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Survey respondents share their thoughts on HIM roles and compensation

2016 HIM director and manager salary survey

More HIM professionals needed to manage an increasing workload, responsibilities

When compared to data from past surveys, HCPro’s 2016 HIM director and manager salary survey revealed a harsh truth that many HIM professionals already know: There has been little movement in HIM manager and director salaries over the years.

This year, the highest percentage of respondents indicated earning between $ 60,000 and $ 89,999 annually, an amount that has not budged much since 2013 (see the figure on p. 3). The percentage of respondents earning less than $ 40,000 decreased from 7% in 2013 to 4% in 2016, and the percentage of those earning $ 150,000 or more increased from just 3% in 2013 to 6% in 2016?but this is happening during a time when the HIM department is often tasked with doing more work with fewer resources.

"As budgets get tighter, we get more responsibility with the increase in pay," one respondent said.

Another respondent echoed those sentiments: "It is not so much the pay as the ever-increasing workload. We need more bodies throughout HIM, not necessarily more money."

Despite the fact that average salaries have remained fairly consistent since this survey was first conducted, 78% of 2016 respondents received a raise in the past year. One-third of respondents (33%) received a 3% raise, and approximately one-quarter (26%) received a 2% raise.

While 56% of respondents feel they are fairly compensated for the work they do, 62% do not believe HIM directors and managers overall are sufficiently compensated for their work.



More than half (53%) of this year’s respondents work as HIM directors, and 29% work as HIM managers. The majority (93%) of respondents are female. One respondent noted the ties between gender and salary in the workplace.

"There is still gender disparity?females are not paid the same as male counterparts for same/similar work," the respondent said. "There are other healthcare professionals with less responsibility/scope earning more. HIM professionals tend to have a wider scope of responsibility with multiple specialized functions."

Half of the respondents work at acute care hospitals, and 15% work in critical access hospitals. The plurality of those working in a hospital setting are in hospitals with fewer than 199 beds (42%), whereas more than one-quarter (26%) work at hospitals with 200?599 beds and 18% work at 600+ bed hospitals. The remainder of respondents do not work in hospital settings.


Experience, education, and certification

The percentage of respondents whose highest level of education is a bachelor’s degree remained steady at 42% from 2015 to 2016, which is an increase from the 30% of respondents with a bachelor’s degree in 2014. Similarly, the percentage of respondents whose highest level of education is an associate’s degree decreased from 22% in 2015 to 20% in 2015, indicating that a baccalaureate-level education is becoming the standard in the HIM profession. Although 21% reported earning a master’s degree, none had a doctoral-level education.

More than half of those whose highest level of education is an associate’s degree earn $ 50,000?$ 69,999 annually (54%), whereas most respondents with a bachelor’s degree earn $ 60,000?$ 89,999 annually (44%). (See p. 4 for more information.)

The majority of respondents are aged 40?59. The plurality of respondents (20%) have 21?29 years of HIM experience, a figure that has remained relatively steady since the 2015 survey. Just 13% have 3?5 years’ experience, and just 7% have 6?10 years, while 16% have been in the profession 30?39 years, indicating that HIM may need some fresh faces as directors and managers near retirement age.

The plurality of respondents with 16?20 years’ experience earn $ 70,000?$ 89,000 annually, whereas the plurality of those in the profession 21?29 years earn $ 80,000?$ 89,000 annually (23%). However, 30% of those with 30?39 years’ experience earn $ 150,000 or more.

Nearly half of this year’s respondents (43%) are certified as registered health information administrators (RHIA), compared to 53% in 2015. The percentage of respondents certified as registered health information technicians (RHIT) increased from 28% last year to 31% this year. The percentage of respondents who are certified coding specialists (CCS) increased from 16% in 2015 to 25% in 2016.

The percentage of respondents with an RHIT certification whose highest level of education is an associate’s degree continues to climb?78% in 2015 compared to 82% in 2016. These respondents appear motivated to earn certifications, with 32% holding a CCS certification this year compared to 19% in 2015.

In general, HIM directors and managers are obtaining CCS certifications. Among respondents whose highest level of education is a bachelor’s degree, one-quarter are CCS certified this year compared to 12% in 2015. However, the percentage of respondents with this level of education who are RHIA certified dropped from 68% in 2015 to 56% in 2016, while the percentage of those with an RHIT certification increased from 17% in 2015 to 22% this year.

RHIA certification also declined among respondents whose highest level of education is a master’s degree?84% in 2015 to 70% in 2016. The percentage of respondents in this group who are RHIT certified increased at a rate similar to respondents in other educational categories, more than doubling from 6% in 2015 to 13% in 2016.


Benefits and overtime

The percentage of respondents who work 42?50 hours weekly continues to increase, with 55% in 2014 compared to 58% in 2015 and 60% in 2016. However, 76% of 2016 respondents indicated that they are not compensated for overtime. Those who are compensated receive one and a half times their regular pay (9%) or time off in lieu of additional pay (2%).

Despite an increasing workload and a growth in the number of hours many respondents work, few have seen an increase in their benefits, including health coverage, retirement plan matching, pension plans, travel budget, vacation and holiday time, tuition reimbursement, continuing education budget, and the ability to accrue time off.

One respondent indicated that he or she does not receive any bonuses or perks, yet is still expected to take on more work. "I was given clinical documentation improvement [CDI] responsibilities in the last year with no salary increase. I am the inpatient coder and I do CDI by myself. I am also over privacy. When my salary is determined, privacy, CDI, and coding are not taken into consideration in the calculation?only the salaries of HIM department managers in the immediate area are considered."

Respondents were split on whether overall HIM salary, benefits, bonuses, and job perks keep up with the cost of living, with 56% stating these benefits have not kept pace throughout the industry. "It is similar to most industries?more work is added and cost of living rises and companies are able to keep up with rising costs," one respondent said.

Similarly, respondents were asked if their personal salary, benefits, bonuses, and perks keep up with the cost of living; more than half (51%) said no.


HIM responsibilities

In years past, respondents listed release of information as their top responsibility, with 76% responsible for this function in 2014. This figure remained steady, at 72% in both 2015 and 2016.

However, in the wake of ICD-10 implementation, the percentage of respondents working on coding increased from 70% in 2014 to 72% in 2015 and 77% in 2016. Other responsibilities appeared to dip slightly as coding took center stage, although the percentage of HIM directors and managers responsible for CDI increased from 45% in 2015 to 56% in 2016, which is not surprising as this function often goes hand-in-hand with coding.

Other responsibilities include the following:

  • Document imaging, including preparation, scanning, indexing, and verification (65% in 2016, 2015, and 2014)
  • Transcription, including report processing, interface failures, corrections, and distribution (53% in 2016, 57% in 2015, and 55% in 2014)
  • Privacy (43% in 2016, 52% in 2015, and 51% in 2014)
  • Recovery Audit program (33% in 2016, 30% in 2015, and 37% in 2014, which may be attributed to the temporary hold on these audits)
  • Compliance (30% in 2016, 27% in 2015, and 32% in 2014)
  • Birth certificates (33% in 2016, 31% in 2015, and 26% in 2014)
  • Tumor registry (21% in 2016, 24% in 2015, and 20% in 2014)
  • Security (15% in 2016 and 2015, 18% in 2014)
  • Utilization review (5% in 2016, 6% in 2015, and 12% in 2014, which may indicate that this function is moving to other departments such as nursing or case management)
  • Case management (2% in 2016 and 2015, 4% in 2014)


Survey respondents share their thoughts on HIM roles and compensation

HCPro’s HIM Briefings asked 2016 HIM director and manager salary survey respondents about their satisfaction with their roles, compensation, and benefits. They said:

"I think that the revenue the HIM departments generate and are required to ensure/validate compliance the salaries are way off in comparison to job requirements!"

"I suspect that people don’t realize the location has a lot to do with salary/compensation. Salaries for these positions in smaller communities is generally less."

"Some of my colleagues have not kept current with trends in the EMR, permitting IT staff to take control. I think this has lessened HIM’s role in some institutions. We have fought to get to the discussion table and have shown how our experience has a great value in implementing systems."

"Sometimes, we are branded one of the ‘non-revenue producing’ departments so we are an afterthought."

"The amount of work and knowledge needed in the role is comparable to information systems roles and the salaries are not comparable."

"HIM work is not understood nor appreciated. We are a critical member of the team." – Briefings on APCs

Postoperative respiratory failure’s introduction into the CMS value-based reimbursement model

Postoperative respiratory failure’s introduction into the CMS value-based reimbursement model

By Robert Stein, MD, CCDS, and Shannon Newell, RHIA, CCS, AHIMA-approved ICD-10-CM/PCS trainer

The accurate capture of acute respiratory failure has been a long-standing challenge for CDI programs. The accurate reporting of this condition as a post-procedural event can be even more difficult.

The importance of data quality for post-procedural acute respiratory failure will impact quality outcomes linked to reimbursement under the Hospital-Acquired Condition Reduction Program (HACRP), as well as the Hospital Value-Based Purchasing Program (HVBP), if language in the fiscal year (FY) 2017 IPPS proposed rule is finalized.

In this article we’ll provide insights into how clinical documentation and reported codes may impact payments, and guidance on some common CDI challenges to strengthen data quality.


Performance may impact reimbursement in FY 2018

A quality measure named Patient Safety Indicator (PSI) 11 has existed since 1998, when it was developed by the Agency for Health Care Research and Quality (AHRQ). The measure has been adopted for use by CMS and other comparative databases, such as the University HealthSystem Consortium and Healthgrades, to compare performance across hospitals.

If the proposed rule is finalized as written, how well your hospital performs on this measure will begin to impact hospital reimbursement under the two hospital pay-for-performance programs noted above. Reimbursement impact will begin in:

  • FY 2018 for the HACRP
  • FY 2019 for the HVBP


Performance for this measure will be assessed and scored, and the score will then be rolled into a weighted patient safety composite measure. Performance for the overall composite measure will then determine reimbursement impact. The name of this composite measure is the Patient Safety and Adverse Events Composite, previously known as the PSI 90 composite measure.

The Patient Safety and Adverse Events Composite measure was reviewed in last month’s column. What is important to note for PSI 11 is that performance for this measure will impact approximately 22% of the composite weight:

Data quality and PSI 11 performance

PSI 11 performance is determined by the diagnosis (ICD-10-CM) codes we submit on claims. This is a risk-adjusted measure evaluated using an observed over an expected ratio.

Discharges included in the measure:

  • All elective surgical discharges treated at the hospital are evaluated for comorbidities which impact the complexity of the patient mix and the associated expected rate of postoperative respiratory failure events

Identification of postoperative respiratory events:

  • Any discharge included in the measure which has one of the following ICD-10-CM codes on the claim triggers a reportable actual?or observed? postoperative respiratory failure event:


Additional details for key measure drivers can be found on review of PSI 11 specifications located on the AHRQ website at


PSI 11 CDI vulnerabilities

In our review of thousands of medical records for hospitals across the country, we see common challenges which impact PSI 11 data quality. We discuss a few of the common questions we encounter below to assist your internal data quality efforts.


How do I recognize acute respiratory failure?

  • Acute respiratory failure is at the end of a continuum initiated by respiratory dysfunction resulting in abnormalities of oxygenation and/or carbon dioxide elimination
  • Acute on chronic respiratory failure is an exacerbation or decompensation of chronic respiratory failure

Clinical criteria to identify if not documented and/or to validate a documented diagnosis include:

  • The use of supplemental oxygen or non-invasive/invasive mechanical ventilation
  • Signs and symptoms indicative of increased work of breathing (e.g., dyspnea, tachypnea [respiratory rate greater than 28], respiratory distress, labored breathing, use of accessory muscles)
  • Impaired gas exchange, which may be identified by the following clinical indicators:

What is the definition of "prolonged" postoperative mechanical ventilation?

  • A code for mechanical ventilation (and intubation) should not be assigned postoperatively for mechanical ventilation when it is considered a normal part of surgery.
  • Prolonged mechanical ventilation should be reported for an extended period postoperatively. A general rule of thumb for extended is 48 hours with the start time as the time of intubation for the procedure. Provider documentation should support what appears to be an extended time, but is in fact unexpected given the procedure and/or patient complexity.


If the patient is extubated postoperatively, but continues to be treated with supplemental oxygen, when is a query for acute respiratory failure appropriate?

  • To determine if this represents acute respiratory failure the values for impaired oxygen exchange can be utilized, along with the amount of oxygen being administered to the patient.
  • The P/F ratio can be a helpful tool to identify respiratory failure criteria above for a patient receiving supplemental oxygen:
  • If an ABG test is not available, an estimated P/F ratio can be calculated:
  • An illustration of the calculation follows:
  • The P/F ratio is a useful tool to validate the presence of acute hypoxemic respiratory failure when patients are receiving supplemental oxygen.


When respiratory failure exists in a post-procedural patient, how do I determine if this is, and/or is not, related to the procedure?

  • Physician education to promote clear documentation which relates the respiratory failure to an underlying condition (e.g., COPD) and/or to a procedure, and/or to the anesthesia, is essential.
  • When such documentation is not clear, a documentation query or clarification is required.


In addition to the above, other record review findings which negatively impact PSI 11 data quality include:

  • Accurate reporting of mechanical ventilation duration:
  • Accurate selection of post-procedural respiratory failure as the principal diagnosis:



Value-based care will increasingly utilize claims-based measures to assess quality and cost outcomes linked to payment. To strengthen organizational performance for PSI 11, the following steps are suggested:

  • Establish synergy between the CDI program and quality department to support:
  • Promote point-of-care capture of risk-adjustment variables pertinent to PSI 11 performance:
  • Actively engage your CDI physician advisor with medical staff education and CDI record reviews to facilitate and promote accurate capture of documentation relevant to accurate cohort identification and risk adjustment


Editor’s note

Stein is associate director of the MS-DRG Assurance program for Enjoin, providing clinical insight and education as part of the pre-bill review process. He earned his CCDS credential in June 2013 and completed AHIMA’s ICD-10-CM/PCS coder workforce training in August 2013. Newell is the director of CDI quality initiatives for Enjoin. Her team provides health systems with physician-led education and infrastructure design to sustainably address documentation and coding challenges essential to optimal performance under value-based payments across the continuum. She has extensive operational and consulting expertise in coding and clinical documentation improvement, performance improvement, case management, and health information management. You can reach Newell at (704) 931-8537 or [email protected] Opinions expressed are that of the authors and do not represent HCPro or ACDIS. – HIM Briefings

Providers see only minor productivity declines after ICD-10 implementation, according to survey

 By Steven Andrews

A decrease in staff productivity has been the top challenge for providers after ICD-10 was implemented, but relatively few organizations have seen a significant decrease in productivity, according to a recent survey from Navicure.
Despite nearly half of the participants (48%) noting a productivity decline as the top issue, only 13% of administrative staff and 15% of clinical staff saw a significant decrease. Another 46% of administrative staff and 42% of clinical staff didn’t see much of an impact, and the remaining respondents saw a minor impact or didn’t know of one.
The survey included 360 participants representing a broad range of specialties and sizes, with 60% from organizations with one to 10 providers.
Beyond productivity, 20% of respondents said revenue disruption was their top concern. However, 60% of organizations did not see any impact on monthly revenue following the transition. In terms of denial rates, 89% of respondents saw either no change or an increase of less than 10%.
All of these statistics are overwhelmingly positive for the industry, which was subject to constant fear mongering from organizations such as the AMA in the months before the transition, with predictions of massive productivity declines leading to insurmountable revenue problems for countless providers.
Predictions about how much providers would spend to get ready for implementation varied widely, depending on the source. An AMA-funded report from Nachimson Advisors estimated small physician practices would spend approximately $ 57,000-$ 200,000 to get ready. Even though this was already questioned, the actual results from the survey show a much different story.
Half of the respondents spent less than $ 10,000 on training and software updates, with another 14% spending between $ 10,000-$ 50,000. Only 5% spent more than $ 50,000, while 20% weren’t sure how much their organization spent.
And organizations are confident they’re coding correctly. Nearly all of the respondents (99%) reported sending the most specific ICD-10 code either all of the time or sometimes.
Watch for the Revenue Cycle Daily Advisor!
We are happy to announce that beginning January 25 you will be receiving the Revenue Cycle Daily Advisor. This free daily email newsletter combines editorial experts from HealthLeaders Media and HCPro to bring insight and news on every aspect of the revenue cycle, covering topics such as Medicare reimbursement rules and regulations, value-based business models, clinical documentation improvement, health information management issues, patient privacy and security, updates to coding and billing rules, utilization review and case management challenges, and hospital and physician practice reimbursement and compliance.
Your current subscription to APCs Insider will be transferred to the Revenue Cycle Daily Advisor. The last issue of the APCs Insider is scheduled for today, January 22. Please watch for your issue of Revenue Cycle Daily Advisor starting next Monday, January 25. – APCs Insider

OCR ramps up HIPAA enforcement efforts

OCR ramps up HIPAA enforcement efforts

The Office for Civil Rights (OCR) stepped up HIPAA enforcement in a big way this year. The agency handed down more than $ 5 million in HIPAA settlement fines in one week in March, and in July reached a HIPAA violation settlement with Advocate Health Care in Illinois that carried a $ 5.55 million payment. OCR kicked off phase two of its HIPAA Audit Program and will likely complete desk audits of covered entities (CE) and business associates (BA) by the end of the year. Comprehensive on-site audits may occur early in 2017.

However, breaches continue to come at a relentless pace and questions have arisen about OCR’s handling of HIPAA violations, particularly repeat HIPAA offenders. And a truly permanent HIPAA audit program may not yet be in sight: OCR states that phase two audits will help the agency plan for a permanent audit program but doesn’t state when that might launch.

In a September 2015 report (, the Office of Inspector General (OIG) said OCR?and the U.S. Department of Health and Human Services (HHS) as a whole?should strengthen its oversight of CEs and be proactive rather than reactive in its approach to HIPAA enforcement. The report found that in 26% of closed privacy cases, OCR did not have complete documentation of corrective actions taken by CEs. In addition, OCR’s case tracking system has significant limitations and makes it difficult for the agency’s staff to check if a CE under investigation has been the subject of previous investigations.

All of this may make some CEs and BAs feel that HIPAA compliance is merely optional, and that leads to a weaker privacy and security culture throughout the industry. Although OCR does take action to make its presence felt, it could do more, Frank Ruelas, MBA, principal of HIPAA College in Casa Grande, Arizona, says.

"I do believe that OCR is trying to let people know that it considers HIPAA compliance an important objective," he says. "With its guidance and ongoing alerts about the occasional enforcement actions here and there, I see OCR’s enforcement a small step above being a paper tiger in terms of how seriously people take it."

The waiting game

The OIG’s September 2015 report wasn’t the first time that agency has found fault with HHS and OCR’s methods, Kate Borten, CISSP, CISM, HCISSP, founder of The Marblehead Group in Marblehead, Massachusetts, says.

"OIG has published a number of reports over the years, identifying problems with HHS’ oversight and enforcement of these HIPAA rules," she says. "I know of no one in the profession who reads the OIG reports and disagrees."

But HHS and OCR have been slow to take action. More than five years passed between the end of phase one of the HIPAA Audit Program and the announcement of phase two, and OCR still has obligations it’s failed to fulfill. The agency’s slow pace may lead some to take it, and HIPAA, less seriously.

"Since the latest round of rule changes back in 2010, over six years ago, there are still outstanding rules and unmet commitments by HHS and OCR," Ruelas says. "In the end, it not only erodes credibility but also questions just how seriously is OCR taking its enforcement duties."


Another day, another fine

HHS and OCR regularly announce breach settlements, but 2016 saw a flurry of high-profile and costly settlements. OCR took the opportunity to make examples of a number of CEs and BAs in its statements, calling attention to the particular violations that tipped the settlements into the hundreds of thousands, or even millions, of dollars.

Although the settlements grab attention and headlines, it may be difficult to determine their positive impact. Some of the HIPAA violations in question date back years. Staff who worked at the organization, and may have been involved in the breach, are likely gone. Even administrators, executive leaders, and owners may change in that time. Some organizations may see OCR’s enforcement actions as too little, too late, Mac McMillan, FHIMSS, CISSM, cofounder and CEO of CynergisTek, Inc., in Austin, Texas, says.

"We all want the same thing: to see our industry do better," he says. "This is just more of the same old, same old. Same issues, different players."

A HIPAA settlement fine might be a crushing blow to a physician practice or small home health or physical therapy organization, but even the largest fines might not make an appreciable impact on larger organizations, McMillan says.

"To be really impactful, there will probably need to be more, they will need to happen closer to the actual event they’re related to, and possibly the fines will need to be bigger," he says. "The fines levied were really not substantial fiscally, and there was no accountability for those responsible for making security decisions, so they pay and move on."

Borten agrees that the long period of time between when a breach is reported and when OCR takes action lessens the impact. "The response or punishment must rapidly follow the event to have a significant impact on future behavior," she says.

Although some find California’s short breach notification timelines and black and white faxing rules burdensome, these measures have caused CEs and BAs to change their behavior and improved privacy and security, McMillan says.

Some CEs and BAs may be willing to take the chance they won’t be caught, Ruelas says. "I truly think that people see enforcement a lot like getting hit by lightning. However, if it does occur, it tends to be a game changer and does make for an interesting day."

But whether the change is meaningful or widespread may be difficult to determine, and any alteration to OCR’s HIPAA enforcement practices would likely be an improvement, he adds.


Learning from others’ mistakes

However, CEs and BAs can get something out of HIPAA settlements. Conscientious entities will fulfill the terms of the corrective action plan and even improve on it. And other CEs and BAs can take valuable lessons from OCR’s breach announcements. The agency often draws attention to specific issues that led to the breach, levies a pricey fine, and points out how the organization could have avoided the problem in the first place.

"HIPAA enforcement actions are important teaching tools," Borten says. "Workforce members can be asked if the same problem could arise in their organization, and how individuals can avoid the same fate."

Many privacy or security failures that lead to breaches are the result of human error and are still relevant regardless of when the breach occurred, she adds.

Although the security landscape has expanded beyond missing laptops and smartphones, Ruelas says there’s still a lot CEs and BAs can learn from these enforcement actions. Organizations may see ransomware, phishing, and privacy and security breaches on social media as the biggest threats?and rightly so. Yet many breaches still come down to 10-year-old HIPAA basics: misdirected faxes, incorrectly addressed emails, or handing the wrong documents to a patient.


While human error is still a concern, McMillan is most worried about the increasing number of breaches due to hacking, particularly the greater loss of data due to hacking and the effects such breaches have on the industry. "Human errors are still an issue, but the relative impact of those incidents compared to the impacts we see from hacking recently pales in comparison. Many of those attacks were the result of misconfigured or poor administration of systems resulting in serious outages and millions of lost records," McMillan says. "This is where OCR needs to focus attention."


Phase two

The launch of phase two of the HIPAA Audit Program may promise some positive change. The audits are intended to help the agency improve HIPAA guidance and tools and pinpoint common problems and challenges CEs and BAs face. Desk audits of CEs began in July, with BAs scheduled to follow in the fall. However, it may take 90 days after submitting documents for CEs to receive a draft audit report. Until then, it will be difficult to predict what OCR’s response to the audits might be.

The audit reports will not be made public, although OCR representatives indicated they will likely be available through a Freedom of Information Act request. Sharing some data might help CEs and BAs.

"I do think that if audit results can somehow be summarized and shared, just by their detailed nature, the audits can be wonderful sources of information for the HIPAA community," Ruelas says.

It took three years for the agency to update the audit protocols to reflect changes made by the HIPAA omnibus rule, he adds. It’s too soon to tell how long it might take the agency to revise or refocus its guidance based on the results of the phase two audits, but it would no doubt be beneficial for all CEs and BAs to see results sooner rather than later.

Establishing a permanent audit program is one of OCR’s responsibilities under HIPAA, and the agency’s failure to develop one has drawn criticism from the industry and from other regulatory agencies such as the OIG. OCR agreed with the OIG’s latest call for a permanent audit program. Phase two is an encouraging step in that direction, but still not quite enough.

"It has been very vocal on its commitment to establishing an effective and permanent auditing program," Ruelas says. "Let’s see if it really is going to walk the talk." – Credentialing and Peer Review Legal Insider

Billing Alert for Long-Term Care, May 2015

Common consolidated billing issues facing SNFs

Consolidated billing can be a challenge for any facility, and many SNFs continue to face confusion over which services are included or excluded. "Confusion over consolidated billing could result in missed reimbursement opportunities and rejected claims," says Maureen McCarthy, RN, BS, vice president of clinical reimbursement at National Healthcare Associates and president of Celtic Consulting in Goshen, Connecticut.

The following is a list of common consolidated billing questions facilities are facing and what your SNF can do to address these issues today.


1. I can’t find the Medicare fee schedule for a given charge from the hospital. What do I do? How much do I owe the hospital?

When a facility gets a bill for consolidated billing from a hospital, it usually does not have the fee-for-service reimbursement amount specifically listed. Instead, it will list the complete amount, including the hospital’s allowable markup for the services provided.

"Many facilities have a difficult time realizing how much they should be paying the hospital," says McCarthy.

Facilities often have trouble finding the codes to bill for the correct service. Here’s an example: A hospital bills a facility for hyperbaric chamber services. The bill amount was listed as $ 7,000. The question for the facility to consider is:

  • What exactly are we being billed for?
  • How much would Medicare pay for these services?


When faced with questions like these, the first step facilities should take is to determine where they need to look up the billing codes. Most facilities may access CMS’ physician fee schedule lookup. This tool, which can be found at, will help you understand many of the charges billed by the hospital.

It is important to note that there are numerous sources of Medicare allowable payments outside the physician fee schedule, according to Bill Ulrich, president of Consolidated Billing Services, Inc., in Spokane, Washington. These include:

  • Ambulance services
  • Durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS)
  • Parenteral and enteral nutrition (PEN)
  • Drug services
  • Clinical laboratory services
  • Ambulatory Payment Classification (APC)
  • Splints, casts, etc.


For these services, there is no single or correct payment option, and there are a number of places facilities may need to look outside of the physician fee schedule.

In answering the question, "How much do I pay?" many facilities are missing a critical first step: Put "under arrangement" transactions in place with outside providers of services, including hospitals, says Ulrich. "CMS says that the entity shall look to the SNF for payment and they have told the SNF it must pay, but never has CMS said, at what level," he explains. "It’s the ‘arrangement’ that sets price, and absent that, state law controls cases where there is a payment dispute. Although we all encourage it, one cannot assume you pay the fee schedule or the fee schedule less co-pay."


2. Do I pay the technical component or the professional component of a provided service? What is the difference between these two components?

This question relates to any of the consolidated billing portion or Medicare Part B services. Under consolidated billing, the SNF is only responsible for paying the technical component of a bill?not the professional component, which is billed by the vendor straight to Medicare Part B.

When billing Medicare, vendors will receive payments under their own provider numbers because they are providing the professional service separately. The SNF has an arrangement with the vendor to supply the service to the resident, so you are only responsible for the technical component.

"The most important thing you can do to avoid confusion in this area of consolidated billing is to provide education on what these two components are and how they involve the SNF," McCarthy says.

Along with education of these components, a related issue facilities face is being asked to pay "facility fees," according to Ulrich. "While CMS says professional fees are not bundled, the hospital and ambulatory surgical center (ASC) bill for the facility portion of the professional services using the professional service code," Ulrich says. "It is important to understand that when the SNF is billed for one of these codes by the hospital or ASC they are not seeking reimbursement for the professional component but rather for the facility overhead associated with the services."


3. Are all forms of chemotherapy excluded under consolidated billing? What happens if the resident changes the chemotherapy they receive after admission to the SNF?

While the SNF Help file for consolidated billing provides information on chemotherapy drugs, the variety of drug treatments can cause confusion for billers when using consolidated billing.

"If a patient is on one type of chemotherapy when they are admitted to a SNF, it does not mean that they will stay on the same chemotherapy treatment throughout their stay," says McCarthy. "Their treatments may change and this is very important to understand."

Certain types of chemotherapy may be excluded under consolidated billing; however, other types are included and are reimbursable. This often leaves billers asking "Do I have to pay for it or not?"

"Many facilities may shy away from taking chemo patients because they were under the assumption that chemo was not paid for," McCarthy says. "This is incorrect?some of it is paid for, and facilities need to be aware of the differences."

When working with a chemotherapy patient, either the billers or the admissions staff?depending on who has the responsibility?should begin by contacting the provider from which they are getting their chemotherapy. This may be a hospital, chemotherapy center, cancer center, physician’s office, etc., to find out exactly which type of chemotherapy medication they are receiving.

"The provider was likely billing someone prior to that patient coming into the SNF, so if you can get the code that they are billing under, you can use that information to look up the type of chemotherapy provided," says McCarthy.

Speak to the physician prior to admission to determine:

  • The likelihood that the patient will switch the type of chemotherapy he or she is receiving
  • How long he or she will be on current chemotherapy medication and/or others

The goal of these questions is to help your facility understand what your cost will be for the length of the resident’s stay.


4. How far back can the hospital or physician provider go to send my facility a bill for any given service under consolidated billing? Is there an expiration date for submitting a bill?

There is not actually a window or a closing date for this, according to McCarthy. "We only have 120 days to adjust a Medicare claim, but we are receiving bills for people who have had stays back in 2010."

In the past, SNFs were not receiving a lot of bills because hospitals were being paid by a Medicare carrier and their business facilities were being paid by a fiscal intermediary. The records between the two were not overlapping, so both facilities were billing and all of the claims, regardless of duplication, were accepted.

Since the billing has become more transparent through reform efforts, SNFs are seeing more bills from hospitals. "When a hospital initially submits a bill, they may not be aware that the patient is or was a Medicare beneficiary," McCarthy says. "Then when their claim is denied, it’s not until they get back around to dealing with it that the SNF will see the bill. It generally shouldn’t take that long, but sometimes there are cases when it does."

Consider the following example: A person is in a no-fault auto accident. The no-fault insurance company says that it will pay for the necessary medical services. The capitated amount the insurance company is providing runs out prior to all of the services provided and the resident is switched over to Medicare Part A. The facility does not find out about the transition to Part A until after the initial bill has been sent.

It is particularly important to be aware of this when you are dealing with a situation where the payer source changes, says McCarthy. "Whether the resident is using auto insurance, Worker’s Compensation insurance, or another form of insurance, if they then ran out of money and switched to Medicare while in a stay at the facility, you don’t find that out until later," she explains.


5. Do I still have to pay a bill if the patient has already discharged or if they have expired?

Yes, in this situation, facilities must still pay for the billed services, if they received the services while covered under Medicare Part A. "Even if the resident owes your facility money, the facility still has to pay these bills," McCarthy says.


6. Is the ambulance ride covered?

Ambulance services are not categorically excluded from consolidated billing, according to CMS. However, certain types of ambulance transportation are separately billable in specific situations. According to CMS, these situations include:

  • An ambulance trip that transports a beneficiary from the SNF at the end of a stay, when it occurs in connection with one of the following events, is not subject to consolidated billing.
    • A trip for an inpatient admission to a Medicare-participating hospital or critical access hospital (CAH)
    • A trip to the beneficiary’s home to receive services from a Medicare-participating home health agency under a plan of care
    • A trip to a Medicare-participating hospital or CAH for the specific purpose of receiving emergency services or certain other intensive outpatient services that are not included in the SNF’s comprehensive care plan
    • A formal discharge (or other departure) from the SNF that is not followed by readmission to that or another SNF by midnight of that same day
  • An ambulance trip from the SNF to the hospital for the receipt of excluded types of outpatient hospital services. Since a beneficiary’s departure from the SNF to receive excluded outpatient hospital services is considered to end the beneficiary’s status as a SNF resident for consolidated billing purposes, any associated ambulance trips are excluded as well. Moreover, once the beneficiary’s SNF resident status has ended in this situation, it does not resume until the point at which the beneficiary actually arrives back at the SNF; accordingly, the return ambulance trip from the hospital to the SNF would also be excluded from consolidated billing.
  • When a beneficiary leaves the SNF to receive off-site services other than the excluded types of outpatient hospital services described previously and then returns to the SNF, he or she retains the status of a SNF resident with respect to the services furnished during the absence from the SNF. Accordingly, ambulance services provided in connection with these services would remain subject to consolidated billing, even if the purpose of the trip is to receive a particular type of service (such as a physician service) that is excluded from consolidated billing.
  • When an individual leaves a SNF via ambulance and does not return to that or another SNF by midnight, the day is not a covered Part A day, and CB would not apply. However, a beneficiary’s departure from a SNF is not considered to be a "final" departure for CB purposes if he or she is readmitted to that or another SNF by midnight of the same day. Therefore, when a beneficiary travels directly from SNF 1 and is admitted to SNF 2 by midnight of the same day, that day is a covered Part A day for the beneficiary, and CB applies.
    • A medically necessary ambulance trip would be bundled back to SNF 1 since the beneficiary would continue to be considered a resident of SNF 1 (for CB purposes) up until the actual point of admission to SNF 2. However, it should be noted that in addition to the "medical necessity" criterion pertaining specifically to ambulance transports under the SNF benefit (i.e., the patient’s medical condition is such that transportation by any means other than ambulance would be contraindicated), coverage in this context also involves the underlying requirement of being reasonable and necessary for diagnosing or treating the patient’s condition.
    • For example, a transfer between two SNFs would be considered reasonable and necessary in a situation where needed care is unavailable at the originating SNF, thus necessitating a transfer to the receiving SNF in order to obtain that care.
    • By contrast, a SNF-to-SNF transfer that is prompted by non-medical considerations (such as a patient’s personal preference to be placed in the receiving SNF) is not considered reasonable and necessary for diagnosing or treating thepatient’s condition and, thus, would not be bundled back to the originating SNF.
  • If a SNF’s Part A resident requires transportation to a physician’s office and meets the general medical necessity requirement for transport by ambulance (i.e., using any other means of transport would be medically contraindicated), then the ambulance roundtrip is the responsibility of the SNF and is included in the PPS rate.
  • Medicare does not provide any coverage at all under Part A or Part B for any non-ambulance forms of transportation, such as ambulette, wheelchair van, or litter van. In order for the Part A SNF benefit to cover transportation via ambulance, the ambulance transportation must be medically necessary. This means that in a situation where it is medically feasible to transport a SNF resident by means other than an ambulance, ambulance service will not be covered.


As with other situations of non-coverage, where the resident may be financially liable, the SNF must provide appropriate notification to the resident of services available in the facility and of charges for those services, including any charges for services not covered under Medicare or by the facility’s per diem rate.


7. Do I have to adjust my paid claims to show the charges for a late bill from a bundled service?

As mentioned previously, SNFs only have 120 days to adjust a claim, but it would be in the provider’s best interest to ensure that all of the services paid for by the SNF for a particular resident under consolidated billing are stated, according to McCarthy. This is important because that will accurately document the amount?in services and dollars?that your facility is spending on Medicare patients.

This information should be included in your cost report under the different revenue codes. "A common problem we see here is related to ambulance services," McCarthy says. "The problem is that the ambulance providers don’t send their billed claims until the SNFs bills have already gone out." As a result, many facilities aren’t adding this information to their claim because it is significantly later and it is already a paid claim.

Just remember that all of the charges that resident incurs for Medicare Part A and B should be reflected on the claim.


8. Should I post all ancillary services my resident receives on my monthly claims?

Yes, all of the ancillary services should be included on monthly claims.

While ancillary service providers are a lot later to send the information to facilities, billers still need to show CMS all of the services that the facility is spending on Medicare covered patients. This is necessary to ensure that each patient is actually receiving the services they require.


9. Are FDA-approved drugs covered by Medicare if a resident is prescribed the drug for an off-label treatment?

There is a growing number of SNF’s residents that are being prescribed FDA-approved drugs for off-label conditions, according to Ulrich. "These off-label uses can really add up when the SNF is not aware of the coverage limitations set by CMS," Ulrich says.

For example, consider the drug Basiliximab (Simulect®), which was FDA-approved on May 12, 1998 for the following indicated use: kidney transplant?prophylaxis of acute organ rejection in patients receiving renal transplantation when used as part of an immunosuppressive regimen that includes cyclosporine and corticosteroids. The Medicare allowable single dose cost for Basiliximab is $ 2,442.92 per 20mg (vial), which can bundled to the SNF.

However, Simulect® is also commonly used to treat the following (off-label) conditions:

  • Atopic dermatitis
  • Psoriasis
  • Ulcerative colitis
  • Uveitis
  • Scleromyxedema
  • Graft versus host disease (a complication that may occur after a stem cell or bone marrow transplant)
  • Prevention of liver (and other organs) transplant rejection


The off-label treatments are not Medicare-approved costs.


Ready for ICD-10?

Ensure your facility’s training is on track


Editor’s note: Karen Fabrizio, RHIA CHTS-CP CPRA, recently presented "ICD-10 Coding and Documentation for Long-Term Care," a 90-minute webinar hosted by HCPro.

Fabrizio is an AHIMA Approved ICD-10-CM/PCS trainer and a medical record administrator and HIPAA privacy and security officer at Van Duyn Home and Hospital, a 513-bed SNF in Syracuse, New York. During the webcast, she identified common documentation pitfalls and reviewed ways that SNFs can prepare their documentation and policies for the transition to ICD-10 on October 1, 2015.

Fabrizio recently shared her suggestions for how to get ready for ICD-10 with Billing Alert for Long-Term Care. Recordings of the webcast can be purchased on CD at


Q: What did you want SNFs to take away from your webcast?

A: My underlying objective was to really identify how important documentation is for accurate and thorough coding and to identify areas that facilities can take a look at across all disciplines.

The identification of a diagnosis is a physician’s responsibility; however, when you get some of the specificity sometimes from different disciplines, a physician may not pick up on the dominate side or the non-dominate side for a stroke, but a physical therapist or an occupational therapist definitely will be focused on that. So it’s looking at documentation on an interdisciplinary standpoint.

So far I’ve highlighted 10 diagnoses that are pretty common. I talk about the pitfalls of bad documentation and things to consider for providing good documentation.

The second takeaway is: I feel very strongly that facilities need to have a coding policy so that if you have multiple people coding or multiple people interpreting codes, they all come up with the same interpretation.

For instance, there is a code for history of falls. It’s important for the facility to determine when they are going to use it. You certainly don’t want to use history of falls for someone who has only fallen once and broken his or her leg. But if someone has fallen frequently, whether or not there is injury, that’s a code that is going to be important for facilities to consider how they are going to use it.

Unfortunately, the whole coding system is new, so there are not a lot of guidelines in terms of you need to have fallen three times in six months to be able to use that code. I think we’ll start to see that develop, but that doesn’t mean a facility can’t make that interpretation now.

For example, in my facility that I worked at previously, we had an interpretation that if someone had fallen three times within six months, we would code that as a history of falls, and if someone had fallen once previously with a significant injury, we would use that code as well.

So, my plan is to identify areas that we should seriously think about how we’re coding it and when we should consider using a specific code.


Q: What should SNFs be doing now to plan for this transition and improve their documentation? Should they begin training staff now?

A: There is mixed thoughts about the training. I think the training should be done soon and I think someone in the facility should be in the process of starting that in-depth training. But if you don’t use it you lose it; it’s a corny phrase, but you don’t want to learn how to do ICD-10 and then not do anything with it.

So I think the facilities should identify a group of people to be part of their stakeholder task force. They need to have their implementation and transition team and have at least one individual become comfortable with the classification system, and that person can go back and lead discussions?not necessarily be the chief decision maker?but lead discussions to say chapter-by-chapter, how are we going to address the endocrine? How are we going to address the neurological system? Do we want to use external cause codes? I think you need someone with that knowledge. It’s unfortunate though, because I don’t know if a lot of facilities really have the resources to do that.


Q: Can you walk our readers through a couple of examples of coding issues that facilities might run into?

A: Sure. So a doctor commonly says that a patient has diabetes. If he doesn’t identify type one or type two diabetes, the coding guidelines say we have to assume that it’s type two. The problem you run into is that type one diabetes is generally maintained on insulin and affects other systems. So if we don’t have good documentation by applying the rules, I would have to code diabetes as type two diabetes, and that might not represent the patient at all.

The other spinoff of that is we really need to identify whether a person is maintained on insulin and whether it’s to control a type one or type two diabetes, or if it’s a short-term use just to bring things back around. When a person is coming in from home and we have our intake people writing down his or her list of meds, and they add insulin, and I see a person that is type two diabetes and on insulin, I have to ask whether or not that is just a short time use of insulin to supplement their diabetes or if this person really does have type one diabetes.

In long-term care it does not directly impact our reimbursement because we are reimbursed by the RUGs. However, with the nation moving toward quality improvement surveys and Medicare making sure skilled services are appropriate and medically necessary, our coding that we do in long-term care is greatly affected by the coding they do in acute care prior, and can affect our discharges to a home health service.


Q: What are facilities still unprepared for regarding the transition to ICD-10?

A: I don’t think a lot of facilities are aware of how long it’s going to take to do the coding. We’ve jumped to one more code that requires us to be more specific and I have heard that a patient record could take up to twice as long to code under ICD-10, just because it is more specific and you’re learning a new system. For example, I know in ICD-9 UTI is 599.0. In ICD-10 I know it starts with an "N" and maybe has a "39," but then it’s getting into all the specifics. Part of it is that transition of it, but you’re getting into more specificity.

I think historically, long-term care facilities have utilized generic codes and maybe have used cheat sheets to be able to quickly assign codes, and that’s going to be very difficult to do with ICD-10.


Q: Anything else that facilities should be thinking about?

A: The other big thing is that this really needs to be multidisciplinary. Very few facilities have the resources of an educated or credentialed health information manager, but they are fortunate to have individuals with other backgrounds who may be comfortable with coding. But you have to include everyone in this process.


Don’t forget the billers

Most ICD-10 training is focused on coding, but don’t forget to train your billing staff, says Maureen McCarthy, president of Celtic Consulting in Goshen, Connecticut, and vice president of clinical reimbursement for National HealthCare Associates based in Lynbrook, New York.

Billers need to understand how changes introduced by ICD-10 codes will affect their work, McCarthy says. They should be comfortable with what codes will look like under the ICD-10 system as well as any software changes related to ICD-10.

CMS has announced that MACs will host an ICD-10 testing week from March 3?7, allowing providers to submit test claims. MACs are expected to provide more information through their websites and listservs.

McCarthy recommends that billers take advantage of the testing week to prepare for the official ICD-10 implementation on October 1. She also recommends that billers check their state and national professional organizations for ICD-10 training.

"There’s a lot of information out there for clinicians, but there’s not a lot for billers," McCarthy says. "The earlier billers can get their claims tested with their new software systems, the better off they’ll be."


Common SNF billing struggles

Written by Lisa McIntire and Julie Bilyeu of BKD, LLP.

With ever changing billing requirements and increased payer scrutiny, skilled nursing facility (SNF) billing personnel encounter more challenges than ever. Providers that don’t stay on top of changes that impact billing are at risk for noncompliance and decreased cash flow. Oftentimes billing issues can be avoided with ongoing education, consistent review of outstanding accounts receivable, and a thorough process for pre-submission claims review.


Lack of understanding about payment methodology

It sounds simple enough, but understanding how each payer reimburses for services is critical to determining if claims are paid correctly.

Important components of Medicare payment methodology include knowing when rates change annually. This can be confusing since Part A rates are updated in October, while coinsurance and Part B rates change each January. If the new rates aren’t loaded into billing software in a timely manner, accounts receivable will not be accurate, which can make follow-up daunting.

Other considerations include accounting for the 2% sequestration cut that has been in effect since April 1, 2013, and the Multiple Procedure Payment Reduction (MPPR) that applies to certain therapy service codes, both of which your software may or may not apply automatically.

Knowing what to expect in reimbursement from insurance primary and Medicare Advantage (MA) plans can also be confusing. Providers often mistakenly assume these plans pay according to Medicare guidelines; however, contracted providers are generally paid a daily rate based on level of care or charges billed. Insurance payment rates may not change, depending on how often the contract is renegotiated, so it is advisable to review your contract on an annual basis.

Determining patient out-of-pocket costs is another burden, as it can vary greatly by payer. But the earlier patients are notified of their financial responsibility, the higher the likelihood the SNF will be able to collect.


Overlooked adjustments and bad debt write-offs

A common theme surrounding aged accounts receivable (AR) is that the claims have paid, but a balance or credit balance remains after the payment was applied. Just because the claim paid does not mean the situation is finalized. If a balance remains after payment posting, further investigation is in order?and the sooner, the better.

Otherwise, these incorrect balances build up over time, making it difficult and time-consuming to determine later if claims were correctly paid or if there are balances that need to be collected or reported as overpayments. This also contributes to inaccurate AR, which can lead to increased scrutiny by stakeholders as well as unrealistic expectations about cash yet to be collected. However, these issues can be easily avoided by researching any discrepancies at the time payments are posted as well as determining?and resolving?the core issue.

As previously mentioned, incorrect rates in billing software is a common contributor to inaccurate AR balances. Depending on the state, Medicaid rates may change as often as quarterly, which requires even more diligence in ensuring they are correct. Not adjusting for sequestration and MPPR, as detailed on the Medicare remittance advices (RAs), is another reason why balances remain after claims have paid.

For providers with a high volume of MA claims, contractual adjustments can come in many forms, depending on how – Billing Alert for Long-Term Care


Which food was declared the official state vegetable of Oklahoma in 2007?
a. Avocado
b. Cucumber
c. Tomato
d. Watermelon
Think you know the answer? E-mail Editor Steven Andrews at [email protected]. If you are one of five randomly selected readers to answer correctly the day you receive your issue, you’ll receive a free three-month trial subscription to the HCPro newsletter of your choice.     
Last week’s question
Which U.S. president attempted to ban Christmas trees at the White House in a bid to encourage environmental conservation?
a. Franklin D. Roosevelt
b. Jimmy Carter
c. Richard Nixon
d. Theodore Roosevelt


The answer is D. Roosevelt’s ban was short-lived, as his two young children conspired with White House staff to set up a tree, complete with lights, in a closet. – APCs Insider

Combat Sagging Inpatient Volumes with Preferred Provider Status

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Combat Sagging Inpatient Volumes with Preferred Provider Status

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Medicare rules reshape hospital admissions

The Wall Street Journal, December 2, 2015

US still in danger of losing war on AIDS, CDC director says

The New York Times, December 2, 2015

UnitedHealth CEO defends possible exit of Obamacare exchanges

CNBC / Reuters, December 2, 2015

Mercy Health invests in $ 135 million joint venture

Cincinnati Business Courier, December 2, 2015

A tale of two Obamacare co-op insurers: One standing, one falling

Kaiser Health News / Colorado Public Radio, December 1, 2015

Study: Obamacare boosting breast cancer screening among poor

U.S. News & World Report / HealthDay News, December 1, 2015

Patients want to price-shop for care, but online tools unreliable

NPR / WHYY, December 1, 2015

Instability in marketplaces draws concern on both sides of health law

The New York Times, November 30, 2015

KY, beacon for health law, now a lab for its retreat

The New York Times, November 30, 2015

Yale-New Haven opens short-term rehab center inside Milford Hospital

New Haven Register, November 30, 2015

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36415 venipuncture code bcbsil

So we bill 36415 with modifier 59 to bcbs and it always gets paid. But now its being rejected as incidental to other labs. PEr bcbs agent, new guidelines since may 2017. Any idea how I can get the 36415 to get paid? Is anyone going thru the same problem. I work for two providers and both of them have the same issue.

Medical Billing and Coding Forum

Q&A: Changes to Joint Commission maintenance standards and AEMs

The following is an edited Q&A from the Association for the Advancement of Medical Instrumentation’s (AAMI) webinar, “Clarifying the Changes to Joint Commission and CMS Standards.” The webinar talked about the changes to The Joint Commission’s maintenance standards, which no longer differentiate between inspecting high-risk and non-high-risk devices for an alternative equipment management (AEM) program. The speakers for the event were George Mills, MBA, FASHE, CEM, CHFM, CHSP, Joint Commission director of engineering, and Stephen Grimes, FACCE, FAIMBE, FHIMSS, managing partner and principal consultant for Strategic Healthcare Technology Associations, LLC. – Briefings on Accreditation and Quality