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Tag Archives: Program
Medicare Diabetes Prevention Program
Has anyone had any success getting MDPP claims into their Medicare Contractor for processing, and received payment? If not, what issues are you facing?
Appropriate Use Criteria Program is Full Steam Ahead
Is your outpatient facility on board with new regulations for the ordering and furnishing of advanced diagnostic imaging services? Advanced diagnostic imaging services have long been under scrutiny by the Office of Inspector General for Medicare fraud and abuse, and the Centers for Medicare & Medicaid Services (CMS) responds to the watchdog’s recommendations each year […]
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Understand the Latest GME Program Guidelines at HEALTHCON
HEALTHCON 2019 (April 28-May 1 in Las Vegas) is for everyone in the business side of healthcare, and provides cutting-edge education, networking, and other opportunities to attendees. Expert speakers, such as Christopher Chandler, MHA, MBA, CPC, CGSC, help make this a professional event you can’t miss. AAPC asked Chandler about his presentation, “An In-depth Understanding […]
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Qualified Medicare Beneficiary program (QMB)
Hello, we have a patient that is part of the Qualified Medicare Beneficiary program (QMB) from Medicare. How is this program billed?
What happened is they gave us their AARP insurance and no medicare info. We billed AARP and they had a copay now she’s asking for a refund.
What happened is they gave us their AARP insurance and no medicare info. We billed AARP and they had a copay now she’s asking for a refund.
Do we now bill medicare instead then this program secondly?
Thank you!
Edward Gee
Human trafficking response program at Dignity Health
The problem of human trafficking has caught the attention of healthcare authorities like The Joint Commission, the National Association of Pediatric Nurse Practitioners, and the Centers for Disease Control and Prevention. All three have put out new resources and alerts on the problem, in addition to teaching providers how to respond to it.
New member resource for your compliance & ethics program
Hospice Quality Reporting Program Dec. 13: CMS
If you’re interested in improving your hospice’s quality reporting, the December 13 webinar, “Update to Public reporting in Fiscal Year 2019: Hospice Comprehensive Assessment Measure and Data Correction Deadlines” is just right for you. Hospice Webinar The Centers for Medicare & Medicaid Services (CMS) will host the two-part webinar covering two different topics for hospice […]
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Claims for Medicare Diabetes Prevention Program services being denied
Has your CDI program shifted its focus for optimal PSI 15 performance?
Has your CDI program shifted its focus for optimal PSI 15 performance?
by Shannon Newell, RHIA, CCS, and AHIMA-approved ICD-10-CM/PCS trainer
The recent adoption of a refined version of the Patient Safety Indicator (PSI) 90 composite by the Agency forHealthcare Research and Quality (AHRQ) has a significant impact on what discharges are included in PSI 15 (Unrecognized Abdominopelvic Accidental Puncture Laceration Rate).
Your clinical documentation improvement (CDI) program has likely focused on this measure due to the well-established challenges associated with accurate reporting of procedure-related accidental puncture/lacerations. Given the changes to PSI 15, should your CDI team shift its focus to promote and support accurate data integrity for this measure? Let’s take a look.
A fundamental understanding of patient safety indicator measures
Optimal data integrity for PSIs requires that we have the appropriate clinical documentation and reported ICD-10 codes to accurately reflect the following:
- The numerator: The numerator for PSI 15, also called the "outcome of interest," reports the actual number of cases which experienced the accidental puncture/laceration.
- The denominator: The denominator for PSI 15, also called the "cohort," establishes the population which is screened to identify the outcome of interest.
- Risk adjustment: Denominator comorbidities, which have a statistically demonstrated impact on the likelihood of a patient incurring the patient safety event. The risk adjustment methodology establishes the expected number of discharges with the outcomes of interest.
The inputs above?numerator, denominator, risk adjustment?are used to calculate our observed over expected performance. CMS compares our performance to that reported by other hospitals, and our reimbursement may be then impacted if we do not appear to manage patients well.
For example, in the Hospital Acquired Condition Reduction program, if our performance for PSI 90 does not meet established thresholds, then our Medicare fee-for-service reimbursement is reduced by 1% the next CMS fiscal year (October 1?September 30) for every claim we submit.
The new PSI 15?what counts?
The revised measure specifications for PSI 15 have altered the numerator (outcome of interest). The denominator, or cohort?which represents the population at risk?has also undergone a noteworthy change).
The revised numerator and denominator greatly narrow the pool of discharges screened for accidental punctures or lacerations as well as those flagged with outcomes of interest.
From a CDI perspective, the likelihood of incorrectly reporting accidental puncture or laceration for the discharges included in the newly defined measure is greatly diminished.
PSI 15: Are you focused on risk adjustment?
Given that our performance for PSI 15 is assessed using our observed over expected rate of procedure related accidental puncture or lacerations, the CDI team’s focus may be better spent on strengthening the capture of comorbidities relevant to risk adjustment.
The AHRQ risk adjustment methodology looks for multiple comorbidities to calculate the predicted likelihood of accidental punctures/lacerations for each discharge.
The revision to the discharges included in the narrowed cohort has also impacted which comorbidities affect risk adjustment. This makes sense given that these comorbidities must be clinically relevant to the numerator and denominator. The number of comorbid categories has been reduced from 13 to 11. Some of the categories remain the same, some have been deleted, and new ones have been added.
Summary
Keeping abreast of revisions to claims-based measures is an expanded responsibility for today’s CDI program. These measures impact both reimbursement and quality profiles. Positioned with this information, the CDI program can then shift efforts to promote and support clinical documentation capture and accurate reporting of codes associated with areas of the greatest vulnerability and impact.
Editor’s note:
Newell is the director of CDI quality initiatives for Enjoin. 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 author and do not represent HCPro or ACDIS.