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Tag Archives: Gives
Joint Commission’s top-cited standards list gives hospitals plenty to work on
In what is likely a result of a new survey matrix, new or revised Life Safety and Environment of Care requirements, and increased pressure from CMS, hospitals scored much worse across the board on The Joint Commission’s list of most challenging standards for the first half of 2017, compared to the same period last year.
Coding Clinic gives direction on heart failure, obstetrics, and linking language
Coding Clinic gives direction on heart failure, obstetrics, and linking language
by Laurie L. Prescott, MSN, RN, CCDS, CDIP
We are more than six months into the transition to ICD-10-CM/PCS, and at times it appears there are more questions than answers.
The last few weeks have brought us some direction, though, including the release of approximately 1,900 new ICD-10-CM codes for 2017. (The list can be found on CMS’ website.) We also have a list of approximately 3,600 new ICD-10-PCS codes for 2017. (This is also available on CMS’ site.) Of course, we will also be looking for changes in DRG mappings and the CC/MCC lists, which will likely appear later this summer.
The transition to ICD-10 was not a one-time process that ended on October 1, 2015?it will continue for quite some time. As CDI specialists, we must keep informed of the new information, including the latest guidance offered by AHA Coding Clinic for ICD-10-CM/PCS®.
The latest release, First Quarter 2016, focused on ICD- 10-CM diagnosis codes, in comparison to 2015, which focused more on the procedure side. One thing remains constant, though: It seems like every Coding Clinic offers some guidance that makes me think, "Finally, it’s about time!" yet also contains other pieces of advice that simply prompt more questions.
Heart failure differentiation
Let’s start with the long-awaited direction related to differentiation of heart failure. Coding Clinic heeded the American College of Cardiology and will now allow the more current descriptions of heart failure with preserved ejection fraction (HFpEF) and heart failure with reduced ejection fraction (HFrEF) to be coded as systolic and diastolic heart failure, respectively. This guidance is highly welcomed.
Obstetrics admission
For those who review obstetrical cases, there is guidance related to selection of principal diagnoses related to an obstetrics admission. The condition prompting the admission should be sequenced as the principal diagnosis for an obstetrical patient. If there is a complication of the delivery, the appropriate code would be assigned as a secondary diagnosis. Coding Clinic provides the example of an admission for premature rupture of membranes with a laceration complicating a delivery. In such a scenario, the principal diagnosis is pregnancy complicated by premature rupture of the membranes, and a secondary diagnosis of laceration would be assigned.
There is also guidance related to ICD-10-PCS code assignment for the repair of obstetrical lacerations; it instructs us to code the body part as related to the degree of the laceration or the deepest level of the repair as described (perineum, perineal muscle, rectal mucosa, and anal sphincter, for example).
Linking language
ICD-10-CM provides many opportunities to assign combination codes, especially those related to diabetes and the many complications associated with this condition. CDI specialists at your facility no doubt have worked diligently with providers to document the relationship using "linking language."
The question posed in this latest Coding Clinic asks if the provider must document the relationship between the two diagnoses or whether the coder can assume the relationship and assign the appropriate combination code. The answer provided (on p. 11 of Coding Clinic) actually left me more perplexed. It states:
The classification assumes a cause-and-effect relationship between diabetes and certain diseases of the kidneys, nerves and circulatory system. Assumed cause and effect relationships in the classification are not necessarily the same in ICD-9-CM as ICD-10-CM.
Several examples provided seem to infer that the relationship between diabetes and conditions such as polyneuropathy and ESRD can be assumed, unless of course there is documentation that indicates another identified cause.
Coding Clinic also reinforced the existing understanding that there is no assumed relationship between osteomyelitis and diabetes, as previously stated in Coding Clinic, Fourth Quarter 2013, p. 114.
So, although the direction related to osteomyelitis reinforces previous instruction, the direction related to diabetes and other conditions of the kidneys and nervous/ circulatory systems is brand-new and not particularly clear. What conditions are assumed and what are not? Where is "linking" required in documentation? I hope to receive further guidance related to these examples.
Review the latest Coding Clinic guidance related to diabetes and its manifestations to make sure that your CDI specialist team interprets these pieces of advice consistently. When you discover one of these "shades of gray" areas within the guidance, submit your questions to the Coding Clinic editorial board for clarification (they can be submitted at www.ahacentraloffice.org). The only way to learn is to ask questions.
Editor’s note: Prescott is the CDI education director at HCPro in Middleton, Massachusetts, and a lead instructor for its CDI-related Boot Camps. Contact her at [email protected]. The article originally appeared in CDI Journal.
CMS gives providers a chance to comment on 2-midnight rule payment methodology
By Steven Andrews
Small tweaks to the 2-midnight rule in the 2016 OPPS final rule should help providers, but a lengthy court battle related to the rule could end up making a bad situation worse.
A suit brought by the American Hospital Association (AHA) and other hospital associations and organizations against CMS recently resulted in the court ruling that CMS had to provide information on how it calculated a negative 0.2% reduction in inpatient payment rates as a result of implementing the 2-midnight rule. The court also said that providers should have an opportunity to comment on the calculation.
In early December, CMS released a notice with comment period to meet the court’s requirement, but providers might not be pleased with forcing the agency’s hand. CMS notes that when originally estimating the number of outpatient cases that should shift to inpatient as a result of the rule, it looked at 2011 claims containing HCPCS codes G0378 (hospital observation service, per hour) and G0379 (direct admission of patient for hospital observation care).
Using this data, CMS identified approximately 350,000 observation stays that lasted two or more midnights. The agency combined that with approximately 50,000 claims that contained major procedures based on APCs that resulted in stays lasting more than two midnights. CMS also analyzed data from the inpatient side by looking at inpatient claims containing surgical MS-DRGs with stays that lasted less than two midnights and found approximately 360,000.
The agency used this data to determine a net increase of 40,000 inpatient discharges as a result of the rule to calculate $ 220 million in increased expenditures on the inpatient side, leading to the reduction.
However, CMS now says that in light of new regulations and by using different metrics to estimate the shift, as many as 570,000 cases could move to the inpatient side, resulting in an even larger payment shift.
Providers are encouraged to comment on the rule in order to let CMS know what the best method for estimating these cases would be. This could have a large impact on payments, so if you’re interested in commenting, head to regulations.gov and make a submission by February 2, 2016.
Ruling Gives Religion-based Hospitals Pension Exemption
On June 5, the U.S. Supreme Court ruled in the Advocate Health Care Network v. Stapleton case that religious-affiliated hospitals are exempt from federal pension requirements. That means faith-based hospitals can avoid pension regulations — such as paying premiums to the Pension Benefit Guaranty Corporation — under the Employee Retirement Income Security Act’s (ERISA) “church plan” exemption. […]
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