively. Technology can become a valuable ally, providing regular updates about pending cases without requiring human intervention all the time. Keeping abreast of open appeals allows for swift redressal, ensuring smooth revenue flow into your healthcare organization and contributing to operational efficiency simultaneously.

Developing action plans is crucial as you move forward. You’ve already worked on identifying the root causes of denials; now it’s time to resolve future ones.

Implementing an effective course of action entails several steps that must be followed consistently. Collect comprehensive data from previous denials as a basis for analysis and understanding of potential pitfalls. Next up, build competent teams who understand their roles clearly in the prevention process and can address issues efficiently when they arise.

Encourage open communication channels to enhance synchronization between different stages of revenue cycle handling processes. Focus attentively on accurate documentation; remember, medical coding also plays a vital role here! It could secure claim approvals effortlessly if done right.

Lastly, automate whenever possible using smart technology tools like AI-based claims scrubbers or predictive analytics engines, which help prevent errors before submission. Remember, these strategies aren’t one-time fixes; they’re ongoing efforts requiring diligence that will ultimately boost financial health significantly.

Ensuring a smooth flow in denial management can be taxing. But you’re equipped to handle it effectively. Our services and proprietary technology platforms provide solutions for identifying problem areas and implementing effective denial management strategies.

Utilization management is a pivotal method to ensure healthcare is delivered effectively and efficiently. When discussing utilization management, remember that it’s all about ensuring you provide the right care at the right time in an appropriate setting. This critical process involves evaluating proposed medical treatments for necessity before they happen, monitoring ongoing treatment to optimize its course, or even revising plans retrospectively after completion, always prioritizing the patient’s well-being.

Think of utilization management like gears within a larger system: hospitals, doctors, insurance companies—everyone gets involved for optimum results. Picture prospective reviews as pre-checks on recommended interventions or potential referrals, excluding emergency admission cases. Concurrent reviews step in mid-treatment, while retrospective ones appraise concluded procedures from various angles, such as suitability and efficacy.

Ultimately, this serves patients, informs educational tools, and aids negotiations between insurers and health institutions during contract talks.

By implementing effective utilization management approaches, healthcare teams can potentially transform patient care. Improved health outcomes become a reality as services are tailored to individual needs. Patients may be directed towards additional resources like case management or disease programs, resulting in optimized personal well-being.

Utilization management offers a blueprint for treatment plans and reduces cases of unnecessary procedures, leading to lower overall costs without compromising the quality of care. Adhering strictly to set protocols amplifies efficiency within the system, minimizing waste on needless tasks and allowing caregivers more time dedicated solely to patients.

Furthermore, administrative burdens can be reduced when guidelines are clearly defined. This facilitates less paperwork for medical providers and allows them to concentrate on tending to their patients. This leads to increased job satisfaction and reduces the chances of overworking and eventually succumbing to burnout, which has become commonplace among today’s practitioners.

All these benefits contribute to fostering mutual understanding between the provider and payer sides, ensuring smooth coordination, and reducing errors due to miscommunication. This elevates standards rightly deemed by regulatory bodies, aligned perfectly with justifying why utilization management holds such significance in contemporary healthcare settings besides conforming to modern research practices.

Utilization management consists of several elements, creating a system that ensures effective care for patients. Firstly, pre-certification plays a crucial role. In this process, medical professionals evaluate whether proposed treatments are justified before they start. This helps to avoid unnecessary or repetitive procedures.

Secondly comes concurrent review, monitoring ongoing treatment progress while monitoring resource use as and when needed during patient recovery phases. Concurrent reviews help identify any potential course corrections based on support level needs at different stages of healing.

Another significant aspect is discharge planning. It outlines criteria for completion and a planned exit from the facility after successful treatment completion, ultimately leading to cost-effective post-hospital care management without compromising quality standards in the interests of stakeholders, both hospitals and insurers.

Lastly, case coordination aims to assist multiple providers in managing their efforts while caring together through well-defined plans, fostering cooperation, and guaranteeing optimal results despite complex differences between individual patient cases.

Doctors’ participation in utilization management is essential, tasked with critically assessing patient needs, including gauging the appropriateness of care and the clinical necessity of services or treatments requested. Doctors contribute to utilization management by ensuring patients get appropriate treatment at the right time from suitable providers, all while keeping costs effective.

At its core, this process maintains high-quality healthcare service delivery, promotes safety, and avoids unnecessary expenses. Collaboration also matters significantly in utilization management. Medical providers will work closely with other professionals, such as case managers or nurses, to review measures implemented following evidence-based medicine practices, thus contributing towards optimizing health management strategies envisioned within utilization management programs.

Your actions also impact regulation compliance since medical practitioners’ assessments contribute substantially to defining the pathways followed during audits conducted under governmental guidelines, such as HEDIS and NCQA standards. The role is pivotal, aiming to establish an equilibrium between quality patient care and efficiency.

Striking a balance between quality care and cost containment is crucial in healthcare. Utilization management ensures resources are used efficiently without sacrificing the patient’s well-being. The utilization management process evaluates treatments for their long-term effectiveness, not just their immediate results, meaning decisions aren’t dictated by upfront costs alone but also consider future health outcomes.

Cost containment doesn’t mean reducing the quality of service due to budget constraints; instead, it ensures that the services provided align with best practices while remaining fiscally responsible. Physicians conduct rigorous assessments before starting treatment using evidence-based criteria from trusted sources like recognized medical societies or government agencies such as the Centers for Medicare and Medicaid Services.

Finally, another dimension of this delicate balance lies within pre-service reviews; scrutinizing proposed procedures beforehand helps prevent unnecessary denials or redundant or unnecessary interventions that may inflate expenses.

Technology plays a pivotal role in the application of utilization management today. Evidence-based software, electronic health records, and data analytics are increasingly leveraged to streamline utilization management processes. Initially, reviewing medical needs was manual work, but nowadays, artificial intelligence aids this process, significantly speeding up review times.

A revolutionary tool you might use is predictive modeling, which uses historical patient data to assess potential risks or outcomes. Machine learning algorithms can even identify trends and patterns within large datasets, making it easier for hospitals to target areas where intervention would benefit most. Telehealth services also integrate seamlessly with these systems, enabling remote monitoring of patients and ensuring their treatment plan aligns correctly with their healthcare coverage, thereby reducing unnecessary hospital visits.

Diverse tech applications like these certainly bring about an innovation-driven change in utilization management. Utilization management ensures the best use of healthcare resources for optimal patient outcomes. By evaluating the medical necessity, appropriateness, and efficiency of services, it fosters quality care at affordable costs, making it pivotal to modern-day healthcare systems.

This guide offers practical strategies for administrators eager to tackle these issues head-on with data-driven decision-making tools.

The strain on ICU capacity can significantly influence this period. Research indicates that a congested intensive care unit might lead to increased mortality rates among admitted patients.

Interestingly, hospitals categorized as ‘safety net’ establishments often exhibit poorer performances under Medicare’s value-based purchasing system than other types of hospitals. That could also affect their average duration of patient stays. Furthermore, emergency department crowding may consume more time and considerably extend your admission span in medical facilities.

Inadequate management or handling during peak hours potentially causes dangerous delays and adversely affects patient outcomes. Notably, too, are studies that suggest associations between lengthy boarding times in emergency departments and higher mortality rates post-admission. Such observations underline how aspects like overcrowding and resource availability directly contribute to fluctuating lengths of hospital stay.

Monitoring remains crucial as you navigate the length of stay. Data from nearly all leading medical institutions hint at a trend: decreases in LOS might be stalling or even rising slightly. Shining the spotlight on LOS brings several factors into focus.

Patient satisfaction measures seldom factor in LOS. Patients value tangible outcomes above the duration spent within hospital walls. Unless instructed to do so by administrators or payers, clinicians may ignore LOS. Despite warnings that prolonged stays increase risks, the evidence to back this is flimsy and nuanced by the severity of illness.

The role of academic medical centers comes under scrutiny with overflowing emergency departments and mounting pressure for costly expansions, a burden passed onto taxpayers, patients, and insurers alike, highlighting an urgent need for strategies beyond mere construction projects. Finally, there’s judiciousness about who needs admission. The potential impact here on lowering avoidable admissions could be significant, but it raises complex questions around diagnosis efficiency too.

Understanding and managing LOS requires multi-faceted approaches sensitive to patient needs and system pressures.

Shifting your focus to better bed management can revolutionize LOS. Making beds available when needed cranks up throughput, decreasing overall patient stay periods. Adopting best practices from other institutions and applying them in real-time scenarios can create a smoother transition.

Adopting technology also plays a significant role, as it facilitates easy access and sharing of health records amongst staff members, promoting efficient service delivery. Furthermore, consider reassessing discharge processes, where inefficiencies often go unnoticed. Ensuring proper planning and communication with patients regarding expected release times can ease bottlenecks that typically occur during peak hours.

Efficient scheduling of tests is another key area worth addressing, as it considerably reduces unnecessary waiting times, thereby effectively trimming the duration of hospital stays. Remember, though, involving front-line employees while developing strategic plans will increase their engagement levels; ultimately fuel improved results.

Managing efficiency in a healthcare setting plays a crucial role. Your focus should center on patient flow and the use of hospital resources. Consider reducing unnecessary wait times, improving organizational structures of care, hastening decision-making processes, and bolstering discharge planning initiatives with technology.

Efficiency can be further boosted by specific interventions that address clinical care improvements, such as early mobility programs for patients, and logistical factors, such as medication management systems to reduce pharmacy-related delays. Carefully designed workforce strategies also prove influential here; consider introducing multidisciplinary teams who can collaborate effectively towards improved workflows within your facility’s unique infrastructure constraints.

Remember, all measures taken should maintain an equilibrium between risk and outcome; efficient treatments shouldn’t compromise safety or thrust unexpected costs onto outpatients. The key is sustaining improvement while being mindful not to disadvantage those facing socio-economic hardships or complex medical needs.

Remember that every individual’s health journey is unique; what works for one might not work for another. Shorter lengths of stay may seem beneficial from an economic standpoint, but they could have potential drawbacks.

In some cases, premature discharges can lead to readmissions if a person isn’t fully healed. Conversely, extended hospitalization puts patients at risk of acquiring infections while potentially straining mental wellness since hospitals aren’t homelike environments. It becomes apparent then why striking a balance matters greatly in this scenario; neither rushing discharge nor delaying it unnecessarily aligns with providing optimal care or upholding patient safety standards.

Monitoring and adjusting lengths of stay needs careful consideration of the condition’s severity and personalized treatment plans. It shouldn’t only be viewed as a cost-saving exercise but also pivotal in enhancing overall healthcare quality.

Clinicians face several challenges in managing hospital length of stay. Data reveals that patient overcrowding, especially during peak times, makes it tough to allot critical care resources properly. This strain on ICU capacity can adversely impact the quality of care provided.

Also, an often unexpected issue is safety-net hospitals performing poorly under Medicaid’s value-based model compared to other hospitals, emerging as a cause for concern. Emergency department crowding bears mentioned here because it further complicates outcomes for admitted patients.

Finally, clinicians grapple daily with balancing efficient discharge strategies without compromising patient health or risking potential readmission. Even though researchers are striving hard to find effective solutions and improvements continue to be made gradually, these issues remain significant obstacles affecting optimal management practices related to hospital stay durations.

Ultimately, managing hospital length of stay is a balancing act. You have to weigh quality care against cost-effectiveness. Reducing prolonged stays isn’t only about revenue; it’s key for optimizing patient satisfaction outcomes.

In the ever-evolving landscape of modern healthcare, the concept of hospital levels of care plays a crucial role in ensuring efficient and effective patient treatment. These levels of care are essential in providing a structured approach to medical services and resource allocation, ensuring that patients receive the appropriate level of attention based on the severity and complexity of their conditions.

A key distinction within these levels of care is between observation and inpatient admission, which carries significant implications for both hospitals and patients.

Hospital levels of care create a tiered system that allows patients to access the most suitable medical attention according to their specific healthcare needs. This classification is structured to provide a continuum of care, starting from basic primary care services focusing on preventive healthcare and general wellness and escalating to specialized quaternary care centers offering cutting-edge medical research and innovative treatments.

Properly understanding and implementing hospital levels of care is paramount for patients and healthcare providers alike. By appropriately identifying the level of care needed, hospitals can ensure optimal resource allocation and streamline patient flow, leading to better overall healthcare outcomes.

The observation level of care, commonly associated with the Emergency Room, is critical in providing immediate medical attention to patients with acute and urgent medical conditions. The ER acts as a crucial gateway to the healthcare system, operating 24/7 to address medical emergencies regardless of the time of day.

Upon arriving at the ER, patients are rapidly triaged based on the severity and urgency of their conditions. Skilled medical professionals, including emergency physicians, nurses, and other healthcare providers, assess and stabilize patients to prevent further deterioration. The observation level of care allows for rapid intervention and often determines the course of treatment for critically ill or injured patients.

In the ER, patients may receive initial diagnostic tests, such as blood work, X-rays, or CT scans, to identify the underlying cause of their symptoms. Treatment in the ER may involve administering medications, providing wound care, immobilizing fractures, or performing life-saving interventions, such as cardiopulmonary resuscitation for cardiac arrest.

The observation level of care is time-sensitive, and patients with less severe conditions may be discharged with appropriate instructions for follow-up care. At the same time, those with more critical needs are admitted to inpatient units for further medical management.

Moving up the hierarchy of hospital levels of care, the inpatient admission level is characterized by continuous and comprehensive medical care provided to patients with conditions that require ongoing monitoring and treatment. Inpatient admission is typically required for patients who cannot be adequately managed in an outpatient setting due to the complexity and severity of their conditions.

When admitted to inpatient units, patients receive specialized care from multidisciplinary teams, which may include physicians, nurses, therapists, and other healthcare professionals. The inpatient setting allows for 24/7 monitoring and immediate intervention as needed.

Patients undergo a thorough assessment during the inpatient stay, and a personalized treatment plan is developed based on their medical needs. The medical team closely monitors the patient’s progress, adjusts treatment as necessary, and ensures that the patient is on the path to recovery.

Inpatient units are equipped to handle various medical conditions, from post-surgical care and complex chronic illnesses to acute infections and severe injuries. Depending on their specific healthcare needs, patients may receive various interventions, such as intravenous medications, physiotherapy, respiratory support, and rehabilitation.

The duration of the inpatient stay varies depending on the patient’s condition and response to treatment. The goal of inpatient care is to stabilize the patient’s health, manage their condition effectively, and prepare them for a safe transition to a lower level of care, such as outpatient or home-based care, once their condition permits.

It’s important to note that patients may transition between different levels of care based on changes in their condition. For example, a patient initially admitted for inpatient care may improve and be deemed appropriate for observation level of care or even discharged for outpatient follow-up if their condition stabilizes further.

For hospitals, the distinction between observation and inpatient admission is critical for patient care and has financial implications. Medical necessity is required for payers to reimburse hospitals appropriately when patients are admitted for inpatient care. Demonstrating medical necessity through thorough documentation and evidence is essential for validating the appropriateness of the level of care provided.

Hospitals must meticulously document the patient’s condition, the necessity for inpatient care, and the treatment plan to meet payer requirements for reimbursement. Properly establishing the level of care is vital for hospitals to ensure their financial viability while delivering the highest quality care to their patients.

There are challenges and limitations that healthcare providers and patients may encounter:

In some regions, especially rural or underserved areas, access to specialized healthcare services at higher levels of care may be limited. This disparity can lead to delayed diagnoses and treatments, affecting patient outcomes.

In tertiary and quaternary care centers, where specialized expertise is concentrated, long waiting times for appointments and treatments can hinder timely access to necessary medical interventions.

The ever-increasing demand for specialized healthcare services poses resource allocation challenges to healthcare systems worldwide. Ensuring equitable distribution of resources and maintaining high-quality care across all levels can be complex.

Higher levels of care, such as quaternary care, often involve cutting-edge treatments and technologies, which can be costly. Balancing the pursuit of advanced medical interventions with cost considerations is a constant challenge for healthcare institutions.

As patients move between different levels of care, ensuring smooth coordination and continuity of care becomes critical. Effective communication and information sharing among healthcare providers are essential to prevent gaps in patient care.

The future of hospital levels of care holds exciting prospects as technology continues to advance. Telemedicine, fueled by advancements in communication and digital technology, is revolutionizing how healthcare services are delivered. Telemedicine allows patients in remote or underserved areas to access specialized care through virtual consultations, reducing the burden of travel and improving overall healthcare accessibility.

Furthermore, artificial intelligence and machine learning are revolutionizing diagnostics, personalized treatment plans, and patient monitoring, leading to more accurate and efficient medical interventions.

Understanding and effectively managing hospital levels of care is a crucial aspect of our work at Brundage Group. We recognize the significance of differentiating between observation and inpatient admission and the challenges and limitations faced in providing the appropriate level of care.

By comprehending these complexities, we empower our clients to overcome challenges, optimize resources, and provide the highest quality care to their patients.

Healthcare revenue cycle management is a process that encompasses all the administrative and financial tasks involved in managing the revenue generated from providing healthcare services. It begins when a patient schedules an appointment and continues through the entire billing and payment cycle until all outstanding payments are received.

The RCM process includes various components and stages, such as patient registration, insurance eligibility verification, charge capture, medical coding, claims management, and payment posting. Each step is critical in ensuring accurate billing, timely claim submission, and efficient payment collection.

Revenue cycle management, often referred to as RCM, is a crucial process that keeps medical facilities operational. This system comes into play the moment a patient schedules an appointment and concludes when all payments have been received from both patients and claims. The initial stage involves administrative tasks such as scheduling appointments, verifying insurance eligibility, and creating patient accounts with detailed health status histories and coverage information.

Pre-registration sets out this fundamental groundwork which can streamline revenue cycle management processes immensely. Once completed treatments are done for each visit by the patients at these healthcare providers or re-organizers, the corresponding ICD-10 codes related directly to the provided treatments are identified. This establishes how much reimbursement should be captured via specific plans based on the documents regarding the service billed.

Let’s delve into the medical billing process in RCM. This is a crucial step where accuracy matters most. Hospital staff should be well-trained, knowing how to avoid errors such as incorrect data entry or coding mistakes.

Missed details cost hospitals earned revenue. First off, patient eligibility and co-pay amounts need to be checked before they arrive at your facility for an appointment. Once services are provided, check missing charges against charge slips diligently.

Next up comes following up on claims, which demands prompt action from your team. Remember that tasks can get forgotten without established workflow protocols in place, leading to increased errors and causing losses for your practice due to delays in receiving payment.

The revenue cycle embodies several key elements that interact with each other. Patient registration begins this journey. Correct details about patients are critical for seamless processing and accurate billing. Next comes insurance eligibility verification to confirm coverage status, benefits restrictions, or specific patient obligations. Charge capture follows closely by recording all services provided within an electronic system for precise bill preparation.

Medical coding translates these provisions into standardized codes used universally in healthcare setups. Claims management is an integral part of the process. It includes creating, submitting, and following up on claims with insurers during the adjudication stage. This is when the insurer decides whether they are liable for payment according to a previously signed agreement between them and the provider.

These steps collectively culminate in the final task: payment posting, where actual remittances received from both parties (insured individuals and insurance providers) get recorded systematically against corresponding bills.

Therefore, every piece contributes significantly to maintaining financial health while improving medical service quality delivered across establishments of varying sizes or specialties.

Automated RCM systems offer many benefits. They can increase your revenue by streamlining the cash flow process, which is essential for any thriving healthcare practice. The enhancement of payment collection is also evident.

These automated processes are advantageous in maintaining an efficient cash flow pattern and optimally timed payments, which can positively impact liquidity. This system can be beneficial when you need more than improved cash flows, such as new funds generated from existing ones or reducing bad debts. Notably, patient satisfaction increases with automation in place.

Happy patients often recommend services, which can boost business growth considerably. Automating administrative tasks allows staff members to concentrate on delivering superior service, driving customer contentment even further. Last but not least, quality data management is important in improving patient care and efficiency within the organization’s operations.

Technologies like automated financial reporting and claims processing can ensure timely service reimbursement while adhering to HIPAA regulations and securely protecting sensitive information.

You might wonder why traditional revenue cycle management systems hit roadblocks. Well, one primary reason is human error. Mistakes can creep in when managing tons of data manually, especially with billing and coding tasks requiring high precision.

Another hurdle comes from outdated technology or a lack thereof. In many local clinic setups, the absence of modern digital tools delays critical procedures like patient registration or claim tracking. Moreover, task separation proves challenging too!

With staff members assigned to different steps within the cycle without any unified system keeping track, it’s easy for things to fall through the cracks. Last but not least are regulatory impediments. Healthcare rules change often, which requires regular updates on RCM practices, making them complex over time!

In essence, conventional revenue models struggle due to systemic inefficiencies along with rapid changes in both technological standards and government regulations.

Given the complexities of healthcare revenue cycle management, striving for efficiency can lead to notable progress. One vital practice includes automating insurance verification, which ensures accurate patient coverage and saves time by reducing manual labor. Adopting a patient-centric approach proves hugely beneficial too.

Studies reveal that patients who understand their costs upfront are likely to return, leading to higher retention rates and increased referrals. Another best practice revolves around successfully increasing revenue collection rates through timely payments and fine-tuned RCM processes, including upfront patient collections. This helps prevent delayed revenue realization.

Moreover, swift claim filing is crucial, as many insurers maintain shorter timelines, usually 90 days, compared with Medicare’s one-year period. Punctual submissions increase your chances of receiving payment without unnecessary delays or denials.

Outsourcing can be a boon for smaller, independent clinics aiming to improve their revenue cycle management. The crux is expertise. Dedicated billing staff often secure greater collections as a percentage charged than DIY efforts bring about. Even modest increases say 5-10%, could result in noteworthy income hikes for your practice.

Likewise, fewer coding errors yield heightened efficiency while reducing HIPAA violation risks from ill-trained internal teams. However beneficial it may seem, there are drawbacks to consider before opting to outsource this aspect of clinical operations. Cost sits topmost among these, typically calculated as part of total billed charges, even with potential savings on salaries surpassing outsourcing fees.

Furthermore, data security must remain at the forefront when considering working with third-party contractors due to its associated risk factors, such as patient breaches or violations related to HIPAA guidelines. Lastly comes control; you inevitably cede some oversight by going outside in-house solutions, although judicious partner selection ensures continued financial insight via regular reports.

Healthcare revenue cycle management plays a key role in maintaining the financial health of healthcare facilities. One crucial component is accurate and efficient medical coding, which streamlines administrative processes. Equally important are skilled professionals who handle insurance inputs, and finalize bills to make the revenue process smoother.

If you aspire to help improve HRCM with your aptitude for detail-oriented work, consider exploring careers in medical billing or coding. Not only will this allow you an inside look into hospital operations, but it will also offer chances for professional growth within these high-demand fields.

Staying up-to-date with industry trends can be easier with the right educational foundation.

Remember, investing time now to understand HRCM can reap great rewards down the line, both personally and professionally, as it continues shaping future facets of patient care across countless hospitals worldwide!

Regulations in healthcare constantly evolve, affecting healthcare providers directly. Changes such as shifts from fee-for-service to value-based models significantly impact revenue cycles. Increasing patient financial responsibility due to high-deductible health plans also adds complexity.

Healthcare providers, both large hospitals and small practices, need agility within their revenue cycle management processes to promptly adapt without sacrificing service quality or getting swamped by paperwork. The rise in government payers’ influence further complicates how transactions are handled and recorded. Inefficient billing has been reported by over 95% of medical practice leaders as a pressing issue that needs resolving quickly; any delays could mean the difference between profit and loss for some organizations.

It becomes all too clear why efficient revenue cycle management matters greatly. Your business’s financial resilience may depend on it. When faced with regulatory changes, consider outsourcing your RCM functions if managing them internally is proving difficult. Many other professional organizations have had success doing this!

With adequate planning plus expert management support, such as a trusted outsourced partner who knows the intricacies of these ever-changing regulations, you’ll be better equipped to navigate uncharted waters while maintaining optimum patient satisfaction scores.

Electronic Health Records, or EHRs, are a game-changer. These digital tools store patient data securely while making it readily accessible. What does this mean? Less administrative tasks to juggle so you can focus on providing quality care. Patient self-service portals fall under tech innovations too.

They grant patients control over their information input, which eases staff workload even more. But what about insurance eligibility verification? There’s an app for that!

Automated software swiftly validates coverage details, slashing claim denials significantly and reducing errors in paperwork. No small feat when navigating complex health plans! Investing in advanced claims processing solutions helps speed up the reimbursement process with real-time adjudication. Plus, automated coding reduces errors further, optimizing the management of denied claims.

Understanding that revenue cycle management is vital as you navigate healthcare. This financial process ensures the smooth running of your care journey, from scheduling appointments to final payment clearance. With Brundage Group’s aid, hospitals can manage their finances effectively.

It also eases patients’ burdens. The cycle guarantees efficiency in services rendered and reduces confusion about payments due—a win-win for all parties involved.

NEWS RELEASE

FOR IMMEDIATE RELEASE

Tampa, Fla. – [June 20, 2023] – Brundage Group and Brundage Workforce Solutions, leading providers of physician-led advisory services, workforce solutions, and revenue cycle analytics to hospital systems nationwide, announce the companies have received the Tampa Bay Business Journal’s Fast 50 award for the second straight year. The Fast 50 recognition signifies exceptional growth and solidifies the companies’ position among the fastest growing in the vibrant Tampa Bay region. Brundage Group, together with its dedicated revenue cycle staffing division, Brundage Workforce Solutions, have been honored as Fast 50 award winners.

The Fast 50 awards rank companies based on their exceptional percentage of annual growth over a three-year period, demonstrating their remarkable ability to adapt and thrive within a competitive landscape. The final rankings will be unveiled during an exclusive event slated for July. To qualify for this highly regarded accolade, companies must meet specific criteria, including being privately held and locally owned, operational since January 1, 2020, or earlier, generating annual revenues of at least $1 million in 2020 or $5 million in 2022, and maintaining headquarters within Hernando, Hillsborough, Manatee, Pasco, Pinellas, Polk, or Sarasota counties.

Dr. Tim Brundage, CEO and Physician Advisor at Brundage Group, expressed his gratitude, stating, “We are humbled to be acknowledged as one of Tampa Bay’s 50 fastest-growing companies for the second consecutive year. Our success is a testament to the remarkable culture we have fostered and the exceptional individuals who contribute to our ongoing achievements. We remain steadfast in our mission to provide hospitals nationwide with revenue cycle management solutions that enable them to deliver unparalleled quality care and remain viable in the communities they serve.”

Brundage Group and Brundage Workforce Solutions have also been recognized as recipients of TBBJ’s Best Places to Work accolade, further emphasizing the companies’ unwavering commitment to cultivating an enriching work environment that fosters creativity, growth, and employee and client satisfaction.

Brundage Group and Brundage Workforce Solutions are actively expanding their exceptional teams and currently offering several exciting employment opportunities. Industry professionals may seek more information and explore current career opportunities at brundagegroup.com.

Brundage Group is the trusted choice of hospital systems for revenue cycle management solutions. We support hospitals nationwide with customized solutions that include a full suite of Physician Advisory services, staff augmentation/workforce solutions, proprietary level of care analytics, and physician-led documentation education to relay high-quality care. Our programs help hospital organizations break down departmental silos by unifying all departments in the mid-revenue cycle. Our dedicated staffing division provides seasoned, veteran RN case managers, utilization review nurses, and appeals/denials professionals, all backed by our team of expert Physician Advisors and documentation and coding experts.

Megan Ford

Brundage Group

Email: mford@brundagegroup.com

Phone: 727.256.3907

https://brundagegroup.com/

By: Cheryl Ericson, RN, MS, CCDS, CDIP

CDI and coding professionals should consider the totality of the record when determining if a diagnosis is reportable.

Some diagnoses can be validated with diagnostic evidence e.g., x-ray, CT scan, ultrasound, etc. while other diagnoses are based on a provider’s experience and patient presentation. Many clinical documentation integrity (CDI) and coding professionals rely upon the Official Coding Guideline for uncertain diagnoses (Section III.C) for these types of diagnoses which states,

“If the diagnosis documented at the time of discharge is qualified as “probable,” “suspected,” “likely,” “questionable,” “possible,” or “still to be ruled out,” “compatible with,” “consistent with,” or other similar terms indicating uncertainty, code the condition as if it existed or was established. The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis. Note: This guideline is applicable only to inpatient admissions to short-term, acute, long-term care and psychiatric hospitals.”

But what CDI professionals may not be aware of there are several American Hospital Association (AHA) Coding Clinics related to this coding guideline that clarify what terminology is considered “uncertain.” Why is this important? Because providers usually don’t document uncertain diagnoses at the time of discharge unless coached to do so. It is also important to note that the above uncertain diagnosis guideline only applies to the inpatient setting because the outpatient setting also has an uncertain diagnosis guideline (Section IV.H) that states,

“Do not code diagnoses documented as “probable”, “suspected,” “questionable,” “rule out,” “compatible with,” “consistent with,” or “working diagnosis” or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit. Please note: This differs from the coding practices used by short-term, acute care, long-term care and psychiatric hospitals.

This context is needed to accurately interpret AHA Coding Clinic Advice related to uncertain diagnoses. Because the guideline includes the phrase “other similar terms,” Coding Clinic has been asked about different qualifiers and if their use results in an uncertain diagnosis or not. Consequently, Coding Clinic determined “concern for is a term that should be interpreted as an uncertain diagnosis and coded following the guideline for ‘uncertain diagnoses’ in the inpatient setting (Issue 1, 2018);” and appears to be “fits the definition of a probably or suspected condition that would not be coded in the outpatient setting (Issue 3, 2009).”

However, the Issue 3, 2009 AHA Coding Clinic also states, “when the provider documents ‘evidence of’ a particular condition, it is not considered an uncertain diagnosis and should be appropriately coded and reported in the outpatient setting.” Some may think this advice only applies to the outpatient setting, but that would be an inaccurate interpretation because the above Coding Guidelines demonstrate that the outpatient coding guideline is much more restrictive than the inpatient coding guideline.

Uncertain diagnoses cannot be reported in the outpatient setting but can be reported in the inpatient setting “if documented as such at the time of discharge.” If “evidence of” is not considered a qualifier that results in an uncertain diagnosis in the outpatient setting, then the same would be true for the inpatient setting.

Why does this matter? Because if a provider documents “evidence of gram-negative pneumonia” or some other clinical diagnosis in a progress note, and the diagnosis is supported with clinical evidence, and meets the definition of a reportable diagnosis or principal diagnosis; the diagnosis can be reported.

In my opinion, it is much more likely a provider will document “evidence of” a diagnosis in a progress note, than qualify a diagnosis as uncertain at the time of discharge. I also feel like use of “evidence of” gives the provider a little bit of wiggle room when they are making a clinical diagnosis, one that cannot be easily validated by diagnostics, but is based on presenting signs and symptoms as well as response to treatment.

There are several instances when providers may rely upon clinical findings to either make a diagnosis or provide more specificity about a diagnosis e.g., specifying the type of pneumonia, ischemic stroke, metabolic encephalopathy, etc. and use of “evidence of” may be appropriate due to a lack of diagnostic evidence. Providers aren’t required to prove a diagnosis beyond a shadow of doubt for it to be reportable, but many are hesitant to document a diagnosis until they reach a degree of certainty due to the potential for liability.

Each provider will have their own threshold of how much clinical evidence they need to make a definitive diagnosis, which is allowable under Coding Guideline 19 that states,

“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. If there is conflicting medical record documentation, query the provider.”

The guideline doesn’t say there must be diagnostic evidence to support a reportable diagnosis, only that the provider must document that the condition exists. Of course, we know there must be clinical evidence to support every reported diagnosis to avoid a clinical validation denial, but we often forget the importance of patient history and presentation. For example, providers in the office setting will often make a diagnosis of pneumonia without a chest x-ray to confirm the diagnosis.

Just to be clear, a diagnosis qualified with “evidence of” will also need to be clinically valid, but the validation may be, for example, the presence of pneumonia, but not the causative organism. In this example the use of “evidence of” allows the provider to further specify the type of pneumonia when they are unlikely to isolate the causative organism through diagnostic tests but can make an educated guess about the causative organism based on the patient’s history, presentation, and response to treatment.

Another example is when determining the type of encephalopathy in a complex patient. Rather than documenting “likely metabolic encephalopathy” which can only be reported if documented at the time of discharge, the provider can document “evidence of metabolic encephalopathy” in any note because it “evidence of” is does not make metabolic encephalopathy an uncertain diagnosis. When educating providers about “evidence of,” I also educate them to document if the condition is later ruled out. I find this to be a more successful approach than hoping a provider will document an uncertain diagnosis at the time of discharge.

Additionally, most of us have been inaccurately applying the inpatient uncertain diagnosis guideline which states, “The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.” Use of the word “and” in this guideline implies that all conditions must be met for the Coding Guideline to apply. One of those conditions is arrangements for further workup or observation. If you encourage providers to document uncertain diagnoses at the time of discharge, also educate them document how the condition will be followed up post-discharge.

I’m not sure why many CDI and coding professionals prefer to rely on the inpatient uncertain diagnosis guideline rather than educating providers to use “evidence of” when they lack diagnostic certainty to support an appropriate diagnosis, but I hope this article will encourage more of you to use this approach. I also encourage CDI and coding professionals to consider the totality of the record when determining if a diagnosis is reportable because providers will often copy and paste documentation where a diagnosis is uncertain pending further workup into subsequent progress notes or even the discharge summary making it appear that a diagnosis is still being worked up, but the diagnosis was ruled out or lacks clinical validation to be reported.

Before applying the inpatient uncertain diagnosis guideline validate the diagnosis was not already worked up and ruled out or that there is sufficient clinical evidence for the diagnosis to be reported.

By: Cheryl Ericson, RN, MS, CCDS, CDIP

Is your hospital receiving a high volume of clinical validation denials? If so, you’re not alone.

Clinical validation denials continue to grow in volume and many organizations remain vulnerable to them. Clinical validation was defined with the 2011 Recovery Auditor (RA) scope of work as a separate process from DRG validation, which involves a clinical review of the case to see whether or not the patient truly possesses the conditions that were documented.

Does your organization have a clinical validation process in place, and if so, it is as robust as your DRG validation process? If not, why not?

When Coding Guideline 19 for Code Assignment and Clinical Criteria was introduced, there was a corresponding Coding Clinic that included some key concepts related to how this guideline should be interpreted. These included the following:

1. Although ultimately related to the accuracy of coding, clinical validation is a separate function from the coding process.
2. If the physician documents sepsis, and the coder assigns the code for sepsis, and a clinical validation reviewer later disagrees with the physician’s diagnosis that is a clinical issue but is not a coding error.
3. A facility or payer may require a physician use a particular clinical definition or set of criteria when establishing a diagnosis, but hat is a clinical issue outside of the coding system

So, who in your organization is responsible for clinical validation? It is not a coding function, but has your organization embraced it as a clinical documentation integrity (CDI) function and dedicated the resources necessary to develop a robust clinical validation process?

I know many organizations have implemented organizational definitions for diagnoses vulnerable to clinical validation like sepsis, acute respiratory failure, malnutrition and others, but organizational definitions are not enough to create a robust clinical validation process. Ironically, my company often sees clinical validation denials associated with diagnoses that were added through a CDI query at a healthcare organization with organizational definitions.

You see, it starts with fundamentals. What is the goal of the CDI department? Is it really documentation integrity and accurate reimbursement? If so, why as a CDI professional don’t we have a defined processes of what to do when a diagnosis isn’t clinically validated but a code is assigned? Is it enough to query to ask if the diagnosis was ruled out?

There are so many gaps in the clinical validation process on the hospital side that need to be addressed it is no wonder that payers are taking full advantage.

By: Cheryl Ericson, RN, MS, CCDS, CDIP

New codes become effective Oct. 1, 2022.

With the start of fiscal year (FY) 2023 right around the corner, this is a good time for clinical documentation integrity (CDI) professionals update their practices to reflect FY 2023 changes. I’m sure most of you have already downloaded FY 2023 ICD-10-CM/PCS and the Official Coding Guidelines, but there are some other lesser-known resources that can help you prepare for FY 2023.

When you visit the 2023 ICD-10-CM on CMS.gov to get a copy of the FY 2023 ICD-10-CM Coding Guidelines, it is often worthwhile to download the 2023 Addendum. As I prepare for FY 2023, I like to review the ICD-10-CM Tabular List of Disease and Injuries 2023 Addenda. The addenda reveal what changes occurred in the tabular list by each chapter so it is an easy way to find new, deleted and revised ICD-10-CM codes. There is a table that I’ll mention below that also lists new, deleted, and revised codes, but I like to see the changes in the context of the tabular list because then I gain insight into how to properly use the code.

For example, did you know code E87.2 for acidosis has been expanded? Instead of one code for all types of acidosis, E87.2 has been expanded to four different codes and these include the following:

• Code E87.2 acidosis has been deleted
• E87.20 is a new code for acidosis, unspecified but still includes lactic acidosis NOS and metabolic acidosis NOS
• E87.21 is a new code for ACUTE metabolic acidosis that includes acute lactic acidosis
• E87.22 is a new code for CHRONIC metabolic acidosis that includes lactic acidosis with a code first note for the underlying etiology, if applicable
• E87.29 is a new code for other acidosis that includes respiratory acidosis NOS

What I find most interesting is the addition of acuity with the diagnosis of acidosis. Code E87.2, which included both acute and chronic acidosis was classified as a complication (CC), but I wonder if differentiating between acute and chronic acidosis will eventually result chronic metabolic acidosis being removed from the CC list. Hold onto that thought as I tell you a way to check out if these new codes are classified as a CC or not.The other must have resource from the 2023 ICD-10-CM CMS.gov webpage is the 2023 code tables, tabular and index. I like to keep a PDF copy of the alphabetic index and tabular list so I can quickly look up diagnoses by either description or ICD-10-CM code. Again, some of you may find it faster to use a grouper, but with the type of work I do, I often what to know every term associated with a particular ICD-10-CM code. Let me give you an example, there are many “other” and “unspecified” codes, and the tabular list does not include all synonyms, so I often search the alphabetic index by that particular ICD-10-CM code to find those other inclusive conditions. Let’s say I wanted to know what diagnoses are included in code G92.8 Other toxic encephalopathy. The tabular list only includes toxic encephalitis and toxic metabolic, but when you search the alphabetic index by “G92.8” you’ll find the additional diagnoses of “drug included metabolic encephalopathy,” “Jamaican neuropathy,” “Jamaican paraplegic tropical ataxic-spastic syndrome,” and “heroin vapor leukoencephalopathy” to name a few. The tabular list is not all inclusive of every condition that will map to a particular ICD-10-CM code.The next site I would strongly encourage you to visit is the FY 2023 IPPS Final Rule home page. There are a couple of different references that I like from this site. Primarily, I get my own copy of Table 5, the list of MS-DRGs, relative weighting factors, and geometric and arithmetic mean length of stay. If you didn’t know, the associated relative weights and length of stay are updated annually based on prior year claims. Many organizations have analyst who will compare the current year Table 5 to the prior year Table 5 to identify potential revenue shifts as some MS-DRGs may have lower or higher relative weights compared to the prior year. I like having an electronic copy of the MS-DRGs because I find it easier to search than using a book.

This site is also where you will find the tables that outline all ICD-10-CM and PCS code changes. Table 6A includes all the new diagnosis codes for FY 2023. Table 6J includes ICD-10-CM diagnosis codes classified as CCs in FY 2023. I often focus on tables 6J.1 and 6J.2 because these tables list what codes have been added or removed from the CC list. Similar tables exist to identify these changes among diagnoses classified as MCCs. In a moment, I’ll share another tool where you can also check ICD-10-CM codes against the FY 2023 CC and MCC list.

I often find that a more useful on-going resource, but I start with these lists so I can begin educating my peers and providers about the impeding code changes, so we aren’t caught off guard. For example, as expected E87.2 has been removed as CC, appearing on Table 6J.2 because the code no longer exists. However, the new acidosis codes are all included on Table 6J.1 for additions to the CC list.

ICD-10-CM/PCS MS-DRG v40.0 Definitions Manual page

One of my favorite resources is the ICD-10-CM/PCS MS-DRG v40.0 Definitions Manual. This version will be in effect from 10/1/22 to 3/31/23. Before you think the associated dates are a typo, remember updates now occur biannually. Why do I love this resource? It allows me to quickly research how ICD-10-CM/PCS codes impact MS-DRG assignment. Whether you are new to CDI or a veteran, this website has some great resources to help you understand MS-DRG methodology. For example, did you know MS-DRG v40.0 contains a combination of 73,639 diagnosis codes and 78, 494 procedure codes? The design and development of the diagnosis related group (DRG) reference includes a table that outlines the breakdown of base MS-DRGs.

The ICD-10-CM/PCS MS-DRG v40.0 Definitions Manual lists all the MS-DRGs by Major Diagnostic Category (MDC). Within each MDC the associated MS-DRGs are separated by surgical and medical MS-DRGs. Want to know what ICD-10-CM and/or ICD-10-PCS codes map to a particular MS-DRG? This is the resource for you when you are doing research on the fly or don’t have access to a grouper.

Perhaps the most valuable resource associated with the Definitions Manual is the appendixes. With the start of a new fiscal year, it is often hard to remember which diagnoses are classified as a CC or MCC. Appendix G includes Diagnoses defined as complications or comorbidities, numerical list of ICD-10-CM codes that are classified as CCs. Appendix H includes those diagnoses defined as major complications or comorbidities or (MCC).

Remember those new acidosis codes I mentioned? Rather than having to access all the different tables within the FY 2023 Final Rules page, I find referencing Appendix G a lot easier. A quick search of Appendix G allows me to verify that all the new acidosis codes (E87.20-E87.29) are currently classified as CCs in FY 2023.

I hope you find these resources as helpful as I do as you prepare for FY 2023.

By: Cheryl Ericson, RN, MS, CCDS, CDIP

Documenting a diagnosis in the health record extends beyond its impact on reimbursement and quality-of-care measures. It is also critical to patient safety.

As a clinical documentation integrity (CD) I professional with a nursing background, since I’m no longer at the beside, I often feel disconnected from the human aspect of my work. I know I am doing important work to ensure healthcare data is accurate, but am I really impacting the lives of patients?

It turns out, I am, but maybe not how you would expect. One of the more challenging aspects of our work as CDI professionals is physician engagement, which is why connecting our work to the patient level is so important. Many providers don’t want to hear about how their documentation impacts hospital reimbursement and it difficult to demonstrate a direct impact between their documentation and quality performance measures except when a patient dies, which is a sensitive subject. That is why I’m so excited to share with you an Agency for Healthcare Research and Quality (AHRQ) call to action to improve diagnosing patients.

The importance of documenting a diagnosis in the health record extends beyond its impact on reimbursement and quality-of-care measures. It is also critical to patient safety. AHRQ states, “The diagnosis explains a patient’s health problem, informs every subsequent healthcare decision, and is developed through the iterative process of information gathering, information integration, and information interpretation.” Good patient outcomes require the right diagnosis.

According to AHRQ, diagnostic errors are an emerging safety concern that can “involve up to 12 million patients annually in U.S. ambulatory settings alone and contribute to death for up to 80,000 patients in U.S. hospitals annually.” It involves missed opportunities related to various aspects of the diagnostic process that includes “recognition of key signs, symptoms, and test results.” Diagnostic errors contribute to diagnostic safety events, which may or may not result in patient harm. These are defined by AHRQ as the following:

There were one or more missed opportunities to pursue or identify an accurate and timely diagnosis (or other explanation) of the patient’s health problems based on the information that existed at the time.

An accurate diagnosis (or other explanation) of the patient’s health problems was available, but it was not communicated to the patient (includes patient’s representative or family as applicable).”

Although there are many factors that contribute to diagnostic errors, the primary objective is to identify a patient’s illness quickly and accurately, a goal shared by CDI professionals. One of the primary contributors to diagnostic errors is the current state of diagnosis education. “Diagnosis begins with obtaining an appropriate history from the patient and performing a hypothesis-driven physical examination, but evidence suggests that even these most basic elements are often deficient. Diagnosis then depends on clinical reasoning to apply the clinician’s depth of knowledge in an effort to make sense of the patient findings in the appropriate context.

Clinical reasoning is challenging and represents the dominant issue in diagnostic error, as repeated studies have shown.” Many medical schools do not explicitly address clinical reasoning through curriculum dedicated to this topic. However, medical schools are not alone in this deficit, AHRQ found it also extends to nursing, pharmacy, and other fields.

CDI professionals can be part of the solution as organizations develop processes to reduce diagnostic errors. The work of CDI already includes reviewing health records for diagnoses that explain abnormal diagnostic indicators. Often CDI professionals are reluctant to query a provider immediately when documentation gaps are identified, instead preferring to give the provider the opportunity to interpret the results and arrive at a conclusion before querying, which could delay the query process and subsequent documentation of an associated diagnosis by days, but is that the best strategy?

I’ll freely admit that not all diagnosis will carry the same weight, but it is clear from the AHRQ research that CDI professionals should be more proactive in supporting patient safety related to diagnostic errors by bringing documentation gaps to the healthcare team sooner than later.

Perhaps this is the “What’s in it for me?” that CDI professionals needed all along to engage providers because accurately documenting diagnoses is a patient safety issue.

Redox, the company accelerating interoperability in healthcare, has partnered with Brundage Group, whose revenue cycle management (RCM) solutions are creating value for health systems across the nation. The partnership makes it secure and seamless for Brundage Group clients to use proprietary level-of-care analytics and Physician Advisor dashboard with minimal IT intervention by the hospital system. Physicians and hospital stakeholders can now utilize real-time data and analytics to make informed decisions around compliant level-of-care, denials management, and revenue optimization.

Brundage Group supports hospital systems nationwide with a suite of Physician Advisory services, workforce solutions, and documentation education to relay high-quality care. With Redox, integration is more efficient for Brundage Group clients. They now have the ability to onboard health systems quickly and begin providing physician-led support with fast case review turnaround.

“Transmitting EMR data is core to the function of our proprietary analytics platform,” explains Dr. Brett Hoggard, Physician Advisor and chief medical officer at Brundage Group. “Our integration with Redox ensures that transmission is secure so clients can take advantage of our powerful, real-time level of care data and Physician Advisor dashboard to make immediate decisions that optimize revenue.”

“Creating a better healthcare ecosystem means making sure that everyone has the tools to build seamless experiences,” notes Redox VP of Product Bryan Dunn. “Redox works at the foundation to make sure every aspect of healthcare gets easier over time, and we’re glad to support Brundage Group in that work.”

Redox accelerates the development and distribution of healthcare software solutions with a full-service integration platform to securely and efficiently exchange healthcare data. With just one connection, data can be transmitted across a growing network of 1,800+ healthcare delivery organizations and 300 independent software vendors. Members of the Redox Network exchange more than 20 million patient records per day, leveraging a single data standard compatible with more than 85 electronic health record systems. Redox exists to make healthcare data useful and every patient’s experience a little bit better. Learn how you can leverage the Redox platform at www.redoxengine.com. Visit us on Twitter and LinkedIn.

Brundage Group is the trusted choice of hospitals for our full suite of Physician Advisory services, workforce solutions, and effective documentation education to relay high-quality care. We help hospital organizations break down departmental silos by unifying clinical documentation across QUALITY, UTILIZATION, DENIALS and CDI. Backed by proprietary level of care analytics, our clinical Physician Advisors and documentation/coding experts support hospitals nationwide with revenue cycle management services. Visit brundagegroup.com.

Read the announcement.

By: Cheryl Ericson, RN, MS, CCDS, CDIP

The best practice is to add any retrospective query response as an addendum to the health record.

Although the goal of clinical documentation integrity (CDI) professionals is to issue queries concurrently, there is a subset of queries, often related to performance on quality-of-care measures (i.e., mortality) that are issued retrospectively. Recently, I’ve received a few inquiries by CDI professionals because providers at their organization are pushing back against retrospective queries, claiming they are improper or even fraudulent, so they will not even respond. So, what are the rules when it comes to retrospective queries? Or, better yet, are there any rules related to retrospective queries?

The irony is, at one time, all queries were retrospective because they were the domain of the coding department, which didn’t identify query opportunities until the coding process began. Yes, in an ideal world, queries would be issued and resolved concurrently, while the patient is still in-house. Concurrent queries allow the relevant diagnosis to be captured while patient care is being rendered, supporting continuity of care as well as providing the coder with a complete and accurate record to expedite the coding process. However, most processes for identifying cases that may be included in quality-of-care measures are post-discharge, if not retrospective, because many quality-of-care measures are identified by the ICD-10-CM and ICD-10-PCS codes that are included on the claim. As CDI professionals become more involved with quality-of-care measures, providers are likely to continue to see retrospective queries.

Are there rules related to retrospective queries? Unfortunately, like many things CDI, there is not one clear source with a definitive answer. Yes, retrospective queries are allowable, but is there a deadline as to how long after discharge a query can be asked? No. To find an answer, it’s best to examine guidelines associated with making changes to the medical record.

First, it is important to note that providers do have an obligation to adhere to general principles of medical record documentation. According to the Evaluation and Management Services Guide (February 2021), the following general principles apply:

• The medical record should be complete and legible
• The documentation of each patient encounter should include:
  • Reason for the encounter and relevant history, physical examination findings, and prior diagnostic test results
  • Assessment, clinical impression, or diagnosis
  • Medical plan of care
• If date and legible identity of the observer if the rationale for ordering diagnostic and other ancillary services is not documented, it should be easily inferred
• Past and present diagnoses should be accessible to the treating and/or consulting physician
• Appropriate health risk factors should be identified
• The patient’s progress, response to and changes in treatment, and revision of diagnosis should be documented
• The diagnosis and treatment codes reported on the health insurance claim form or billing statement should be supported by documentation in the medical record

The Medicare Program Integrity Manual states that “all services provided to beneficiaries are expected to be documented in the medical record at the time they are rendered. Occasionally, certain entries related to services provided are not properly documented. In this event, the documentation will need to be amended, corrected, or entered after rendering the service. When making review determinations, the MACs (Medicare Administrative Contractors), CERT (Comprehensive Error Rate Testing), Recovery Auditors, SMRCs (Supplemental Medical Review Contractors) and UPICs (Unified Program Integrity Contractors) shall consider all submitted entries that comply with the widely accepted Recordkeeping Principles … the MACs, CERT, Recovery Auditors, SMRC, and UPICs shall NOT consider any entries that do not comply with the principles listed in section B below (Recordkeeping Principals), even if such exclusion would lead to a claim denial. For example, they shall not consider undated or unsigned entries handwritten in the margin of a document. Instead, they shall exclude these entries from consideration.”

These Recordkeeping Principals apply to both paper and electronic health records that contain amendments, corrections, or late entries, which are the three ways a provider can compliantly alter their documentation within the health record:

• An addendum is used to provide information that was not available at the original time of entry, and should include the reason for the addition or clarification of information being added to the medical record
• A late entry is a record amendment used to add information that was omitted during the original entry, or
• A correction is used when a prior entry was made in error. A correction should not obliterate the initial entry.

Although many organizations allow providers to respond directly to a query, depending on the timing of the query (e.g., if it is concurrent or retrospective), a best practice would be to add any retrospective query response as an addendum to the health record, to comply with Recordkeeping Principals. As long as the response to the retrospective query is correctly added to the health record, it is not falsified documentation. According to Noridian Healthcare Solutions, a MAC for the Centers for Medicare & Medicaid Services (CMS), examples of what can be considered falsifying a health record include the following:

• Creation of a new record when a record is completed;
• Back-dating entries;
• Post-dating entries;
• Pre-dating entries;
• Writing over; and
• Adding existing documentation (except as described in late entries, addendums, and corrections).

Noridian does not reference an acceptable timeframe when record amendments can or cannot occur, but they do state that “corrections to the medical record legally amended before claims submission and/or medical review will be considered in determining the validity of services billed. If these changes appear in the record following payment determination based on medical review, only the original record will be reviewed in determining payment of services billed to Medicare.” Suggesting that queries to add documentation to refute a denial from a MAC is likely futile.

Perhaps the best guidance regarding how a CMS contractor should process clinical information derived from a query comes from Risk Adjustment Data Validation (RADV) contractors, which support audits related to the Medicare Advantage (MA) program. Their contractor reviewer guidelines include a section on query forms. Included in the guidance is a simple but accurate description of a query: “a tool used to clarify documentation in the health record for accurate code assignment.” The guidance also builds upon the definition of a query within the glossary, with a very thoughtful description: “the desired outcome from a query is an update (an “update” can be a late entry, addendum, or approved query form, per individual facility medical record documentation policy) of a health record to better reflect a practitioner’s intent and clinical thought processes, documented in a manner that supports accurate code assignment.”

This addition, how the record update should occur (e.g., in the form of an addendum), should be an important component of any organization’s query process. If the provider is not required to amend the discharge summary to support a retrospective query, then the query form should be designed to act as an addendum to the health record and meet all the Recordkeeping Principals.

RADV guidance related to the acceptance of query forms is as follows: “when submitted with the associated medical record, diagnosis query forms that are completed, signed, and dated promptly (i.e., within 90 days of the date of service) by the physician/practitioner and became part of the official medical record will be reviewed for validity and clinical consistency with the medical record documentation.”

This guidance contrasts with what was issued in 2004, as referenced in the article, “Querying Physicians to Improve Documentation and Dx Coding” (Barton, D. 2017), which references that “the correction should be within 30 days of the initial documentation, and substantial reasoning must be provided for the change.” Most organizations will likely remain within a 30-day time frame when it comes to retrospective queries due to the potential impact on facility metrics like days of bill hold, and the potential issues associated with rebilling a claim, so maybe this discrepancy is not an issue for most organizations.

What is particularly interesting regarding the RADV guidance is that it also clearly states whose documentation can and cannot be used to amend the health record, stating, “only the attending or treating physician can amend the medical record … it is not appropriate to add diagnoses to the medical record that have been identified by a source other than the treating physician (e.g., identifying diabetes from a disease management program).”

Although this seems like a reasonable requirement, I have heard discussions regarding the use of non-treating providers to amend health records as a way to “expedite” the query process. As more CDI departments have Physician Advisors who see patients, it is important to clearly outline when the Physician Advisor may document in a health record. A best practice would be to include a policy that only allows a member of the medical staff to document a patient’s health record when they are part of the treating medical team.

The RADV guidance also elaborates upon who can perform queries:

“Query type forms generated by the MA organization, or their coding staff contractors, are not acceptable for review as part of the medical record. They are considered extraneous data from an alternative data source not allowed, per risk-adjustment policy.”

“Query forms will be considered on a case-by-case basis to determine whether the document is an acceptable standard physician query made by a coder or similar facility staff at or near the time of the encounter, or if it is some other unacceptable late addition of conditions after the original encounter.”

“RADV reviewer will not code from documents even if labeled (incorrectly) as ‘coder query’ if the documentation is not generated at or near the time of the encounter by the facility or physician office.”

The query process is the responsibility of the organization’s CDI or coding staff, and responding to a query is the responsibility of a treating provider. Querying is a complex process, and it involves coordination between CDI and coding professionals with the treating medical team, as well as other members of the health information management team who manage and release the health record. Often, multiple sources of information must be cobbled together to create a compliant process. When it comes to a compliant query process, it is not only important to understand the rules pertaining to that process, but also the rules for amending the health record. Embracing these rules can grow physician support for retrospective queries by helping them understand that record amendments are an ethical and compliant process, accepted by CMS.

Learn about the specific outcomes of the emergency department pilot program during Dr. Timothy Brundage’s session at the ABQAURP Annual HCQ&PS Conference, “Optimizing Coordination Among Mid-Revenue Cycle Stakeholders,” on Friday, October 7, 2022, at 4:30 p.m. Read the article on the ABQAURP website.

—

Across many hospital systems, the demand for patient beds outweighs the supply. This can lead to a plethora of problems, including surgery cancellations, declining patient and staff satisfaction, and increased length of stay for patients in every setting, e.g., inpatient, emergency department, etc. Further, when capacity is a problem, hospital leadership spends unnecessary time addressing capacity management issues—valuable time that cannot be regained.

Hospital leadership would agree there is a need to develop a strategic process to manage bed capacity. Ideally, a plan would be developed through collaboration of hospital leadership and hospital-wide staff, with solutions that focus on maintaining or improving quality and outcomes. From a staffing perspective, when staff efficiency increases, employees are less burdened with managing capacity issues and more focused on patient care. For patients, having a bed available in the right setting makes them feel valued and cared for, resulting in a positive effect on patient satisfaction and outcomes.

Emergency Department (ED) crowding is not a problem that exclusively impacts the ED, but rather one that impacts all patient care areas and requires hospital-wide solutions. Long wait times can lead to potential safety events and dissatisfaction with overall care. Addressing ED crowding should be at the forefront of organizational improvement efforts, as it is costly and compromises care quality and public perception and trust.

Brundage Group embarked on an ambitious pilot project to solve patient throughput issues by targeting patients with hospitalization orders who remained in the ED awaiting bed assignment. Integral to the project was a dedicated Physician Advisor in the ED to help optimize workflows, admission, and discharge processes. The goals of the pilot were to confirm accurate level of care orders at the time of admission; reduce avoidable admissions; and improve communication between the ED physician, admitting hospitalist, and ED case manager.

The ED project was a collaboration between Brundage Group and a Level 1 Trauma Center that is one of the largest hospitals in Florida. A hospital representative will co-present the session, Optimizing Coordination Among Mid-Revenue Cycle Stakeholders, along with Physician Advisor, Dr. Timothy Brundage, during ABQAURP’s Annual Health Care Quality & Patient Safety Conference.

The project team included a Physician Advisor as the dedicated resource for the pilot; a utilization management nurse to create a UM presence that did not previously exist in the process; an ED care coordinator/case manager (CM), who refocused efforts to prioritize ED discharge planning; and an ED social worker (SW), who remained focused on serving ED patients.

The team developed a process to target “boarder” patients – a patient who requires care beyond ED services but remains in the ED because there is no hospital bed available. As part of the pilot, the project team would meet in the ED at multiple standing times throughout the day to review all boarder patients.

To help encourage efficient patient throughput, the team leveraged case management services. While CM is required for inpatient, the team realized the CM role could also be applied in the ED to help support the patient discharge process as appropriate while enabling the ED to treat a greater capacity of patients. During the frequent meetups, the team leveraged these dedicated ED CM/SW teams to identify patients for whom referrals could be obtained for additional services allowing discharge directly from the ED.

Level of care determinations had a two-prong approach. Led by the Physician Advisor, the boarder round team helped to ensure appropriate level of care status and would contact the attending physician if a status order needed correction. Additionally, UM nurses were tasked with reviewing ED cases outside of boarder rounds, referring identified cases directly to the dedicated ED Physician Advisor. A key element was the physical placement of the UM nurse within the ED to directly communicate with ED physicians as quickly as possible to support accurate status determination and maximize real-time communication.

The results of the pilot program showed significant reduction in avoidable admissions, validated patient status determinations, and a change in the ED physician culture, becoming more confident that discharge planning could be safe and efficient with appropriate support from the CM/SW role.

The outcomes underscored the need for a dedicated ED Physician Advisor to add credibility to the project and to optimize the discharge process. Further, reviewing a case for appropriate level of care early in the ED stay improved the accuracy of level of care determinations and ultimately improved hospital capacity management. The pilot project also spurred a change in ED physician culture that extended to the general medical staff through education and Physician Advisor engagement.

By: Cheryl Ericson, RN, MS, CCDS, CDIP

HACRP is designed to reduce rates of healthcare-associated infections

Most clinical documentation improvement (CDI) professionals are aware of hospital-acquired conditions (HACs). In fact, reviewing a record and looking for potential HACs may be part of their standard workflow. What many who perform these reviews or manage the CDI process may not realize is that the concept of HACs, and along with it a focus on patient safety, was expanded with the Hospital-Acquired Conditions Reduction Program (HACRP). Yes, HACs are still around, but their potential financial impact at an individual healthcare organizational level is far less than a penalty incurred under the HACRP.

HACs were one of the Centers for Medicare & Medicaid Services’ (CMS’s) first ventures into aligning payment and quality of care. They were developed as part of the Deficit Reduction Act (DRA) of 2005, which required the Secretary of the U.S. Department of Health and Human Services (HHS) (which oversees CMS) to “identify conditions that are: a) high-cost, high-volume, or both; b) result in the assignment of a case to a DRG that has a higher payment when present as a secondary diagnosis; and c) could reasonably have been prevented through the application of evidence-based guidelines.” However, HACs were not implemented until the Inpatient Prospective Payment System (IPPS) Final Rule for the 2009 fiscal year (FY). Part of the reason for this delay was that implementation of HACs was dependent upon implementation of the present-on-admission indicator (POA). Prior to implementation of the POA indicator, CMS did not have an objective way of differentiating co-morbidities (e.g., those conditions that existed prior to the admission) from complications (those conditions that arose during the admission). In this context, complications do not imply wrongdoing on the part of the healthcare organization; it is merely the terminology CMS used.

There were initially 10 categories of HACs, but it subsequently grew to 14 categories, and has remained at 14 since the IPPS for FY 2013 was introduced. Basically, few changes have occurred with HACs, except for the conversion to the ICD-10-CM/PCS code set (which occurred in FY 2016), since the FY 2013 update. The current categories of HACs are:

• Foreign Object Retained After Surgery
• Air Embolism
• Blood Incompatibility
• Stage III and IV Pressure Ulcers
• Falls and Trauma (e.g., Fractures, Dislocations, Intracranial Injuries, Crushing Injuries, Burn, Other Injuries)
• Manifestations of Poor Glycemic Control (e.g., Diabetic Ketoacidosis, Nonketotic Hyperosmolar Coma, Hypoglycemic Coma, Secondary Diabetes with Ketoacidosis, Secondary Diabetes with Hyperosmolarity)
• Catheter-Associated Urinary Tract Infection (UTI)
• Vascular Catheter-Associated Infection
• Surgical Site Infection, Mediastinitis, Following Coronary Artery Bypass Graft (CABG):
• Surgical Site Infection Following Bariatric Surgery for Obesity
  • Laparoscopic Gastric Bypass
  • Gastroenterostomy
  • Laparoscopic Gastric Restrictive Surgery
• Surgical Site Infection Following Certain Orthopedic Procedures
  • Spine
  • Neck
  • Shoulder
  • Elbow
• Surgical Site Infection Following Cardiac Implantable Electronic Device (CIED)
• Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) Following Certain Orthopedic Procedures:
  • Total Knee Replacement
  • Hip Replacement
• Iatrogenic Pneumothorax with Venous Catheterization

You can find a listing of HACs for FY 2022 and the associated ICD-10-CM/PCS codes online at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/icd10_hacs.

So, what is the possible impact of HACs, and why do some CDI departments include identification of potential HACs in their review process? According to a 2020 FAQ published by CMS, “hospitals no longer receive additional payment for cases in which one of the identified HACs occurred but was not POA. Instead, the case is paid as though the HAC was not present. This payment provision applies only to secondary diagnosis codes, given that the identified HACs are designated as a complication or comorbidity (CC) or a major complication or comorbidity (MCC) when reported as a secondary diagnosis. Payments will be adjusted only if no other CC/MCC conditions are reported on the claim.” In other words, if a HAC is identified on the claim, that condition can no longer impact the MS-DRG assignment as a CC or MCC, which could negatively impact reimbursement for that particular claim if there is not another CC or MCC to replace the impact of the HAC. The impact is limited to one claim, and only if it was the only secondary diagnosis that impacted the MS-DRG assignment.

Due to efforts by CDI departments to have multiple CCs and MCCs on every claim, when possible, HACs have little if any financial impact on most healthcare organizations. CMS does, however, publicly report HACs for Foreign Object Retained After Surgery; Blood Incompatibility; Air Embolism; and Falls and Trauma because these measures are not covered by any other CMS quality program. However, CMS does not risk-adjust HAC measures based on patient case mix, because these are considered by CMS “to be serious, reportable events that should not occur, regardless of the patient’s condition.” All other HACs have been “absorbed” into other CMS quality measures, such as CMS PSI 90, which is included in the HACRP. Although they both include the concept of hospital-acquired conditions, the HAC (POA) program and HACRP are two distinctly different quality programs.

According to CMS, “the Hospital-Acquired Condition (HAC) Reduction Program is a Medicare value-based purchasing program that reduces payments to hospitals based on how they perform on measures of hospital-acquired conditions.” It was established by the Patient Protection and Affordable Care Act of 2010 and implemented with the IPPS for FY 2015. The HACRP is designed to encourage use of best practices by healthcare organizations to reduce rates of healthcare-associated infections (HAIs) and improve patient safety. Unlike the HAC program, which only impacts CMS reimbursement on a per-claim basis, the HACRP “adjusts payments to hospitals that rank in the worst-performing quartile (above the 75th percentile) … with respect to measures of hospital-acquired conditions. On an annual basis, CMS evaluates overall hospital performance by calculating a Total HAC Score for each hospital as the equally weighted average of their scores on measures included in the program. Hospitals with a Total HAC Score greater than the 75th percentile of all Total HAC Scores … receive a payment reduction of 1 percent on overall Medicare fee-for-service (FFS) payments.”

Additionally, data collected for the HACRP is publicly reported. The HACRP is updated annually as part of the IPPS. Currently, The HAC Reduction Program includes the following six quality measures:

• One claims-based composite measure of patient safety:
  • CMS Patient Safety and Adverse Events Composite (CMS PSI 90)
• Five chart-abstracted measures of HAIs submitted to the Centers for Disease Control and Prevention’s (CDC’s) National Healthcare Safety Network:
  • Central Line-Associated Bloodstream Infection (CLABSI)
  • Catheter-Associated Urinary Tract Infection (CAUTI)
  • Surgical Site Infection (SSI) for abdominal hysterectomy and colon procedures
  • Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia
  • Clostridium difficile Infection (CDI)

It is important to note that data related to HAIs is not based on claims data; this data is routinely collected as surveillance data by infection control teams and submitted directly to the CDC. Another key difference between the HAC program and HACRP is that the HAC program occurs in real time. The penalty is assessed when the claim is submitted because it is built into claims payment logic. Conversely, data used to determine payment penalties for the HACRP is collected several years prior to the application of the penalty. The FY 2022 HACRP performance period for CMS PSI 90 is based on data collected from July 1, 2018 to Dec. 31, 2019, and the data for the HIA measures was collected from the 2019 calendar year (CY). If organizations only improve patient safety once they receive a HACRP penalty, it could take several years before they are able to right the ship to avoid additional penalties. The good news about HACRP from the CDI perspective is that monitoring performance aligns with efforts to monitor patient safety indicators (PSIs) due to the composite measure of CMS PSI 90, so many CDI departments already have processes in place that could be expanded to include the HACRP.

By: Cheryl Ericson, RN, MS, CCDS, CDIP

“Upcoding” remains a common mechanism of improper payments.

“Healthcare compliance is the process of following rules, regulations and laws that relate to healthcare practices,” according to the PowerDMS Policy Learning Center. Although all healthcare organizations have a compliance department, how the clinical documentation integrity (CDI) department interacts with compliance and supports practices compliant with Centers for Medicare & Medicaid Services (CMS) regulations varies across health systems. The purpose of a compliance program is to prevent, detect, and correct non-compliance to avoid fraud, waste, and abuse.

According to the U.S. Department of Health and Human Services (HHS), some healthcare entities pose a heightened risk to the financial security of Medicare due to the volume of improper payments they incur. Healthcare organizations have a duty to submit proper claims to CMS; however, “upcoding” remains a common mechanism of improper payments. Because compliance is the responsibility of everyone employed by the health system, CDI leadership should be actively engaged in monitoring CMS claims data for potential overpayments that could represent simple errors or process issues resulting in institutional non-compliance. In particular, CDI departments should be gatekeepers meant to avoid “billing for services at a level or complexity higher than services actually provided or documented in the medical record,” according to CMS.

An overpayment is defined by Medicare as one that “exceeds regulation and statute properly payable amounts.” Medicare overpayments can occur due to “incorrect coding and/or insufficient documentation,” both of which should be monitored by CDI and coding leadership. Healthcare entities have 60 days from overpayment identification to report and return a self-identified overpayment to Medicare. Reporting of an overpayment should include a written explanation for the overpayment, e.g., coding error, failure to follow organizational billing practices, etc. The concept of “identification” is broadly applied, as the rule states that this means when a person has or “should have, through the exercise of reasonable diligence” determined an overpayment.

Misusing codes on a claim, such as upcoding (when a provider assigns an inaccurate billing code to a medical procedure or treatment to increase reimbursement) and coding errors are examples of Medicare abuse if the incorrect coding or billing practices are not widespread practices, in which case it could be an example of fraud. CDI and coding professionals are both subject to the federal civil False Claims Act (FCA):

“The civil FCA imposes civil liability on any person who knowingly submits, or causes the submission of, a false or fraudulent claim to the Federal Government. The terms ‘knowing’ and ‘knowingly’ mean a person has actual knowledge of the information or acts in deliberate ignorance or reckless disregard of the truth or falsity of the information related to the claim. No specific intent to defraud is required to violate the civil FCA.”

CMS has a variety of tools to monitor inaccurate payments, including the Comprehensive Error Rate Testing (CERT) Program, Medicare Administrative Contractors (MACs), and the Recovery Auditors. According to CMS, the CERT program reviews a statistically valid stratified random sample of Medicare fee-for-service (FFS) claims to determine if they were paid properly under Medicare coverage, coding, and payment rules. CERT findings create the framework for MAC audits and those performed by Recovery Auditors. While CERT leverages a random sample of claims, the Program for Evaluating Payment Patterns Electronic Report (PEPPER) data provides hospital-specific Medicare claims data. Target areas included in PEPPER were identified by Recovery Auditors and MACs, and are updated periodically.

“PEPPER is an electronic report that provides provider-specific Medicare data statistics for discharges/services vulnerable to improper payments. PEPPER cannot be used to identify the presence of payment errors, but it can be used as a guide for auditing and monitoring efforts to help providers identify and prevent payment errors.”

If you manage a CDI or coding department, you should be reviewing your PEPPER data on a quarterly basis; however, the national download rate is currently at 62 percent. Failure to monitor Medicare claims data included in PEPPER can be an example of “deliberate ignorance or reckless disregard,” according to ACDIS, if your organization is an outlier. Although PEPPER data is not specifically distributed to Recovery Auditors or MACs, both of these Medicare contractors have the ability to request charts related to PEPPER target areas, and have sophisticated data mining techniques to identify outliers.

PEPPER target areas are constructed as a ratio. The numerator includes discharges identified from paid Medicare claims per CMS fiscal year (i.e., October to September) quarter that are identified as potentially problematic because they are likely to be miscoded or result in medically unnecessary services. The denominator is the larger reference group that includes the numerator.

For this article, our focus is coding target areas that include:

• Stroke Intracranial Hemorrhage;
• Respiratory Infections;
• Simple Pneumonia;
• Septicemia;
• Unrelated OR Procedures;
• Medical DRGs with CC or MCC;
• Surgical DRGs with CC or MCC;
• Single CC or MCC;
• Severe Malnutrition;
• Excisional Debridement;
• Ventilator Support; and
• Emergency Department Evaluation and Management Visits.

Each hospital’s ratio is compared to other hospitals at the state, MAC jurisdiction, and national levels, resulting in a ranking by volume percentage. PEPPER data uses the high outlier threshold of the 80th percentile and a low outlier threshold of the 20th percentile. If the percentage of paid Medicare claims for the specific target area ranks at the 80th percentile or above, the organization is considered a high outlier for that target area. In other words, the percentage range for a particular target area may be from 20 to 75 percent. The 80th percentile may result in all those hospitals with a target area ratio of 68 percent or higher. The ratios among all hospitals and the 80th percentile cutoff will vary from quarter to quarter.

If you are new to PEPPER and integrating a compliance focus into your CDI or coding practices, a good place to start is the National High Outlier Ranking Report. This page of PEPPER data will have red if your organization is a high outlier in any target area across the most recently reported 12 quarters of data, as well as the total number of times your organization was a high outlier for each target area. If your organization happens to be a high outlier for any coding target area, that does not necessarily mean there is a compliance issue. A best practice is to investigate why your organization is an outlier by sampling claims and reviewing documentation to validate the assigned codes and billing. Ask yourself, does it make sense for your hospital to be among the top 20 percent of all hospitals for that particular target area?

CDI departments are increasingly renaming the “I” from “improvement” to “integrity.” Integrity is defined as “the quality of being honest and having strong moral principles.” Reviewing PEPPER data is a way for CDI and coding managers to identify areas that may be vulnerable to overpayment. If outliers exist, investigate the associated claims to validate the coding and billing. If coding or billing errors occurred, determine the cause(s) of the errors, e.g., human error or process issues, and look for ways to prevent future non-compliant coding and billing practices. Even if your organization is not an outlier or the internal investigation does not reveal the potential for overpayment, CDI and coding leadership should ensure there are safeguards in place to prevent non-compliance, and monitor staff adherence to those processes.

By: Cheryl Ericson, RN, MS, CCDS, CDIP

Do health information management (HIM) and clinical documentation integrity (CDI) professionals need a standard operational definition for “clinical documentation?” Put another way, should everything within a physician note, for example, be considered clinical documentation?

Back in the day of paper records, it was easy to distinguish between a template header, a prompt, and physician documentation, because the template was preprinted and the physician documentation was handwritten or transcribed. With movement towards the electronic medical record (EMR), it is more difficult to differentiate what the provider entered into the record from what is part of a template, from what was “pulled forward” by the provider, from what was auto-populated by the EMR, etc.

Why does this matter? Well, I review a lot of records in my role, and I am seeing a lot of cases in which words or phrases within the health record are being used to report an associated diagnosis; however, Official Coding Guidelines for reporting “other diagnoses” are not met. Specifically, the Coding Guidelines state:

For reporting purposes, the definition for “other diagnoses” is interpreted as additional conditions that affect patient care in terms of requiring:

• Clinical evaluation;
• Therapeutic treatment;
• Diagnostic procedures;
• Extended length of hospital stay; or
• Increased nursing care and/or monitoring.

The UHDDS (Uniform Hospital Discharge Data Set) item No. 11-b defines other diagnoses as “all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay. Diagnoses that relate to an earlier episode which have no bearing on the current hospital stay are to be excluded.” UHDDS definitions apply to inpatients in acute care, short-term care, long-term care, and psychiatric hospital settings.

Not only is technology changing how the medical record is formatted, but it is also changing how CDI and coding professionals perform their duties. A 2015 article published by the American Health Information Management Association (AHIMA, Weinberg, J, et. al) defined computer-assisted coding (CAC) as the use of computer software that automatically generates a set of medical codes for review and validation, based upon the clinical documentation of healthcare practitioners. Furthermore, “CAC includes a variety of computer-based approaches that do not require human interaction to transform narrative text in clinical records into structured text, which may include assignment of codes from standard terminologies such as ICD-9-CM, ICD-10-CM/PCS, CPT/HCPCS, and SNOMED CT.”. However, the article also warns,

“CAC requires a very high level of data integrity. This is due to the inherent nature of natural language processing (NLP) engines. These engines utilize a lexicon to determine if documentation meets criteria to be assigned a final code. If the CAC engine cannot understand a term, concepts are not completely documented, or terms are spelled incorrectly, then the engine may not recognize the term and assign a code accordingly.”

As someone who works in the technology field, I must say that my personal experience is that few CAC tools are robust enough to actually consider the context of the documentation to see if it meets criteria for code assignment. Yes, CAC tools can identify when a term like “shock” appears, for example, and map it to the associated unspecified code for shock, but not all of them are able to realize that the word was highlighted as part of the phrase “shock index,” which is a header within the template to support clinical assessment. In other words, in this context “shock” isn’t even a documented diagnosis. It is simply a header within the health record prompting the provider to complete a comprehensive patient assessment. Depending on the sophistication of the NLP engine, some are able to determine the context of a word as a positive or a negative mention. For example, “no heart failure” would be a negative mention, but what about when the assessment of heart failure is part of a template, so it appears as “heart failure: negative” or “heart failure: absent,” or any other number of variations? Not all NLP engines are able to process terms like a historical mention of a condition, or when it references a family member (or when it is uncertain).

There are also many EMRs that can import ICD-10-CM Codes or SNOMED CT codes with an associated code title as the physician enters data. In some records, the only reference to a particular diagnosis may be the code title. Is this really clinical documentation? I know there has been and continues to be much debate about problem lists, but what about code titles? Keep in mind that the Official Coding Guidelines state, “the assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists.” A code title is not the same as a diagnostic statement, and it doesn’t support the condition as reportable.

Another situation to consider is related to the ability to copy notes within the EMR. I have reviewed many records in which documentation from the history and physical (H&P) is copied forward into the discharge summary. Although this may be a time-saver for the provider, it is problematic when the H&P states that a patient is admitted for “possible pneumonia” or “suspected sepsis” – or any other condition that is, understandably, uncertain at the time of admission. However, when this documentation is copied into the discharge summary, many coders erroneously invoke the Official Coding Guidelines regarding the reporting of uncertain diagnoses:

If the diagnosis documented at the time of discharge is qualified as “probable,” “suspected,” “likely,” “questionable,” “possible,” or “still to be ruled out,” “compatible with,” “consistent with,” or other similar terms indicating uncertainty, code the condition as if it existed or was established. The basis for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.

Note: This guideline is applicable only to inpatient admissions to short-term, acute, long-term care and psychiatric hospitals.

Yes, the discharge summary contains the words “possible pneumonia;” however, the totality of the record usually demonstrates that the pneumonia (or other possible conditions) was ruled out. Again, the diagnosis likely does not meet reporting guidelines. I find that these cases are particularly prevalent within the newborn population, as many within this patient population are admitted for a suspected condition or in order to rule out a condition.

So, let’s get back to basics, and make sure our CDI and coding teams are taking the time to validate terms within the health record to confirm them as clinical documentation that reflects a “diagnostic statement.” Let’s also reinforce the need to meet Official Coding Guidelines for reporting “other diagnoses.”

Not all words that can be mapped within a health record to a diagnosis code are clinical documentation or reportable.

By: Cheryl Ericson, RN, MS, CCDS, CDIP

As a former manager of clinical documentation integrity (CDI) and utilization review (UR) at an academic medical center, my focus was on understanding all possible sources of revenue leakage. At that time, the UR staff focused on activities that demonstrated a patient’s medical necessity, as defined by a variety of payers, but often required application of InterQual criteria, while the CDI team focused on capturing patient acuity to support accurate reimbursement under the Inpatient Prospective Payment System (IPPS) and other DRG payers.

However, we had a blind spot – before medical necessity can be supported and diagnoses reported on a claim, the services provided must first be covered by the payer. The approval process is somewhat straightforward, when it comes to commercial payers, as it involves prior authorizations (or precertification) – and most healthcare organizations have staff dedicated to obtaining these authorizations. But this is less well-known when it comes to Medicare beneficiaries.

Medicare coverage polices specify which items and services are covered under the Medicare program, and under which circumstances – such as when required specific clinical criteria are met. We see some outpatient CDI efforts supporting medical necessity (e.g., ensuring that the right diagnosis codes are included with imaging or injections), but it is far less common in the inpatient setting, where healthcare is much more expensive. When specific clinical criteria must be met to support Medicare coverage, it is often outlined in National Coverage Determinations (NCDs) or Local Coverage Determinations (LCDs). The Centers for Medicare & Medicaid Services (CMS) states that “services must meet specific medical necessity requirements in the statute, regulations, manuals, and specific medical necessity criteria defined by National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs), if any apply to the reported service. For every service you bill, you must indicate the specific sign, symptom, or patient complaint that makes the service reasonable and necessary.”

Now, not all services have NCDs or LCDs, but if there is one associated with a service, the medical necessity must be demonstrated with specific clinical criteria. Some services are specialized (e.g., transcatheter aortic valve replacement, or TAVR), and there may be a dedicated team within your organization to serve these types of patients – and they may be responsible for demonstrating the service as covered, while other, less specialized procedures (e.g., implantable cardioverter defibrillators (ICDs) or cardiac pacemakers) may also have associated NCDs. The NCD for ICDs has only been effective since 2018, but the NCD for single-chamber cardiac pacemakers has been effective since 1983.

An example of criteria that must be included for a single-chamber cardiac pacemaker to be covered are the following diagnoses, which must be “chronic or recurrent and not due to transient causes such as acute myocardial infarction, drug toxicity, or electrolyte imbalance:”

• Acquired complete (also referred to as third-degree) AV heart block;
• Congenital complete heart block with severe bradycardia (in relation to age), or significant physiological deficits or significant symptoms due to the bradycardia;
• Second-degree AV heart block of Type II (i.e., no progressive prolongation of P-R interval prior to each blocked beat. P-R interval indicates the time taken for an impulse to travel from the atria to the ventricles on an electrocardiogram);
• Second-degree AV heart block of Type I (i.e., progressive prolongation of P-R interval prior to each blocked beat) with significant symptoms due to hemodynamic instability associated with the heart block; and
• Sinus bradycardia associated with major symptoms (e.g., syncope, seizures, congestive heart failure), or substantial sinus bradycardia (heart rate less than 50) associated with dizziness or confusion. The correlation between symptoms and bradycardia must be documented, or the symptoms must be clearly attributable to the bradycardia, rather than to some other cause.

NCDs are established criteria for when a service is not covered by Medicare, for example regarding the single-chamber pacemaker: “conditions which, although used by some physicians as a basis for permanent cardiac pacing, are considered unsupported by adequate evidence of benefit and therefore should not generally be considered appropriate uses for single-chamber pacemakers in the absence of the above indications.” These include:

1. Syncope of undetermined cause;
2. Sinus bradycardia without significant symptoms;
3. Sino-atrial block or sinus arrest without significant symptoms;
4. Prolonged P-R intervals with atrial fibrillation (without third-degree AV block) or with other causes of transient ventricular pause;
5. Bradycardia during sleep;
6. Right bundle branch block with left axis deviation (and other forms of fascicular or bundle branch block) without syncope or other symptoms of intermittent AV block);
7. Asymptomatic second-degree AV block of Type I, unless the QRS complexes are prolonged or electrophysiological studies have demonstrated that the block is at or beyond the level of the His bundle (a component of the electrical conduction system of the heart); and
8. Asymptomatic bradycardia in post-MI patients about to initiate long-term beta-blocker drug therapy (effective Oct. 1, 2001).

LCDs are similar to NCDs, but defined by the Social Security Act as a “a determination by a fiscal intermediary or a carrier under Part A or Part B, as applicable, respecting whether or not a particular item or service is covered on an intermediary- or carrier-wide basis.” General information about LCDs can be found in Chapter 13 of the Medicare Program Integrity Manual. However, specific LCDs would be available from the applicable Medicare Administrative Contractor (MAC), or there is a searchable database for both NCDs and LCDs at https://www.cms.gov/medicare-coverage-database/new-search/search.aspx. An example of an LCD is cardiac catheterization and coronary angiography, which is currently effective for two contractors. This LCD outlines indications supporting a right, left, or both a right and left heart catheterization, as well as limitations (such as when a right heart catherization or left heart catheterization is not considered medically necessary).

As you can see from the NCD example above, these criteria don’t really fall into typical CDI or UM work, but could result in significant lost revenue if not provided when necessary. There is a component of both departments, as there is often a requirement for specific diagnoses to be present, often with an associated ICD-10-CM code (of note, CMS is still in the process of converting ICD-9-CM codes to ICD-10-CM/PCS codes for some NCDs and LCDs), as well as supporting clinical criteria so the diagnosis can be clinically validated. To see an example of what updated codes are included in the NCD for ICDs, effective July 6, 2021, go online to www.cms.gov/files/document/r10635CP.pdf. This document provides instructions to the MACs when processing claims for ICDs to ensure that NCD criteria are met by listing what ICD-10-CM and ICD-10-PCS codes should be present on the claim.

As CDI departments continue to grow, some are venturing out into to new areas like covered services, as defined by NCDs and LCDs, to avoid service denials. Unlike DRG changes, these types of denials often result in no payment, rather than reduced payment, which can be costly if it involves a procedure and the cost cannot be shifted to the Medicare beneficiary if due diligence was not completed by the organization. This is not an area that can be easily integrated in the CDI workflow, so it would likely require dedicated CDI staff with knowledge and understanding of where to find NCDs/LCDs and how to apply the criteria correctly.

By: Timothy Brundage, MD, CCDS, Medical Director & CEO of Brundage Group

The diagnosis of Healthcare-Associated Pneumonia (HCAP) is clinically out of date and does not effectively code. The diagnosis of HCAP maps to the DRG for simple pneumonia. Simple pneumonia is a diagnosis that can often be treated in the outpatient setting. HCAP clearly does not fit into this DRG grouping, so physicians should update their clinical practice and their documentation.

Here’s why physicians should not document Healthcare-Associated Pneumonia:

• The diagnosis of HCAP is clinically out of date.
• HCAP does not code effectively.
• The use of HCAP as a diagnosis is discouraged by the Infectious Diseases Society of America.
• HCAP is the wrong diagnosis!

Oral antibiotics are extremely effective in treating simple pneumonia. If a patient truly demonstrates medical necessity for inpatient admission to the hospital, the patient likely has either complex pneumonia or sepsis. (Severe) sepsis is now defined as organ dysfunction due to the infectious process, however, physicians often fail to link the pneumonia with the organ dysfunction. Physicians should update their documentation practices.

As an example: a patient is admitted to the hospital with the diagnoses of pneumonia and acute kidney injury (AKI). Effective documentation would link the conditions as “pneumonia causing AKI.” When pneumonia causes the AKI, then the physician should properly diagnose the patient with sepsis or severe sepsis, explicitly linking the organ dysfunction to the infection.

It is exceedingly common for physicians to admit patients to the hospital and treat them with very aggressive antibiotics without adequately documenting a diagnosis to support the reason why “big-gun” antibiotics are necessary. Physicians should allow their choice of antibiotics to drive their documentation.

For example, the following language is clinically appropriate and codes effectively.

• Zosyn, to treat suspected gram negative (pseudomonas) pneumonia
• Vancomycin, to treat suspected MRSA pneumonia
• Zosyn, Clindamycin or Flagyl, to treat suspected aspiration pneumonia

If hospitalists are scrutinized by length of stay metrics, they should understand that expected length of stay (LOS) is calculated using the documented diagnoses. Suspected gram-negative pneumonia creates a longer expected LOS in the hospital than does simple pneumonia.

Our physician-to-physician education creates savvy documenters who understand how to use coding-based language to demonstrate medical necessity and accurately calculate the DRG. With our support, physicians can learn to document effectively to capture the patient’s severity of illness to support the DRG and quality metrics.

Learn more about our services.

The SCCM and ESICM have published “Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-associated Organ Dysfunction in Children” to provide guidance for clinicians caring for children with septic shock and other sepsis-associated organ dysfunction (not sepsis without shock/organ dysfunction). New included guidelines are not intended to update or iterate on prior recommendations for the care of children with sepsis and septic shock (not sepsis without shock/organ dysfunction).

Although application of Sepsis-3 to children has been attempted (19,20), formal revisions to the 2005 pediatric sepsis definitions remain pending (21). Therefore, the majority of studies used to establish evidence for these guidelines referred to the 2005 nomenclature in which severe sepsis was defined as 1) greater than or equal to two age-based systemic inflammatory response syndrome (SIRS) criteria, 2) confirmed or suspected invasive infection, and 3) cardiovascular dysfunction, acute respiratory distress syndrome (ARDS) or greater than or equal to two non-cardiovascular organ system dysfunctions; and septic shock was defined as the subset with cardiovascular dysfunction, which included hypotension, treatment with a vasoactive medication or impaired perfusion.

The article defines septic shock in children as severe infection leading to cardiovascular dysfunction (including hypotension, need for treatment with a vasoactive medication or impaired perfusion) and “sepsis-associated organ dysfunction” in children as severe infection leading to cardiovascular and/or non-cardiovascular organ dysfunction. Because several methods to identify acute organ dysfunction in children are currently available (17,19,20,22,23), the authors chose not to require a specific definition or scheme for this purpose.

This report covers five main topic areas:

• early recognition
• infection therapies and adjunctive therapies
• hemodynamics therapies and adjunctive therapies
• ventilation therapies and adjunctive therapies
• endocrine therapies adjunctive therapies
• metabolic therapies and adjunctive therapies

Some notable aspects/differences of this report:

• The article did not issue a recommendation about using blood lactate values to stratify children with suspected septic shock or other sepsis-associated organ dysfunction into low- versus high-risk of having septic shock or sepsis. However, in practice, if lactate levels can be rapidly obtained, measure blood lactate in children when evaluating for septic shock and other sepsis-associated organ dysfunction may have merit. Unfortunately, the optimal threshold to define “hyperlactatemia” in children remains unclear.
• The article suggests using balanced/buffered crystalloids, rather than 0.9% saline, for the initial resuscitation of children with septic shock or other sepsis-associated organ dysfunction (weak recommendation, very low quality of evidence).
• Recommendations do not apply to premies < 37 weeks or infants < 28 days of age.

17. Goldstein B, Giroir B, Randolph A; International Consensus Conference on Pediatric Sepsis: International pediatric sepsis consensus conference: Definitions for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care Med 2005; 6:2–8

19. Matics TJ, Sanchez-Pinto LN. Adaptation and validation of a pediatric sequential organ failure assessment score and evaluation of the sepsis-3 definitions in critically ill children. JAMA Pediatr 2017; 171:e172352

20. Schlapbach LJ, Straney L, Bellomo R, et al. Prognostic accuracy of age-adapted SOFA, SIRS, PELOD-2, and qSOFA for in-hospital mortality among children with suspected infection admitted to the intensive care unit. Intensive Care Med 2018; 44:179–188

21. Schlapbach LJ, Kissoon N. Defining pediatric sepsis. JAMA Pediatr 2018; 172:312–314

22. Leteurtre S, Duhamel A, Salleron J, et al.; Groupe Francophone de Réanimation et d’Urgences Pédiatriques (GFRUP): PELOD-2: An update of the PEdiatric logistic organ dysfunction score. Crit Care Med 2013; 41:1761–1773

23. Proulx F, Gauthier M, Nadeau D, et al. Timing and predictors of death in pediatric patients with multiple organ system failure. Crit Care Med 1994; 22:1025–1031

By: Pamela Bensen, MD, MS, FACEP

Emergency departments (EDs), the US healthcare system “safety net”, are seeing sicker patients as the “less sick” are routed to offices and urgent care. This concentration of complicated patients requiring more extensive workups and treatments has increased the percentage of Evaluation and Management (E/M) level 4 and 5 visits.

UnitedHealthcare (UHC), whose stock has gone up 1000% since 2010, conducts ED coding, documentation, and claim reviews via its wholly owned subsidiary, Optum Payment Integrity. Despite appropriate documentation to support the complexity of the E/M codes submitted, Optum denies payment for ED services. Written appeals that support the original code(s) are almost universally denied, with UHC refusing to pay for ED services, or paying the claim at a reduced level.

Denials are due to Optum’s software algorithms that use the final ED ICD-10-CM diagnosis codes to determine the E/M code. However, the AMA’s Current Procedural Terminology (CPT Manual) and the CMS 1995 Documentation Guidelines for Evaluation and Management Services (DGs) clearly direct that determination of the proper E/M code for emergency medicine encounters is not based on the ICD-10-CM code, but instead requires a combination of three key components:

• History
• Physical Exam
• and Medical Decision Making

And, the level of each of these key components should only be based on the Medical Decision Making defined as, “the complexity of establishing a diagnosis and/or selecting a management option as measured by”:

1. Number of possible diagnoses/management options considered;
2. Amount/complexity of medical records, diagnostic tests, other information reviewed and analyzed; and
3. Risk or significant complications, morbidity, mortality, and comorbidities, associated with the patient’s presenting problem(s), diagnostic procedure(s) or possible management options.

After a four year battle, in a September 16, 2019 letter (read original here), the American College of Emergency Physicians (ACEP), representing 40,000 emergency physicians, and the Emergency Department Practice Management Association (EDPMA), representing about half of the 146 million patient visits to US EDs, notified UHC that they are advising their members that all necessary and appropriate legal action should be considered, including litigation addressing non-payment for services rendered. Copies were sent to federal and state officials and U.S. Senators and Representatives.

State PLP laws that apply to state regulated health plans. For additional information visit: https://newsroom.acep.org/2017-06-09-prudent-layperson-standard

CMS letter from April 2000 clarifying the definition of PLP in the BBA of 1997: https://www.medicaid.gov/Federal-Policy-Guidance/downloads/smd040500.pdf

Federal Register Nov. 10, 1999 (Vol 64, No. 217) page 166 link

The health care industry continues to transition toward a value-based, pay-for-performance system, but there’s still confusion surrounding the different quality and value programs that have been introduced by CMS and how they impact hospitals.

There’s good reason for the confusion. The programs themselves share terminology, leaving you asking yourself, “How does the HAC Deficit Reduction Act differ from the HAC Reduction Program?” Further, quality measures, such as catheter-associated urinary tract infection (CAUTI), span all three programs, yet are calculated differently depending on the program.

It’s critically important for stakeholders to understand the components of each program, as well as how the programs are measured, to implement appropriate action plans to improve quality and prevent CMS penalties. We travel the country clearing up the confusion for hospital organizations, and we’re breaking it down for you here.

This program includes the traditional hospital-acquired conditions (HAC). All of these conditions qualify as either a complication/comorbidity (CC) or a major complication/comorbidity (MCC). However, if the condition develops after admission, it will be excluded from counting as a CC or MCC for reimbursement purposes. In addition, the first four conditions on the list are publicly reported on the Hospital Compare website.

• Foreign object retained after surgery **
• Air embolism **
• Blood incompatibility **
• Falls and trauma **
  • Fractures
  • Dislocations
  • Intracranial injuries
  • Crushing injuries
  • Burn
  • Other injuries
• Stage III and IV pressure ulcers
  • Manifestations of poor glycemic control
  • Diabetic ketoacidosis
  • Nonketotic hyperosmolar coma
  • Hypoglycemic coma
  • Secondary diabetes with ketoacidosis
  • Secondary diabetes with hyperosmolarity
• CAUTI
• Vascular catheter-associated infection
• Surgical site infection, mediastinitis, following coronary artery bypass graft (CABG)
• Surgical site infection following bariatric surgery for obesity
  • Laparoscopic gastric bypass
  • Gastroenterostomy
  • Laparoscopic gastric restrictive surgery
• Surgical site infection following certain orthopedic procedures
  • Spine
  • Neck
  • Shoulder
  • Elbow
• Surgical site infection following cardiac implantable electronic device (CIED)
• Deep vein thrombosis (DVG) / Pulmonary embolism (PE) Following certain orthopedic procedures
  • Total knee replacement
  • Hip replacement
• Iatrogenic pneumothorax with venous catherization

**Publicly reported on Hospital Compare

It’s a startling fact: Under the HAC Reduction Program, hospitals performing in the bottom 25% receive a 1% penalty. The penalty is applied across all Medicare hospitalizations for the year. For a large hospital, the penalty can be over $1 million per year.

The HAC Reduction Program is comprised of patient safety indicator (PSI) 90 (The Patient Safety and Adverse Events Composite), as well as healthcare-associated infections (HAI). PSI 90 was developed by the Agency for Healthcare Research and Quality (AHRQ) and is used to track potential complications and adverse events. Each PSI has unique criteria based on the coded diagnoses in the medical record. Accurate clinical documentation is critical to ensure appropriate clinical care is not inadvertently captured as a complication. PSI 90 is a composite of the following 10 PSIs:

1. PSI 03 Pressure Ulcers
2. PSI 06 Iatrogenic Pneumothorax
3. PSI 08 In Hospital Fall with Hip Fracture
4. PSI 09 Perioperative Hemorrhage or Hematoma
5. PSI 10 Post-op Acute Kidney Injury Requiring Dialysis
6. PSI 11 Post-op Respiratory Failure
7. PSI 12 Peri-op Pulmonary Embolism or Deep Vein Thrombosis
8. PSI 13 Postoperative Sepsis
9. PSI 14 Postoperative Wound Dehiscence
10. PSI 15 Unrecognized Abdominopelvic Accidental Puncture/Laceration

In contrast to PSIs, HAIs are less dependent on clinical documentation and are instead based on abstraction rules developed by the CDC. The following HAIs are abstracted from the hospital chart and reported to the National Healthcare Safety Network (NHSN):

• Central line-associated bloodstream infection (CLABSI)
• Catheter-associated urinary tract infection (CAUTI)
• Surgical site infection (SSI) (colon and hysterectomy)
• Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia
• Clostridium difficile infection

Performance measures under this program give hospitals the potential for up to a 2% penalty or even a bonus, based on the performance of the various measures. There are four domains that are equally weighted: clinical care, person and community engagement, safety, and efficiency and cost reduction.

The same five HAIs reported in the HAC Reduction Program are also included in the Hospital Value-Based Purchasing Program.

• CLABSI
• CAUTI
• SSI (colon and hysterectomy)
• MRSA bacteremia
• Clostridium difficile infection

In addition, PC-01, elective delivery prior to 39 completed weeks gestation, is included for hospitals that offer obstetrics.

This domain is assessed based on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS).Also known as the CAHPS Hospital Survey, it measures patients’ perceptions of their hospital experiences.

This domain is based on Medicare spending per beneficiary. It is risk adjusted and the spending per beneficiary is compared to all hospitals across the nation. The goal of this measure is to reward hospitals that provide comparable care at a lower cost.

The clinical care domain includes six mortality metrics that are publicly reported:

• Acute myocardial infarction (AMI)
• Heart failure (HF)
• Pneumonia
• Chronic obstructive pulmonary disease (COPD)
• Stroke
• CABG

While all six of these mortality metrics are publicly reported, only AMI, HF, and pneumonia are included in the financial calculation of the Hospital Value-Based Purchasing Program.

Medicare’s mortality metric has significant financial and reputation implications. It is important to understand that conditions that develop after admission are not included in the risk adjustment, whereas conditions that are present on admission (POA) are included in risk adjustment. Herein lies the importance of capturing diagnoses as POA when clinically appropriate.

If it’s unclear whether the condition is POA, a query may be warranted to ensure that all diagnoses that contribute to risk adjustment are captured. Additionally, diagnoses that are coded as W—the provider cannot determine if the condition is POA—are counted as POA and thus used in risk adjustment calculations. It’s also important to note that any conditions that are coded in the 12 months prior to admission are included in risk adjustment. This includes prior hospitalizations as well as outpatient encounters.

We share these recommendations with our own clients on how to optimize mortality metrics:

• Ensure diagnoses are captured as POA when appropriate
• Ensure diagnoses capture the appropriate acuity—acute vs. chronic
• Ensure diagnoses are captured to the highest specificity possible

To avoid penalties and thrive under CMS’s HAC Deficit Reduction Act, HAC Reduction Program and Hospital Value-Based Purchasing Program, it’s critical to have a strong CDI department that works collaboratively with the quality department. In addition, thorough clinical documentation combined with accurate coding is essential to ensure correct CC/MCC assignment and appropriate risk adjustment. And lastly, now that you have this summary as a guide, don’t let all the acronyms confuse you!

By: Brett Hoggard, MD, CCDS, Chief Medical Officer, Brundage Group

Documentation and coding myocardial infarction is a common pain point for CDI departments, caused by conflicting or incomplete documentation that requires further clarification with a query. Type 2 MI is frequently incorrectly diagnosed and inconsistently documented.

To diagnose a Type 2 MI, there needs to be:

• Myocardial injury as evidenced by cTn > 99th percentile upper reference limit (URL)

• Evidence of imbalance between myocardial oxygen supply and demand causing acute myocardial ischemia (one of the criteria below):
  • Symptoms of myocardial ischemia (chest pain, etc.)
  • New ischemic ECG changes
  • Development of pathological Q waves
  • Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality in a pattern consistent with an ischemic etiology

When considering a Type 2 MI diagnosis, a common mistake is to forget about the requirement of acute myocardial ischemia. If the patient does not meet one of the criteria for myocardial ischemia, the patient should not be diagnosed with a Type 2 MI.

MI due to demand ischemia or MI secondary to ischemic imbalance are equivalent to Type 2 MI from a coding perspective. These terms map to ICD 10 code, I21.A1, MI Type 2.

Type 2 NSTEMI is a problematic term. According to coding guidelines, when Type 2 NSTEMI is documented, the code for Type 2 MI should be assigned and the code for NSTEMI should be withheld. If a coder incorrectly assigns the code for a NSTEMI – I21.4 – the case will be inappropriately pulled into the National Cardiovascular Data Registry and included in the CMS cohort for 30-day readmission rate and 30-day mortality rate.

The updated 2020 coding guidelines are creating further confusion in the accurate coding of Type 2 MI. For easy reference, here are the deletions and additions to the guidelines.

The ICD-10-CM provides codes for different types of myocardial infarction. Type 1 myocardial infarctions are assigned to codes I21.0-I21.4 and I21.9.

Type 2 myocardial infarction (myocardial infarction due to demand ischemia or secondary to ischemic imbalance) is assigned to code I21.A1, Myocardial infarction type 2 with a code for the underlying cause coded first. Do not assign code I24.8, Other forms of acute ischemic heart disease, for the demand ischemia. Sequencing of type 2 AMI or the underlying cause is dependent on the circumstances of admission. When If a type 2 AMI code is described as NSTEMI or STEMI, only assign code I21.A1. Codes I21.01-I21.4 should only be assigned for type 1 AMIs.

Acute myocardial infarctions type 3, 4a, 4b, 4c and 5 are assigned to code I21.A9, Other myocardial infarction type.

The most significant change to note is when a Type 2 MI is diagnosed, the etiology will need to be linked. The cause of the MI will be coded first. This makes sense from a clinical perspective but will require education for clinicians who don’t always document or link the etiology. And, occasionally, there are patients where the etiology of the Type 2 MI is unclear.

Education for clinical providers is critical. When a Type 2 MI is diagnosed, the clinical provider should make it a habit to document the etiology of the MI. If the provider does not document the etiology, a query will need to be issued. Overtime, linking the etiology will become a habit for clinicians, but in the meantime, expect more queries.

The National Association of Healthcare Revenue Integrity (NAHRI) recently asked our medical director, Dr. Tim Brundage, for his insight on Medicare Advantage denials. Click to read the complete NAHRI Journal article, “Take control of Medicare Advantage denial challenges”.

“It isn’t surprising that MAOs are looking to make a profit; after all, they are private companies. But the implications of denying or delaying medically necessary treatment to cancer patients while offering benefits such as high-tech fitness trackers raises reasonable concerns about how some MAOs are using federal money, says Timothy Brundage, MD, CCDS, medical director of The Brundage Group in St. Petersburg, Florida. “They’re promising all the bells and whistles. The only way you can provide bells and whistles is if you’re actually saving cost, and the way to save cost is to have the care of the patient be lower than the expected cost of caring for the patient,” he points out.

In theory, MAOs will keep patients healthy by encouraging them to make use of lower-cost outpatient services such as regular primary care checkups. In turn, MAOs are encouraged to keep patients healthy and out of the hospital through risk-sharing and capitated payments. However, as the OIG report pointed out, that can incentivize MAOs to deny or delay medically necessary care that can only be provided in a hospital. “The biggest-ticket item that you have as a risk dollar is an inpatient hospitalization. That’s a super-expensive place to receive care, and obviously that patient is very sick if they get admitted to the hospital,” Brundage says. “The managed Medicare folks do everything in their power to keep the patient in observation or outpatient so they’re caring for their patient at the lowest cost possible.”

By: Michael A. Salvatore, MD FACP CHCQM, Physician Advisor

Suggestions for conducting peer-to-peer appeals for denials

If you are wondering why you should read this if you think you are not a rebeginner, well, it is because you actually are one. Beginnings do not disappear, they just reproduce. Novices are just starting, veterans have started over and over. We all begin as beginners and then we begin rebeginning.

So as a perpetual rebeginner, I would like to share some of my ‘relearnings’ about doing peer-to-peer (P2P) appeals for insurance denials:

1. Insurance denials are not personal, so don’t take them personally. Why was best answered years ago by Michael Corleone in the Godfather trilogy, “Don’t hate your enemies, it affects your judgment.”

2. Many denials are made on incomplete clinical information. The peer often doesn’t know the whole story. Get the whole story and tell it vividly – this may be the first time the peer is hearing it, so make it cogent.

3. Recognize that some denials are appropriate denials and learn from them. Use them for ‘Teachable Moments’: Why the INPT should have been OBS. Why the documentation was inadequate. Why the patient should have gone home from the ER. Consider insurance denials as a painful form of clinical documentation integrity (CDI).

4. Do NOT just repeat the clinical record; present YOUR review of the whole clinical record.

5. Read the nursing notes.

6. Do NOT be limited by the current hospital record. If a patient was admitted with an elevated creatinine but no prior creatinine is referenced in the H&P – look it up. Old labs can result in overturns.

7. NEVER take a Progress Note as the whole story, very often today’s Progress Note is yesterday’s note or even the day before that – pay attention for poorly or unedited copy/pasting.

8. Always review the all vital signs yourself. Look for abnormal VS not mentioned in PNs. If you are not metric-minded be careful: 37.7O C looks innocuous but it is 100O F!

9. Always thoroughly review the MAR. Look for PRN aerosol Rxs and PRN IV medications, etc. They may not be in PNs but can contribute to severity of illness.

10. If the peer refuses to overturn the denial, ask why. An effective strategy is to inquire what would have made the case INPT. Sometimes in the discussion you find the something you need to get it overturned. Get the peer talking Medicine.

11. Keep records of which doctors are having their cases denied – give them 1:1 feedback but also present the feedback at departmental meetings unblinded.

12. Track denials by provider and reason, know what insurers are doing what.

13. Study your peers – learn their style. Know who will consider the whole clinical picture and who will strictly adhere to MCG or IQ.

14. Know the contract your hospital has negotiated with the insurer, e.g., does it allow for combining repeated admissions within 30 days. Never take the insurer’s word for it.

15. Know if the MA insurer has a contract, if not it defaults to traditional Medicare guidelines.

16. If the peer upholds denial just because it was only 1 MN but met their criteria (MCG or IQ) take it to their Medical Director, review the contract, and if necessary, appeal to the Centers for Medicare & Medicaid Services (CMS).

17. When in doubt – always appeal.

18. Always be gracious in defeat but know your appeal rights in your contract.

19. Doing Multidisciplinary Rounds and doing P2Ps are synergistic.

Insurance details are opportunities, do not waste them. They are chances for PAs to learn about the state of documentation in their shop, about their staff’s comprehension of policies, e.g. Observation, and to keep up to date on clinical medicine.

Denials are also an opportunity to demonstrate the vital financial role of the PA in today’s hospitals and to this end:

20. Keep a detailed record of the denied charges you have recovered.

21. Do not keep #20 to yourself.

By: Trey La Charité, MD, FACP, SFHM, CCS, CCDS, Brundage Group Physician Advisor

DRG 853 Infectious and Parasitic Diseases with OR Procedure w/MCC is Under Attack!

Procedural titles should not be taken at face value! What the surgeon actually did in the OR may be different than what the surgeon said they did in the OR. If auditors can change the coding of a documented procedure from a valid OR procedure to one that is not, that kicks the case out of the 853-855 set of MS-DRGs, moving the case from a surgical DRG to a lower reimbursing medical MS-DRG.

Pay particular attention to the documentation of excisional debridement. This can be performed by physical therapists at the bedside and still count as a valid OR procedure regardless of performance location. Auditors/CMS/OIG are opposed to the idea that a bedside procedure bumps a medical MS-DRG to a surgical one.

If it can be traced/linked/ascribed to some previous medical intervention, the principal diagnosis should be the corresponding complication code, which may change the MS-DRG.

Remember that the chapter specific coding guidelines state that sepsis is the principal IF the reason for admission is both sepsis and a localized infection. If the patient came to the hospital for some other reason, and that reason is not attributable to sepsis, sepsis is probably not the correct principal diagnosis.

Auditors do not waste time reviewing charts with multiple MCCs or CCs. Therefore, make sure single MCC and single CC charts in the MS-DRGs 853 and 854 have rock-solid, consistent and repeated documentation throughout the record, including the D/C summary—and that definitive, clear, widely accepted clinical criteria thresholds were demonstrably reached.

By: Dr. Timothy Brundage

I just returned from the ACPA National Physician Advisor Conference where I met with physicians who truly care about providing support to their hospitals.

As a key takeaway from the conference, I’d like to encourage Physician Advisors around the country to break down the silos that exist within hospital organizations. Physician advisors should be focused on much more than patient status assignment; they should be looking at the chart from a global perspective to accurately reflect the care provided. This perspective should supersede the utilization review department, the quality department and the CDI department.

The Physician Advisor should examine the chart to ensure that medical necessity is present while also ensuring the documentation supports accurate code assignment and the timeliness of the documentation supports the quality of care provided.

Only diagnoses that are captured Present On Admission (POA = Y or W) are used by Medicare to risk adjust expected mortality. The Physician Advisor should be keenly aware that mortality observed to expected rates are publicly reported. Our hospitals should provide the community with high-quality care that should be reflected as such in the metrics.

The Physician Advisor should be able to take a case review for medical necessity, which contains the documentation of cystitis and acute kidney injury with an acutely elevated Cr of 2, for example, and understand that this may or may not support inpatient status. If the Physician Advisor understands the global care provided to the patient, he or she should immediately work with the attending physician to document more effectively. If the acute kidney injury is explicitly linked to the cystitis, then the clinician should contemplate the diagnosis of severe sepsis based on SOFA.

This will immediately improve documentation that may potentially support inpatient status, support the appropriate DRG assignment to track expected resource consumption and track to the accurate expected mortality.  The utilization management team is supported, the CDI team is supported, and the quality team is supported. Most important, the accurate picture of the patient is reported—and the patient is supported!

The Sepsis-3 JAMA article published in 2016 reports a 10% expected mortality when diagnosing (severe) sepsis using the SOFA criteria.  This patient is sick, even more so than you may believe.

The role of a Physician Advisor is to support the clinician who is caring for the patient. The patient needs high-quality care and the clinician needs to be able to provide the care in the appropriate setting while also demonstrating that he or she is providing high-quality care to the community.

Physician Advisors should be breaking down the silos within hospitals to advocate for global care and global tracking of high-quality care.  They should get involved with the CDI team and the quality team, and make sure they are working with the utilization review team in a coordinated fashion.

It is not uncommon for me to go into a hospital and see the utilization review, CDI and quality teams working completely independently from one another, with very little communication.

The role of the Physician Advisor is to lead the team toward the accurate portrayal and status of the patient, as well as the appropriate tracking of the quality of care that physicians are providing to the community.

And I almost forgot to mention—this will also reduce the risk of denial if audited.

By: Dr. Timothy Brundage

Do you recall the days of being graded on a bell curve? Your grade didn’t necessarily depend on how well you knew the information and performed on a test, but rather on how you compared to your peers.

It occurred to me—after sensing nervousness from hospital administrators who watched their hospitals slip down industry ranking lists, such as U.S. News & World Report Best Hospitals—that these rankings are based on a similar curve.

According to the official announcement, “Prominent changes to the 2018-19 rankings methodology included more emphasis on patient outcomes and patient experience measures.”

You’ll never convince me that the well-respected hospital organizations that slipped down the list are no longer employing capable physicians who provide leading, high-quality care. That’s not it at all! Rather, the hospitals that top the list are focusing on CDI education, and thus documenting more effectively to support quality. The hospitals that rank lower aren’t performing worse than before—they’re just being outperformed on key metrics, such as mortality O/E.

Metrics and subsequent rankings are driven by how well your organization is documenting the entire patient tenure. If there is misalignment across the documentation spectrum, it will appear that you are underperforming, when that’s not the case at all.

Recent data—and personal observance—suggests that many programs within hospitals are designed for local vs. global optimization. For example, documentation teams are focused on optimizing the MS-DRG. Quality teams are focused on HACs (Hospital Acquired Conditions) and PSIs (Patient Safety Indicators). Utilization management teams are focused on documentation to support medical necessity. Each of these teams are effectively addressing the problems within their own space; however, they’re operating in silos. There needs to be a holistic strategy for the organization’s total performance, and each group needs to coordinate its efforts to contribute to that end.

If you’re not getting better, you’re falling behind—and you’re paying for it. There’s more urgency now than ever, as hospitals are facing a 1% penalty to revenue through CMS’s HAC reduction program. We can help! Keep up with the list leaders by keeping up with physician education, and get credit for the high-quality care you provide!