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Are You Ready to Manage a Remote Workforce?

Know how to best face the challenges brought on by working from home. How times have changed. In the 1950s, working from home was primarily what women did, which those days typically included housework, raising children, cooking, and gardening. Fast forward 50 years and we saw a significant increase in women in the workforce. Fast […]

The post Are You Ready to Manage a Remote Workforce? appeared first on AAPC Knowledge Center.

AAPC Knowledge Center

Are You Ready for the Big E/M Overhaul?  

The clock is ticking on 2021. Yes, we know that it’s not 2020 yet. But a year from now, the way you code evaluation and management (E/M) office visits is going to change completely. For starters, you will be selecting visit levels based only on time or medical decision making (MDM). There’s a lot to […]

The post Are You Ready for the Big E/M Overhaul?   appeared first on AAPC Knowledge Center.

AAPC Knowledge Center

AAPC Certified experienced coder READY TO JOIN YOUR TEAM!

SHEELA SHIVRAMAN
11322 Wishing Well Lane, Clermont FL 34711
248-787-3942 • [email protected]

PROFESSIONAL SUMMARY
AAPC trained CPC Certified. Hard working and fully certified and two years of experience. Medical Coding Specialist has a full understanding of ICD-10-CM and CPT coding procedures. Fully proficient with
medical terms and procedures.
CORE QUALIFICATIONS
 Strong understanding of ICD-10-CM and CPT codes
 Extensive knowledge of medical terminology across a broad range of medical practice areas
 Excellent data entry skills
 Good multi-tasking abilities
 Good interpersonal skills and the ability to function as a team member
 Experience with fast-paced medical care environments
PROFESSIONAL EXPERIENCE
Synapse Neurology, Clermont, FL 2014 – 2019
Medical Office Coordinator
 Worked in a fast-paced medical office and reviewed patient charts and assign diagnosis codes (ICD-10) for
insurance billing
 Utilized knowledge of CPT and ICD-10-CM to properly translate performed services into numerical code
for insurance billing
 Interpreted medical terminology and pharmacological information for translation into the coding system.
 Obtained authorizations for the EMG, EEG and Botox injections
 Resolved patient issues in regards to patient care satisfaction
 Reconciled patient records and invoices
ST. MARY MERCY HOSPITAL, Livonia, MI, 2005-2013
Certified Nuclear Medicine Technologist
 Successfully performed general and specialized Nuclear Medicine procedures while exercising initiative,
judgment, problem solving, and decision-making. Daily Cardiology/EKG systems experience.
 Gained proficiency in radiation safety, protection, regulations, JACHO, HIPPA, MQSA and ACR
guidelines.
 Proficient with medical applications, Radnet, Powerchart, HealthStream and McKesson PACS.
 Medical billing performed using ICD-9-CM codes, CPT codes, and HCPCS codes.
 Took the initiative to improve patient care and safety standards.
EDUCATION
AAPC Trained Certified Professional Coder, 2019
William Beaumont Hospital School of Nuclear Medicine Technology, Royal Oak, MI 2007
Associate Degree in Nuclear Medicine Technology, Oakland Community College, Southfield, MI 05/08
Bachelor of Science, National College, Bangalore, India 1993
References Available Upon Request

Attached Files

Medical Billing and Coding Forum

Ready CDI teams for CMS’ proposed expansion of mandatory ortho episode payment models

Ready CDI teams for CMS’ proposed expansion of mandatory ortho episode payment models

by Shannon Newell, RHIA, CCS, AHIMA-approved ICD-10-CM/PCS trainer

If your hospital resides in one of the 67 metropolitan statistical areas (MSA) required to participate in the Comprehensive Joint Replacement Model (CJR), you will also be required to participate in a new orthopedic payment model called SHFFT (surgical hip and femur fracture treatment) if an August 2 proposed rule is finalized. The impact? The following assigned MS-DRGs will no longer define hospital reimbursement:

  • Major Joint Replacement or Reattachment of Lower Extremity (MS-DRGs 469, 470)
  • Hip and Femur Procedures Except Major Joint (MS-DRGs 480, 481, 482)

 

MS-DRGs 469 and 470 are included in the CJR, which we have discussed in prior articles. Let’s take a look at the proposed SHFFT episode payment model (EPM), which involves the other three MS-DRGs, and see what role the CDI program can play as reimbursement shifts to episode-based payments.

Model overview

The episode of care defined for the SHFFT EPM begins with an admission to a participating hospital of a fee-for-service Medicare patient assigned MS-DRGs 480?482. This admission is referred to as the anchor hospitalization. The episode continues 90 days post-discharge from the hospital, and payments for all related Part A and Part B services are included in the episode payment bundle. CMS holds the hospital accountable for defined cost and quality outcomes during the episode and links reimbursement?which may consist of payment penalties and/or financial incentives?to outcome performance.

This is a mandatory EPM for hospitals already impacted by the CJR; the SHFFT model will apply to the same 67 geographic MSAs. The EPM is proposed to begin July 1, 2017, and will last for five years, ending in December 2021.

Cost outcomes

CMS will initially pay the hospital and all providers who bill for services during the episode using the usual fee-for-service models. Thus, the SHFFT EPM will not impact the revenue cycle at first. However, at the end of each performance period, which typically represents 12 months (January through December), CMS will compare or reconcile the actual costs with a preestablished "target price."

CMS will set target prices using an approach that will phase in a blended rate of hospital to regional costs. In recognition of the higher costs associated with discharges in MS-DRGs with an MCC or CC, CMS has developed an algorithm to adjust the target price for this subset of the patient population.

If the reconciliation process indicates that the costs to deliver services for the episode were higher than the target price, CMS will require repayment from the hospital. If, however, the costs to deliver care for the episode were lower than the target price, CMS will provide additional payments to the hospital for the provided services. To receive additional payments, however, performance for defined quality outcomes must meet or exceed established standards.

 

Quality-adjusted target price

To receive any earned financial incentives, the hospital must meet or exceed performance standards for established quality outcomes. CMS therefore adjusts the target price based on quality performance, referred to as the quality-adjusted target price.

The SHFFT EPM uses the exact same quality outcomes as those defined for the CJR:

  • Patient experience. This is the HCAHPS measure also used in the Hospital Value-Based Purchasing Program (HVBP). The source of information for this measures is the HCAHPS survey.
  • Patient-reported outcome data. As with the CJR, the hospital can collect and submit patient-reported data elements and at present will earn quality composite points for submitting the data. These data elements are collected both before and after the procedure and will be used by CMS to create a functional status measurement tool.
  • THA/TKA complication rates. This is the Hospital-Level Risk Standardized Complication Rate (RSCR) following the THA/TKA measure. This measure already impacts financial performance under the HVBP. Like the CJR, performance for this measure is weighted the heaviest in the quality composite comprising 50% of the composite score.

 

Hospital (accountable party), collaborators, and Advanced Payment Models

The hospital is held accountable for episode cost and quality outcomes and all associated financial risks/rewards, even though a variety of providers deliver services and impact performance. As with the CJR, the hospital has been designated as the accountable party because CMS believes the hospital is best positioned to influence coordinated, efficient delivery of services from the patient’s initial hospitalization through recovery.

CMS permits the hospital to enter into collaborative arrangements with physicians and other providers to support and redesign care delivery across the episode and to share financial gains and/or losses. The proposed rule expands the list of collaborators defined in the previous CJR final rule to include other hospitals and Medicare Shared Savings Program accountable care organizations.

The proposed rule also provides an Advanced Payment Model (APM) track for the EPMs, an important step that will further incentivize collaborator participation.

 

CDI program opportunities

There are five key ways that clinical documentation and reported codes across the continuum impact SHFFT performance:

  • Identification of patients included in the EPM. The assigned MS-DRG impacts which discharges are included in the cohort. As one example, consider a patient who would fall into the EPM (MS-DRGs 480?482) unless he or she has a bone biopsy. If reported, the bone biopsy would result in assignment of different MS-DRGs (477?479) and the discharge would not be included in the EPM.
  • Establishment of target costs. The capture of the MCC and/or CC impacts establishment of the episode target price.
  • Determination of related costs. The costs for hospital readmissions within the episode are included in episode costs if the readmissions are related. The assigned MS-DRG for the readmission determines whether the readmission is related.

The costs associated with Part B claims are included in episode costs if the services are related. The primary diagnosis for each visit determines whether the visit is related.

  • Reported complications. Assignment of ICD codes for the following conditions are counted as complications when those conditions result in inpatient readmission:
  • Complication risk adjustment. As with other hospital-centric measures such as risk-adjusted readmission and mortality rates, comorbidities reported for the 12 months prior to the anchor hospitalization are used to assess case-mix complexity. The CMS risk adjustment module uses defined comorbidity categories to identify conditions that impacted predicted rates of complications for the THA/TKA cohort.

The capture of at least one condition for each of the 28 comorbid categories over the 12-month period will strengthen risk adjustment and RSCR performance. RSCR performance contributes to 50% of the quality composite score, which, in turn, impacts the quality-adjusted target price.

 

Summary

Together the CJR and SHFFT models cover all surgical treatment options (hip arthroplasty and fixation) for Medicare beneficiaries with hip fractures. These MS-DRGs typically represent one of the largest inpatient surgical volumes for most short-term acute care hospitals.

As hospitals and collaborators assess and refine the management of patients to achieve or exceed the quality-adjusted target price, the data we submit on claims will be used to assess our performance. The CDI program in the inpatient and ambulatory setting must be positioned to promote and support the capture and reporting of impactful documentation.

Additional information on the proposed rule can be located at https://innovation.cms.gov/initiatives/epm.

 

Editor’s note

Newell is the director of CDI quality initiatives for Enjoin. Her team provides CDI programs with education, infrastructure design, and audits to successfully and sustainably address the transition to value-based payments. She has extensive operational and consulting expertise in coding and clinical documentation improvement, case management, and health information management. You can reach Newell at 704-931-8537 or [email protected].

HCPro.com – Briefings on Coding Compliance Strategies

Ready CDI teams for CMS’ proposed expansion of mandatory ortho episode payment models

Ready CDI teams for CMS’ proposed expansion of mandatory ortho episode payment models

by Shannon Newell, RHIA, CCS, an AHIMA-approved ICD-10-CM/PCS trainer

If your hospital resides in one of the 67 metropolitan statistical areas (MSA) required to participate in the Comprehensive Joint Replacement Model (CJR), you will also be required to participate in a new orthopedic payment model called ‘SHFFT’ (surgical hip and femur fracture treatment) if an August 2 proposed rule is finalized. The impact? The following assigned MS-DRGs will no longer define hospital reimbursement:

  • Major Joint Replacement or Reattachment of Lower Extremity (MS-DRGs 469, 470)
  • Hip and Femur Procedures Except Major Joint (MS-DRGs 480, 481, 482)

 

MS-DRGs 469 and 470 are included in the CJR, which we have discussed in prior articles. Let’s take a look at the proposed SHFFT episode payment model (EPM), which involves the other three MS-DRGs, and see what role the CDI program can play as reimbursement shifts to episode-based payments.

Model overview

The episode of care defined for the SHFFT EPM begins with an admission to a participating hospital of a fee-for-service Medicare patient assigned MS-DRGs 480?482. This admission is referred to as the anchor hospitalization. The episode continues 90 days post-discharge from the hospital, and payments for all related Part A and Part B services are included in the episode payment bundle. CMS holds the hospital accountable for defined cost and quality outcomes during the episode and links reimbursement?which may consist of payment penalties and/or financial incentives?to outcome performance.

This is a mandatory EPM for hospitals already impacted by the CJR; the SHFFT model will apply to the same 67 geographic MSAs. The EPM is proposed to begin July 1, 2017, and will last for five years, ending in December 2021.

 

Cost outcomes

CMS will initially pay the hospital and all providers who bill for services during the episode using the usual fee-for-service models. Thus, the SHFFT EPM will not impact the revenue cycle at first. However, at the end of each performance period, which typically represents 12 months (January through December), CMS will compare or reconcile the actual costs with a preestablished ‘target price.’

CMS will set target prices using an approach that will phase in a blended rate of hospital to regional costs. In recognition of the higher costs associated with discharges in MS-DRGs with an MCC or CC, CMS has developed an algorithm to adjust the target price for this subset of the patient population.

If the reconciliation process indicates that the costs to deliver services for the episode were higher than the target price, CMS will require repayment from the hospital. If, however, the costs to deliver care for the episode were lower than the target price, CMS will provide additional payments to the hospital for the provided services. To receive additional payments, however, performance for defined quality outcomes must meet or exceed established standards.

Quality-adjusted target price

To receive any earned financial incentives, the hospital must meet or exceed performance standards for established quality outcomes. CMS therefore adjusts the target price based on quality performance, referred to as the quality-adjusted target price.

The SHFFT EPM uses the exact same quality outcomes as those defined for the CJR:

  • Patient experience. This is the HCAHPS measure also used in the Hospital Value-Based Purchasing Program (HVBP). The source of information for this measure is the HCAHPS survey.
  • Patient-reported outcome data. As with the CJR, the hospital can collect and submit patient-reported data elements and at present will earn quality composite points for submitting the data. These data elements are collected both before and after the procedure and will be used by CMS to create a functional status measurement tool.
  • THA/TKA complication rates. This is the Hospital-Level Risk Standardized Complication Rate (RSCR) following the THA/TKA measure. This measure already impacts financial performance under the HVBP. Like the CJR, performance for this measure is weighted the heaviest in the quality composite comprising 50% of the composite score.

 

Hospital (accountable party), collaborators, and Advanced Payment Models

The hospital is held accountable for episode cost and quality outcomes and all associated financial risks/rewards, even though a variety of providers deliver services and impact performance. As with the CJR, the hospital has been designated as the accountable party because CMS believes the hospital is best positioned to influence coordinated, efficient delivery of services from the patient’s initial hospitalization through recovery.

CMS permits the hospital to enter into collaborative arrangements with physicians and other providers to support and redesign care delivery across the episode and to share financial gains and/or losses. The proposed rule expands the list of collaborators defined in the previous CJR final rule to include other hospitals and Medicare Shared Savings Program accountable care organizations.

The proposed rule also provides an Advanced Payment Model (APM) track for the EPMs, an important step that will further incentivize collaborator participation.

 

CDI program opportunities

There are five key ways that clinical documentation and reported codes across the continuum impact SHFFT performance:

  • Identification of patients included in the EPM. The assigned MS-DRG impacts which discharges are included in the cohort. As one example, consider a patient who would fall into the EPM (MS-DRGs 480?482) unless he or she has a bone biopsy. If reported, the bone biopsy would result in assignment of different MS-DRGs (477?479) and the discharge would not be included in the EPM.
  • Establishment of target costs. The capture of the MCC and/or CC impacts establishment of the episode target price.
  • Determination of related costs. The costs for hospital readmissions within the episode are included in episode costs if the readmissions are related. The assigned MS-DRG for the readmission determines whether the readmission is related.

The costs associated with Part B claims are included in episode costs if the services are related. The primary diagnosis for each visit determines whether the visit is related.

  • Reported complications. Assignment of ICD codes for the following conditions are counted as complications when those conditions result in inpatient readmission:
  • Complication risk adjustment. As with other hospital-centric measures such as risk-adjusted readmission and mortality rates, comorbidities reported for the 12 months prior to the anchor hospitalization are used to assess case-mix complexity. The CMS risk adjustment module uses defined comorbidity categories to identify conditions that impacted predicted rates of complications for the THA/TKA cohort.

The capture of at least one condition for each of the 28 comorbid categories over the 12-month period will strengthen risk adjustment and RSCR performance. RSCR performance contributes to 50% of the quality composite score, which, in turn, impacts the quality-adjusted target price.

 

Summary

Together the CJR and SHFFT models cover all surgical treatment options (hip arthroplasty and fixation) for Medicare beneficiaries with hip fractures. These MS-DRGs typically represent one of the largest inpatient surgical volumes for most short-term acute care hospitals.

As hospitals and collaborators assess and refine the management of patients to achieve or exceed the quality-adjusted target price, the data we submit on claims will be used to assess our performance. The CDI program in the inpatient and ambulatory setting must be positioned to promote and support the capture and reporting of impactful documentation.

Additional information on the proposed rule can be located at https://innovation.cms.gov/initiatives/epm.

 

 

Editor’s note

Newell is the director of CDI quality initiatives for Enjoin. Her team provides CDI programs with education, infrastructure design, and audits to successfully and sustainably address the transition to value-based payments. She has extensive operational and consulting expertise in coding and clinical documentation improvement, case management, and health information management. You can reach Newell at 704-931-8537 or [email protected].

HCPro.com – HIM Briefings

Getting ready for MOON

Getting ready for MOON

Learning objective

At the completion of this educational activity, the learner will be able to:

  • Identify challenges related to implementing the Medicare Outpatient Observation Notice (MOON) and the Notice of Observation Treatment and Implication for Care Eligibility (NOTICE) Act.

 

When CMS decided to postpone the MOON notification requirement a few days before the scheduled implementation date of August 6, it provided a welcome reprieve for many hospital staff members who were scrambling to get ready (see related story on p. 1).

"We were almost ready to go, however, plans are actually now on hold until the final draft is approved, in probably January," says Frantzie Firmin, MS, RN, director, utilization management and care coordination of Brigham & Women’s Hospital in Boston.

The hospital’s preparations included development of a process to deliver the notification to patients who needed it.

"Our organization, Partners Healthcare System, has decided to address the MOON implementation systemwide. As a result, we set up a case management expert panel, which is a collaborative practice committee that meets regularly to address and develop a plan that will ensure regulatory compliance across the system," she says.

The group worked with the electronic medical system team to develop an automated workflow directly within the system. "Each hospital has its own work queue set up," says Firmin. "The Medicare patients in the work queue are only those in observation status that have been there 12 hours or more."

Care coordinators and insurance support nurses have access to the work queue, which allows them to identify their observation patients. "Furthermore, we have also added functionality in [our electronic system] to document that the notice has been given," she says. Staff members are able to check off the status and date of receipt for each patient, and then the patient’s name moves out of the work queue.

The system also allows the insurance support nurse or care coordinator to print the form and provide a copy to the patient before discharge.

Other organizations had taken similar steps.

RWJ Barnabas Health in Toms River, New Jersey, also formed a small task force to ensure compliance with MOON, says Shawna Grossman Kates, MSW, MBA, LSW, CMA, the organization’s case and bed management director. But while MOON is new to them, this type of observation notification requirement is not. New Jersey hospitals have already been subject to an even more restrictive patient notification requirement for several years, she says.

Hospitals in New Jersey must issue a letter to patients detailing their status at the time of placement.

Sometimes that’s difficult to do. It requires different portals because notifications may affect everyone, from the elderly adult coming in through the ER to pediatrics observation patients or labor and delivery observation patients.

"To some degree, the emphasis on MOON has instigated a renewed attention to make sure we’re in compliance with the state of New Jersey’s regulations and that we have continuity and standard practices on a systemwide basis," she says.

Massachusetts General Hospital in Boston has come up with a workflow for how the form will be delivered and a communication plan to deliver it, says Nancy Sullivan, MBA, CMAC, executive director of case management at the organization.

But like other organizations, plans at Massachusetts General Hospital are on hold as CMS prepares the final version of the new MOON form.

Part of the hospital’s initial plan to comply with MOON prior to the postponement was to print a daily report that listed the patients who would need the notice and to use case management resource specialist staff members, who provide support to case managers, to deliver the notification. The hospital worked with staff members to develop a training script.

 

A challenging requirement

While case management experts agree that notifying patients and giving them information about their status is the right thing to do, there are significant challenges they are trying to work past to make the notification a reality.

For example, CMS’ new proposed form, says Kates, is not written in simple language that is easy for most patients to understand. "The Medicare MOON document is not third-grade reading level language," she says. This means that unless CMS makes changes to the form before finalizing it, there will be an additional burden on staff members delivering the notification to clearly explain it to patients. Many organizations will likely need to come up with simpler materials to augment the form to help patients understand the complex subject matter.

Organizations are not permitted to modify the finalized version of the MOON form. "But many are coming up with a one-page handout or an FAQ, or adapting their state hospital association FAQ on observation documents," says Kates.

While CMS estimates the notification process would take about 15 minutes per patient, says Sullivan, it’s likely to take much more staff time due to the complexity of the material.

"The kinds of topics that they plan to include in the letter are complicated," she says.

The challenging nature of these discussions was reinforced by a recent conversation Sullivan had with an elderly family member whose husband was admitted to the hospital.

The woman had called Sullivan in hopes of having her explain all the hospital jargon and insurance-speak. Trying to explain the billing nuances involved in skilled nursing facilities and Medicare Advantage is no easy task, says Sullivan?particularly if the family is in the midst of a medical crisis.

"I feel like the patient should know what their financial responsibilities will be, I support the concept," she says. But at the same time she says she also understands the real challenges hospital staff members involved in delivering that information will face.

Another factor complicating the notification is that it’s unclear how many languages the document will be available in. At Massachusetts General Hospital, patients speak a multitude of languages so the hospital will likely need translation services when delivering the written and verbal notices.

A third challenge is having a system in place to ensure all the patients who need notifications, get them.

"The biggest implementation challenge will be to ensure we have a mechanism in place to capture all the patients that have been in observation across the hospital," says Firmin. "Although we have a dedicated observation unit, we often have observation patients overflowing across the hospital."

In order for the notification process to be successful, staff members?including nursing staff?should be engaged in the process, says Sullivan. Ideally, nursing staff should have a working knowledge of these issues, particularly in the event a case manager isn’t available and a patient starts asking questions.

It remains to be seen what the final MOON form will look like. CMS opened a 30-day comment period on the MOON August 1 and has said that the rule will go into effect no more than 90 days from the finalization of the form.

Based on this timeline, Kates says she anticipates a January 1 start date, but that remains to be seen.

In the meantime, organizations will be waiting to see the final result of this process, and from there determining how to comply.

HCPro.com – Case Management Monthly