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Coding Clinic – 4th Quarter 2018- Key Highlights

Coding Clinic 4th Quarter 2018 had an extensive question and answer section seeking to clear up any confusion regarding BMI coding. Much of the information was a reiteration of what has already been published in prior Coding Clinic issues and the Official Guidelines for Coding and Reporting. Below is a...

Proposed Model to Drive Down Prescription Drug Costs – the potential impact on providers and hospital billing

A recent proposal from the Department of Health and Human Services (HHS) is aimed at reducing prescription drug costs paid under Medicare Part B.  The proposed pricing model would gradually shift Part B payments for delineated outpatient drugs to international prices in late 2019/early 2020, starting with providers in randomly...

AHA Coding Clinic 3rd Quarter 2018 – Key Highlights

Below are highlights from Coding Clinic 3rd Quarter 2018 (effective with discharges starting September 24th). Diabetes with necrotic pressure ulcer, diabetic peripheral vascular disease and neuropathy   If a provider documents an association between diabetes and a pressure ulcer due to gangrene, the principal diagnosis is gangrene The “code first”...

AHA Coding Clinic 2nd Quarter 2018 – Key Highlights

Coding Clinic 2nd Quarter 2018 (effective with discharges starting June 6th) Below are highlights from the latest release: Diabetes Combination Codes – Not Elsewhere Classified (NEC) As previously noted in Coding Clinic, 2nd Quarter 2016: Page 36, The subterm “with” in the Index should be interpreted as a link between...

Protect Revenue Through Proactive Compliance Audits

Over the past six months, in our own client work and published settlements, it is evident that the Department of Justice (“DOJ”) is continuing to focus its audit efforts on patient status.  Most recently, a Houston-based health system agreed to pay $1.9 million to resolve allegations that three of its...

AHA Coding Clinic 1st Quarter 2018 – Key Highlights

Coding Clinic 1st Quarter 2018 (effective with discharges starting February 18) unsurprisingly did not include any significant changes since the previous Coding Clinic release was more extensive. It is a good sign that many of the controversial and pressing issues like COPD with pneumonia sequencing has been addressed and now...

Telehealth Services – Proactively Assess Your Risk

In a recent review of telehealth services, the Office of Inspector General (OIG) found approximately one-third (31/100) of the claims reviewed did not meet Medicare telehealth requirements.  Of the 31 cases, the majority were noncompliant because the patients received care in a location not considered “rural.”  Institutions/facilities that provide telehealth...

March Regulatory Updates

Review of Statistical Sampling Methods: Pursuant to the regular updates to the Office of Inspector General Work Plan, the Centers for Medicare & Medicaid Services (CMS) is assessing statistical sampling methods used within the Medicare fee-for-service administrative appeal process.  Specifically, CMS is reviewing if the Medicare Administrative Contractors and Qualified...

Is Your Organization a Potential Target for OIG Compliance Review?

As part of a series of hospital compliance reviews, the Office of Inspector General (“OIG”) identifies target hospitals, reviews a probe sample of cases in identified risk areas and determines compliance with Medicare billing requirements. Recent results? Two major hospital systems being asked to pay back large sums of money...

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