UnitedHealth Group, Inc. vs. the United States of America: The case for CDI

ACDIS Director Brian D. Murphy

Part 3 (to read part 1, click here. To read part 2, click here.)

By Brian D. Murphy

In part 1 of this series, I introduced the developing story of UnitedHealth Group, Inc. vs. the United States of America. In part 2, I detailed the facts of the case. Part 3 looks at the regulations and commentary regarding claims submission to Medicare Advantage and the ramifications for CDI.

Section III of the complaint United States of American ex rel. Benjamin Poehling, explains the payment methodology which UnitedHealth Group, Inc. allegedly manipulated for financial gain. The Medicare program pays Medicare Advantage (MA) organizations a pre-determined monthly amount for each Medicare beneficiary in the plan. The payment amount for each beneficiary is based on their particular risk adjustment factor (RAF) score, which among other factors including the beneficiary’s demographics is impacted by assigned Hierarchical Condition Categories (HCC). [more]

Outpatient CDI Workshop: Join us for five weeks of education and networking

Join us tomorrow as we kick-off the Outpatient CDI Workshop!

Due to the overwhelming success of our first ever ACDIS Symposium: Outpatient CDI, ACDIS has responded with a one-of-a-kind multimedia platform to keep the education, networking, and development going—right from your home office.

The Outpatient CDI Workshop features a broad sampling of the presentations delivered at the ACDIS Symposium in an easy-to-access online format. Participants in the Workshop will also enjoy facilitated collaboration with their peers and event presenters.

Take part in an ideas lightning round with the ability to send questions to presenters, enjoy conversation with your fellow attendees through an email discussion group, and participate in a live networking and problem-solving call with workshop participants and moderators. Get your outpatient CDI program off the ground with help from your peers and the experts at ACDIS! [more]

Note from the instructor: Reminiscing over 10 years in CDI

Sharme Brodie, RN, CCDS

By Sharme Brodie, RN, CCDS

One of the wonderful things that time allows us is the ability to look back with an experienced eye and either learn from the past or at the very least have some fun with it.

I remember my first weeks as a CDI specialist as if it just happened. It was a  grueling hiring process and I was thrilled to have gotten the job. Looking back, I have no idea why I thought this would be a good step in my career. None of us knew at that time what we were doing and we had no idea what to expect from this new profession. [more]

Q&A: Coding mixed cardiogenic and septic shock

Have CDI questions?

Q: If the attending documented, “likely mixed cardiogenic and septic shock,” can I assign codes R57.0 and R65.21?

A: Refer to the documentation within the code book. If you open the book to the R57 code grouping (Shock not elsewhere classified) listed below there is an Excludes1 note. Remember, Excludes 1 notes instruct us that we cannot use codes from this grouping with those listed within the Excludes 1 note. Cardiogenic shock (R57.2) falls within this grouping. Also listed is R65.2 septic shock. Purely relying on the coding conventions, I would conclude that we cannot code septic shock with cardiogenic shock. See the image below. [more]

Guest Post: New ICD-10-CM/PCS codes up the ante in coding compliance, part 3: Right heart failure

James S. Kennedy, MD, CCS, CDIP

by James S. Kennedy, MD, CCS, CDIP

Editor’s note: With the fiscal year 2018 ICD-10-CM/PCS codes released, Kennedy unpacked some of the compliance pitfalls and opportunities awaiting CDI and coding professionals when these new codes are implemented on October 1. Some of these issues may be addressed in the 2018 ICD-10-CM Official Guidelines for Coding and Reporting or the American Hospital Association’s Coding Clinic, Fourth Quarter, 2017, so be sure to compare Kennedy’s opinions with these documents. This article is part three in a three-part series. Click here to read parts one and two!

Right Heart Failure

Notice that we now have new codes for acute, chronic, and acute-on-chronic right heart failure. Remember also that Coding Clinic, Third Quarter, 2013, p. 33, states that the documented term of “decompensated” indicates that there has been a flare-up (acute phase) of a chronic condition. [more]

Note from the CCDS Coordinator: Happy birthday, ACDIS!

CCDS Coordinator Penny Richards

by Penny Richards

ACDIS and I are both celebrating our birthday this week. ACDIS is turning 10. I turned 10 a long time ago.

In 2007 (the year of ACDIS’ “birth”):

• Apple launched the iPhone
• Bob Barker appeared for the last time as host of “The Price is Right”
• “Harry Potter and Order of the Phoenix” debuted in theaters
• Helen Mirren won the Oscar for best actress for “The Queen”
• The Boston Red Sox swept the Colorado Rockies to take the World Series

In the year of my birth: [more]

Note from the Associate Director: Symposium lookback and a preview of things to come

Rebecca Hendren

By Rebecca Hendren

Two weeks ago we held our inaugural ACDIS Symposium: Outpatient CDI in the intimate setting of a suburban Chicago hotel. The hotel was surrounded by a beautiful golf course, where the first golden colors of autumn were beginning to emerge on the trees, and the setting made us feel somewhat cut off from the rest of the world as we spent two days discussing the new frontier in CDI.

We had sessions focused on practical issues, such as building compliant queries in the outpatient setting, and we had sessions from organizations that have established outpatient programs, where the speakers shared how they do it and their lessons learned along the way.

But the most fun parts were the times that we had open discussions. It was fascinating to hear everyone talking together and sharing ideas and thoughts. We all learned a lot and people made connections to lean on as they develop their outpatient programs. [more]

Guest Post: New ICD-10-CM/PCS codes up the ante in coding compliance, part 2: Pediatric Glasgow coma scales

James S. Kennedy, MD, CCS, CDIP

by James S. Kennedy, MD, CCS, CDIP

Editor’s note: With the fiscal year 2018 ICD-10-CM/PCS codes released, Kennedy unpacked some of the compliance pitfalls and opportunities awaiting CDI and coding professionals when these new codes are implemented on October 1. Some of these issues may be addressed in the 2018 ICD-10-CM Official Guidelines for Coding and Reporting or the American Hospital Association’s Coding Clinic, Fourth Quarter, 2017, so be sure to compare Kennedy’s opinions with these documents. This article is part two in a three-part series. Click here to read part one. Return to the blog next week to read part three!

Pediatric Glasgow coma scales

In what should have been a welcome change, the National Center for Health Statistics amended the ICD-10-CM Alphabetic Index to allow for reporting of the clinical descriptors of the pediatric Glasgow coma scale. Notice that in the best motor response section, “flexion to pain” gets three points in the clinical scale whereas “withdrawal from pain” gets four points. Now notice how ICD-10-CM manages these conditions in 2018: [more]

Note from the Instructor: Your 2018 IPPS Final Rule questions, answered

Allen Frady, RN-BSN, CCDS, CCS, CRC

By Allen Frady, RN-BSN, CCDS, CCS, CRC

Yesterday, 845+ codes took effect thanks to the fiscal year 2018 IPPS Final Rule, which was released at the beginning of August. As you review the updates, additions, and deletions in this year’s rule, I wanted to answer some of your burning questions to help guide you through this transition.

1.) Is it true that chronic obstructive pulmonary disease (COPD) does not have to be sequenced before pneumonia?

The Index for 2017 had the language “use additional code to identify infection.” This was misinterpreted as applying to conditions such as pneumonia by both coders using the index and the AHA’s Coding Clinic. “Use additional code” means that a subsequent diagnosis must be sequenced as a secondary code. However, “use additional code to identify infection,” usually means to assign an additional organism code from the organism code category of B95 to B97. [more]

Guest Post: Using coding, CDI to transform hospitals’ revenue integrity, part 2

Want to write for ACDIS? Send us your ideas!

by Amber Sterling, RN, BSN, CCDS, and Jana Armstrong, RHIA, CPC

Seven lessons learned in physician education

The following lessons were learned at KRMC and proved to be instrumental in improving communication between physicians, CDI staff, and coders: [more]