progresses in most of the country, I cannot help those of you with tans, great vitamin D parties. Here in the western North Carolina still putting on the fireplace in the mornflannel sheets with two blankets on that summer is passing us by this year and commenting about how weird and unusual the
fingers and hope that summer is just late later into the fall, but I can’t—my finwon’t bend that way. Sigh.
video that showed two AI chatbots other about what dinner would be that on so many levels, but I cannot help but future will bring. An article that just came about an AI chat company executive will be obsolete in three years, lamentyears old and wondering what her
went on to mention that a McKinsey study nearly 12 million U.S. workers may need to due to automation. 2030 is a lot closer feelings are mixed on this area as I see tasks that some could consider boring, monotonous, but at the same time, where will it rewatched The Terminator…) I have no know that the human mind, though fallible,
is an exquisite thing that has created the world as we know it and is capable of creating more extraordinary things both good and bad for us all. I suppose we’ll just have to wait and see what the future brings.
For the here and now, this issue brings an excellent range of articles for you to read on this topic with many familiar names and a couple of new ones.
I know you’ll enjoy reading all that their (human) experience brings you!
Until next time.
www.billing-coding.com
EXPERT Contributors this issue
AIHC Volunteer Education Committee. AIHC is a non-profit organization. We value our members, credentialed professionals, and greatly appreciate the talents offered by our member volunteers! aihc-assn.org
Nathaniel Arana is a nationally recognized healthcare business consultant and CEO of NGA Healthcare. NGA Healthcare works with practices to negotiate reimbursement rates and help physicians remain autonomous. Over the last 10 years, NGA Healthcare has negotiated millions of dollars back into physician pockets with the goal of supporting small to medium-sized physician practice groups. www.ngahealthcare.com
Audrey E. Coaxum, CHC, CPC, CEMC, CMC, CMIS, CMOM, CMCO, is an Instructor/Consultant with Practice Management Institute. She is an influential leader with more than twenty-five years of relevant experience involving many facets of healthcare operations. Audrey has a sterling reputation across the healthcare community as a customer-service oriented strategic problem solver and trusted advisor. www.pmimd.com
Sandy Coffta is Vice President of Client Services at Healthcare Administrative Partners. www.hapusa.com
Betty Hovey, CCS-P, CDIP, CPC, COC, CPMA, CPCD, CPB, CPC-I, is the Senior Consultant/Owner of Compliant Health Care Solutions, a medical consulting firm that provides compliant solutions to issues for all types of healthcare entities. Chcs.consulting
David Jakielo. Sign up for Dave’s FREE weekly success tips at www.Davespeaks.com.
Trevor McElhaney, JD, is the Associate Director of Consulting for Doctors Management. His focus areas include feasibility studies for potential ventures, practice startups, strategic planning for growth-stage practices, transactional advisory, and succession planning. His extensive knowledge and experience across primary care and specialty practices allow him to structure each engagement to the individual needs and goals of each client. www.doctorsmanagement.com
Sonal Patel, BA, CPMA, CPC, CMC, ICDCM, is CEO and Principal Strategist at SP Collaborative, LLC. www.spcollaborative.net
Rachel V. Rose, JD, MBA, is an Attorney at Law in Houston, TX. Rachel advises clients on healthcare, cybersecurity, securities law, and qui tam matters. She also teaches bioethics at Baylor College of Medicine. She has been consecutively named by Houstonia Magazine as a Top Lawyer (Healthcare) and to the National Women Trial Lawyer’s Top 25. She can be reached at rvrose@rvrose.com. www.rvrose. com
Erin Stephens, CPC, CIRCC, is Sr. Client Manager of Education at Healthcare Administrative Partners. www.hapusa.com
Ranadene (Randi) Tapio, MBA, CMRS, CCES, CS, CHM, CHBP, is the Owner/CEO of MedCycle Solutions based in St. Cloud, MN. www.medcyclesolutions.com
Effective Sept. 1, 2024, Blue Cross and Blue Shield of Illinois will update its Clinical Payment and Coding Policy for Evaluation and Management Coding (CPCP024).
Under this revised policy, BCBSIL will no longer reimburse for outpatient or inpatient consultation services billed with Current Procedural Terminology (CPT®) codes 99242-99245 and 9925299255. Consultation services should be reported with an appropriate office outpatient or inpatient evaluation and management code representing the location where the visit occurred and the level of complexity of the visit performed.
What do you need to do?
Refer to the AMA’s Clinical Payment and Coding Policies page to review in detail the revised policy: Evaluation and Management Coding CPCP024.
(CPT copyright 2023 American Medical Association. All rights reserved. CPT is a registered trademark of the AMA.)
Source: AMA – ama-assn.org
Shifting Toward Quality-Focused Healthcare
Tips and best practices for providers transitioning from fee-forservice to value-based care models like BPCI Advanced or TEAM.
Transitioning from a fee-for-service payment model to a value-based care model requires providers to adapt their practices, workflows, and mindset to succeed in a new healthcare environment.
Here are some tips for organizations preparing for this transition:
Understanding the Shift: Providers transitioning to value-based care models need to understand the fundamental differences between fee-for-service and value-based reimbursement. In feefor-service, payment is based on the volume of services provided, while in value-based care, payment is tied to quality, outcomes,
and efficiency.
Aligning Incentives: Providers should align incentives with value-based care goals to focus on delivering high-quality, cost-effective care. This may involve restructuring compensation models, performance bonuses, and quality incentives to reward outcomes and patient satisfaction rather than volume of services.
Care Coordination: Transitioning to value-based care requires strong care coordination among providers, specialists, and other healthcare stakeholders. Providers should establish care pathways, communication protocols, and collaborative workflows to ensure seamless care transitions and coordinated patient management.
Data Utilization: Providers need to leverage data analytics and performance metrics to monitor and improve care quality, outcomes, and cost efficiency. Utilizing data to identify trends, gaps in care, and opportunities for improvement is essential in value-based care models.
Patient Engagement: Engaging patients in their care and decision-making processes is crucial in value-based care. Providers should educate patients about their conditions, treatment options, and the importance of preventive care to empower them to actively participate in managing their health.
Quality Improvement: Implementing quality improvement initiatives and evidence-based practices can help providers enhance care quality, patient safety, and outcomes in a value-based care setting. Continuous monitoring, feedback, and performance improvement are key components of transitioning to value-based care.
Training and Education: Providers and staff should receive training and education on value-based care principles, care coordination strategies, and performance measurement techniques to successfully transition to value-based care. Continuous learning and skill development are essential in adapting to new care models.
Collaboration and Partnerships: Building collaborative relationships with other providers, payors, community organizations, and stakeholders can support providers in transitioning to value-based care. Partnerships can facilitate care coordination,
*** AHIMA Recertification Policy Updates ***
Starting January 2025
BC Advantage (Billing-Coding, Inc.) is a "AHIMA Featured CEU Provider", and through this partnership, BCA can provide you with 60% of your annual CEUs required for your AHIMA recertifications.
AHIMA recertification policy updates!
What’s Changed?
Key policy updates include:
• 40/60 Rule: Effective January 1, 2025, AHIMA will require that 40% of CEUs in a 2-year recertification period must come from AHIMA resources and/or Component Associations, with the remaining 60% of CEUs from AHIMA Approved Continuing Education Provider Program (ACEP) providers or other resources (changed from 80/20 requirement previously).
• 20% Rollover: Effective January 1, 2024, AHIMA will allow up to 20% of additional CEUs, earned from AHIMA, a Component Association, or an ACEP and aligned with a HIIM domain, beyond the minimum amount required within the last three months of a certified professional’s current recertification period to roll over into the next reporting period.
• Ways to Earn: Log in to your BC Advantage Magazine account, and access all the CEUs you need at no additional cost!
For additional details about recertification, visit: ahima.org/certification-careers/recertify/
resource sharing, and population health management initiatives. By following these tips and best practices, providers can navigate the transition to value-based care models successfully and drive improvements in care quality, patient outcomes, and cost efficiency.
North Carolina GOP Lawmakers Agree to Add a Health Exemption to a Bill That Limits Masking
Republican lawmakers in North Carolina struck a compromise on a bill that now maintains a health exemption for masking in public while preventing the use of masks during criminal activity, but only one chamber chose to vote on it in early June.
The state Senate passed the new masking bill—negotiated by both chambers to remedy concerns on the removal of a pandemic-era health exemption—in a 28-0 vote that Senate Democrats were absent from in protest. But after a canceled committee and a lengthy private discussion among House Republicans, the House did not take up an immediate vote, which stalls the bill’s passage to Democratic Gov. Roy Cooper.
Source: High Point Enterprise – hpenews.com
Practice Management Institute Forges New Partnership with Lamar State College to Bring Affordable Medical Practice Specific Training to Port Arthur and Jefferson County, TX
Practice Management Institute and Lamar State College Port Arthur have forged a partnership that will result in localized continuing educational courses for the region’s medical practice staff. Areas of concentration will be in patient experience, coding, billing, reimbursement, compliance, and the nationally recognized PMI certification tracks.
“There is an identified need for local in-person and online continuing education opportunities for area medical office teams,” stated Dr. Ben Stafford, Vice President of Workforce Training at LSCPA. “Aside from that availability, these courses address the need for an affordable alternative when it comes to continuing education in Southeast Texas.”
According to PMI, rules and regulations safeguarding the business of medicine are numerous and in constant flux, especially those
relating to reimbursement. “The partnership between PMI and LSCPA is meant to create ongoing educational opportunities that will improve training accessibility, which, in turn, leads to healthcare worker success and enhanced patient care.”
Training began in June with PMI’s “Medical Practice Front Desk Success: How to Shine on the Front Line and Patient Collections/ AR Management” session. Students learn the complete scope of operations in the medical front office with the instructor accentuating the quality of care on the front line as an important benchmark for the practice’s performance and success. In the Patient Collections and A/R Management session, which covers A/R as well as compliance and practice management efforts, students learn to improve insurance data collection, eligibility verification, and patient communication to reduce payment problems that can crush the bottom line of the medical practice.
For information on taking these continuing education courses, email the Workforce Training and Continuing Education department at workforce@lamarpa.edu, or contact counselor Donna Thomas at abramsdl@lamarpa.edu.
Source: Practice Management Institute – pmimd.com
HAP Team Members Selected to Serve on Multiple RBMA Committees for the 2024-2025 Year
Healthcare Administrative Partners (HAP), a leading provider of outsourced billing, coding, and practice management solutions for radiology practices, recently announced the appointment of several of its employees to committee positions within the Radiology Business Management Association (RBMA) for the 2024-2025 year. The RBMA is an industry-leading organization comprised of nearly 2,000 professionals who focus on the business of radiology.
The following five HAP team members will serve on their respective committees this year:
• Rebecca Farrington – Membership Committee
• Sandy Coffta – Data Collection & Reporting Committee
• Erin Stephens – Virtual Education Subcommittee
• Mark Walker – Payor Relations Committee
• Julia Turpin – Young Professionals Subcommittee
HAP is a long-time partner of the RBMA and engages with the association through national and regional tradeshow participation, speakerships, and article contributions, in addition to committee
service. According to Rebecca Farrington, “We are excited to once again support RBMA again this year through our committee membership. We are looking forward to advancing the business of radiology together.”
Semantic Health’s AI-Powered Auditing Software Will Supplement AAPC’s Suite of Business Solutions That Safeguard Against Revenue Cycle Errors
AAPC, a leading global solutions provider in healthcare revenue cycle management, is pleased to announce the successful acquisition of Semantic Health, an early-stage healthcare technology company focused on creating AI-powered inpatient medical auditing software for health insurance plans and hospitals.
“We are thrilled to integrate Semantic Health’s advanced technology and skilled AI team to AAPC,” said Bevan Erickson, AAPC’s CEO. “This acquisition is a leap forward in our mission to elevate the quality and efficiency of healthcare. We’re not just streamlining processes; we’re empowering professionals at the center of healthcare payment and delivery. By providing our members with the innovative tools now being developed by Semantic Health and AAPC in unison, we’re augmenting their capabilities and increasing the value they deliver their employers. This move keeps our 250,000 members on the forefront of healthcare’s digital transformation, ensuring they remain vital and effective in their current roles and future-proof their careers in this evolving industry.”
Based in Toronto, Semantic Health has made significant strides in streamlining manual auditing processes, reducing denials, and improving documentation quality for auditing teams.
“The world of health technology is advancing at a rapid pace with the rise of generative AI,” said Nicola Sahar, MD, Semantic Health’s President. “We’re excited to join forces with AAPC to accelerate our joint ability to deploy cutting-edge AI technology for auditing inpatient services. This will help us improve data quality, optimize revenue cycle management (RCM) efficiency, and unlock generative AI in healthcare.”
For more updates on AAPC’s innovative and state-of-the-art solutions serving the healthcare industry, visit AAPC.com/business.
Source: Semantic Health – semantichealth.ai
HHS Drastically Expands Mental Health/Substance Use Pilot Program
The Certified Community Behavioral Health Clinic (CCBHC) Medicaid Demonstration Program, a collaborative effort by the U.S. Department of Health and Human Services (HHS), Centers for Medicare & Medicaid Services (CMS), and Substance Abuse and Mental Health Services Administration (SAMHSA), has expanded significantly. Ten states—Alabama, Illinois, Indiana, Iowa, Kansas, Maine, New Hampshire, New Mexico, Rhode Island, and Vermont— have been added to the program after developing the necessary infrastructure and meeting CCBHC standards.
This expansion aims to address the nation’s mental health and substance use crisis by providing sustainable funding to improve access to services. The program requires participating clinics to offer a comprehensive range of services, including crisis services available 24/7, and prioritize care coordination and evidence-based practices.
The Bipartisan Safer Communities Act facilitated this expansion, allowing HHS to add 10 new states every two years. These states join eight others already enrolled in the program. The CCBHCs funded under Medicaid aim to transform mental health and substance use treatment by providing sustainable funding for community outpatient mental health treatment.
Statistics reveal a significant need for such services, with more than one in five U.S. adults living with a mental illness. However, there are disparities in treatment access, particularly among minority populations. The expansion of CCBHCs aims to address these issues by increasing access to crisis and behavioral healthcare, particularly in underserved populations.
The program provides reimbursement through Medicaid for the full cost of services provided by CCBHCs, aiming to offer a more comprehensive range of services without the fragmentation often driven by separate billing codes. Currently, there are over 500 CCBHCs operating across 46 states, the District of Columbia, and Puerto Rico, supported through SAMHSA’s CCBHC Expansion Grant program.
If you or someone you know needs help, resources such as the national 988 Suicide & Crisis Lifeline or FindSupport.gov are available.
Use Caution When Billing for Remote Radiology Reading
The ability to have radiologists work at locations remote from the patient exam site can be a great boon to efficiency and turnaround time. This practice has become more prevalent with the advent of faster network connections, and it has increased significantly since the COVID-19 pandemic when more people began working off-site. Compliant billing for remote reading services is not always as straightforward as normal on-site billing, and radiology practices must be aware of the requirements of each payor, most especially those of Medicare and other government programs.
Medicare Regulations
Medicare first issued its Place of Service (POS) reporting regulations with an effective date of April 1, 2013.
Those rules have been in effect for well over ten years, and radiology practices most likely are already familiar with their application. Here’s a quick summary:
• Service Facility Location (Payment Locality):
- The use of Global Billing depends on the location of the professional and technical component services, as well as the relationship between the parties.
- When professional and technical components are billed separately, the Service Facility Location should reflect where the service was actually provided. In the case of a radiologist, this would be where the interpretation was completed.
- The fee schedule to be used for payment will depend on the actual location of the services, based on zip code. The fee schedule for the professional component may be different from that of the technical component.
• Place of Service (POS) Coding: This generally follows the location where the patient’s exam took place, even if the interpretation was performed remotely by teleradiology.
Global vs. Split Billing
Global billing is used when the interpreting physician is a part of the same billing entity as the imaging center (either as an employee or under direct contract) and when the physician’s location while providing the interpretation is in the same payment locality. In this case, the address to be used is that of the imaging center alone, regardless of the physician’s location when providing the interpretation. However, if the interpre-
tation takes place in a different payment locality, split PC/TC billing (attaching modifier -26 for the PC) must be used with the location of each component reported separately. An unusual or infrequent location, such as a hotel or other vacation location, is not to be entered on claim forms; instead, the address of the physician’s most common practice location is to be used.
When the billing entity providing the Professional Component (PC) is different from the one providing the Technical Component (TC), e.g., in the case of hospital patients, the PC is billed separately using modifier -26. The location (address and zip code) where the interpreting physician performed the professional component services is reported.
See Table 1 for assistance with applying these rules.
Location of Physician (PC) Services
The physical address, including the zip code, where the radiologist provided the interpretation is to be entered on claims in Box 32 of CMS-1500. The address entered in Box 32 will determine the fee schedule to be used based upon the payment locality of the zip code. Practices located near the border of payment localities should be aware of the payment levels in each in order to avoid unintended lower payments or to take advantage of higher payment levels by using teleradiology strategically.
Many radiologists interpret images from their homes, and the home address will have to be reported whenever separate PC billing is required if the home is in a different payment locality than the imaging site. An unusual or infrequent location, such as a hotel or other vacation location, is not to be entered on claim forms; instead, the address of the physician’s most common practice location is to be used.
Place of Service Code Assignment
The Place of Service (POS) code should reflect the place where the patient “face-to-face” interaction occurred, regardless of where the reading was done. PC claims for hospital outpatient cases read by the radiologist from an imaging center would carry the POS code 22 for Outpatient Hospital because that is where the patient was seen, not code 11 for the radiologist’s location.
An exception to this rule is for inpatients of a hospital or other facility that might be transported to an imaging center for an exam. In this case, the patient exam would be code 21 (Inpatient Hospital), rather than code 11, for the office where the exam
actually took place. The same would apply for a registered hospital outpatient if services were provided elsewhere.
The POS code is to be entered in Box 24 of claim forms. The most common POS codes for radiology services are:
• 11 - Physician Office
• 21 - Inpatient Hospital
• 22 - Outpatient Hospital
• 23 - Emergency Department
• 24 - Ambulatory Surgery Center
The Medicare rules are contained in CMS Change Order #7631 and clarified in a Frequently Asked Questions document.
Scenarios Common in Today’s Practice
What has changed in recent years is the increased mobility of radiologists and the inadvertent failure to properly report their reading location. The radiologists may not realize the necessity to tell their billing staff about their reading location when it differs from their usual workplace.
The issue with billing arises when the radiologist is reading from a location that is in a different Medicare payment locality from their regular practice locality. Often the payment locality covers an entire state, but in some states, there is more than one locality. An example is New Jersey, where a practice in the northern part of the state might have a radiologist who lives in the southern part of the state and reads from their home. This can easily occur by traveling one town away from the practice’s main location!
A radiologist who does final reading offsite from the hospital or imaging center needs to understand these guidelines:
• If you are reading in a state other than the one in which the imaging facility is located, you must have a medical license in the state where you are reading.
• The practice must submit claims for Medicare patients in the payment locality where the final reading takes place. If you are reading from an off-premises site, be sure to let your billing team know so they can ascertain that the practice is registered with Medicare in your locality.
• There are a few caveats:
- If you do preliminary reading off-site and complete the final reading from the hospital or imaging center where the patient exam took place, these rules do not apply.
- If you are out of state temporarily (e.g., vacation), then the Medicare rules do not apply. You should still investigate the medical-legal aspect of state licensure in that circumstance.
Here are some examples using a hypothetical practice located in Massachusetts:
• You work and live in Massachusetts; you may read and create final reports from home.
• You work in Massachusetts but live in New Hampshire; you may create final reports from home if you have a New Hampshire license and notify the billing team of the reading address. You may create preliminary reports from home if the final is signed off from the hospital.
• You live and work in California reading exams done in Massachusetts; you must have a license in both California and Massachusetts and notify the billing team of your reading address.
• You work and live in Massachusetts but are on vacation in Cape Cod, MA; you may create final reports. There is no need to notify billing.
• You work and live in Massachusetts but are on vacation in Florida; you may create final reports but check on the legal aspect of licensure. There is no need to notify billing.
Some practice systems might automatically capture reading location, but in the end, it is the physician’s responsibility to notify the practice about their work location. Making them aware of these guidelines, especially as they relate to medical licensure,
will help to ensure that the practice is in full compliance.
Conclusion
The easy availability of remote shift to off-site work has renewed aware of the Medicare rules in order to be compliant. After-hours distant locations will produce than the one in effect at the cases, this can be used strategically a location with higher reimbursement to develop a system that allows location of the reading services, rules properly.
Table 1: See below
Sandy Coffta is Vice President Administrative Partners. In this responsible for achieving and sistently high retention and years of experience in client reimbursement analysis, workflow education. She specializes in development, is a subject matter billing, and has deep expertise contract issues. www.hapusa.com
Note: “Office” includes any location where the radiologist regularly works, which could include his or her home. “Imaging Center” includes a physician office or ASC setting. A vacation hotel or other temporary location should not be reported; the address of the radiologist’s regular work location should be reported in Box 32.
How to Prepare for the New HIPAA PHI Disclosure Guidelines
New HIPAA proposals are part of the final rule for regulations in 2024. As of this writing, only one provision has been listed in the Federal Register. The update is related to reproductive healthcare. The provision went into effect on June 25, 2024, but will not be enforced until January 1, 2025. Other proposed revisions are expected to be published in the Federal Register sometime in the second half of 2024.
Some revisions are expected to have a wider impact, and involve:
• Adding definitions and terms for the electronic health record (EHR)
• Amending the definition of healthcare operations
• Creating an exception to the minimal necessary standard
• Allowing patients to expect their protected health
information (PHI) in person and take notes and/or photographs
• Changing the maximum time to provide access to PHI from 30 days to 15 days
• Clarifying the form and format required for responding to individuals’ requests for their PHI
• Requiring covered entities to inform individuals that they retain their right to obtain their direct copies of PHI
• Reducing the identity verification burden on individuals exercising their rights
Requests by individuals to transfer ePHI to a third party will be limited. Individuals will be permitted to request that their PHI be transferred to a personal health application, specifying when individuals should be provided with ePHI at no cost.
HIPAA-covered entities will be required to inform individuals of their right to obtain or direct copies of their PHI to the third party when a summary of the PHI is offered instead of a copy. These entities will also be required to post estimated fee schedules on their website for PHI access, as well as disclosures that provide individualized estimates of the fees for providing the individual copies. Be aware of amendments to the permissible fee structure for responding to requests, and the pathway created for individuals to direct the sharing of PHI maintained in an EHR among covered entities.
Additional updates to HIPAA-covered entities include:
• Healthcare providers and health plans will be required to respond to certain record requests from other covered healthcare providers and healthcare plans.
• HIPAA-covered entities will be required to obtain written confirmation that a notice of privacy practices has been provided/dropped/not yet provided.
• There are modifications attending the content requirements of the non-physician practitioner to clarify the individual’s rights with respect to their PHI and how to exercise those rights.
• Covered entities will be allowed to disclose PHI to avert a threat to health or safety when harm is seriously and reasonably foreseeable.
• Covered entities will be permitted to make certain uses and disclosures of PHI based on their good faith belief that it is in the best interest of the individual.
• There is an addition of a minimum necessary standard exception for individual level care coordination and case management.
• The definition of healthcare operation has been broadened to include care coordination and case management.
• The armed services permission to use or disclose PHI to all uniformed services has been expanded.
• There are clarifications attending the scope of covered entities’ abilities to disclose PHI to social service agencies, community-based organizations, home and community-based service providers, and other third parties.
• The privacy standard that permits covered entities to make certain uses and disclosures of PHI based on their professional judgment is replaced.
• There are expressly stated permitting disclosures to telecommunications relay services, communication assistance for persons who are deaf, hard of hearing, blind, or who have a speech disability, as well as modifications to the definition of business associate to include the telecommunications relay services.
In November 2022, the Office of Civil Rights, in coordination with the Substance Abuse and Mental Health Services Administration (SAMHSA), issued a notice of proposed rulemaking to revise the confidentiality substance use disorder patient regulations, which are responsible for protecting the confidentiality of substance use disorder treatment records. Confidentiality protections help address the concerns of discrimination and fear of prosecution, which deter people from entering those substance use disorder treatments.
Part two protects records of the identity, diagnosis, prognosis, or treatment of any patient connected to the performance of any program. So, what we’re looking at under the CARES Act is to improve part two regulations by expanding the ability of healthcare providers to share records of individuals who are under the substance use disorder (SUD) programs but tightening the requirements
in the event of breach of confidentiality.
We’re looking at single consent for all future uses and disclosures of SUD records for treatment, payment, and healthcare operations allowed with repeated re-disclosure of SUD records in accordance with the HIPAA privacy rule. Patients will be able to obtain the accounting of disclosures of their SUD records and request restrictions on certain disclosures.
Lastly, we are looking at the expansion of prohibitions on the use and disclosure of SUD records and civil criminal administrative and legislative procedures. On April 12, 2023, the Office of Civil Rights issued a notice of proposed rulemaking to strengthen HIPAA privacy protections prohibiting the use and disclosure of PHI to investigate or prosecute patients, providers, and others involved in the provisions of legal reproductive care.
This particular portion was moved forward under the definition of reproductive healthcare and is expected to go into effect on June 25, 2024, with enforcement on January 1, 2025.
These changes impact billing records included in the definition of an electronic health record system; keep in mind that billing records will also need to be provided when an individual requests a copy of their records.
The Office of Civil Rights has been cracking down on violations of the HIPAA right of access when timely access to medical records is not being provided. So, if we’re going to go from 30 days of responding to a patient’s request down to 15 days, when this does occur, we must prepare for potential rule changes.
Healthcare organizations may be required to inform individuals about the privacy and security risk of sending their PHI to a third-party application that is not required to have safeguards mandated by HIPAA.
Medical offices will need to work through that part of the process, as patients will need to be allowed to inspect their PHI privately.
New HIPAA regulations may allow patients to inspect their PHI in person and take notes and photographs.
Care would need to be taken to ensure patients are not photographing excluded PHI or any other information that they are not authorized to photograph.
These elements have not been approved as of this writing, but we have to take into consideration how we will make this work
in our practices if/when it is updated in the Federal Register. Start planning now based on the what ifs. When that final rule does go into place, how are we going to strategically make that work in our practice?
Review and update policies and procedures and communicate those changes to your patients. You do not have to publicize the new effective date yet, but as you are reviewing your processes and planning things for the future, make sure that you are ready to expedite your policies and procedures when those rules are released. How might your workflows change? What kind of training material updates must be made? For example, requirements from HIPAA are updated so that the training materials, just like the policies and procedures, are updated.
If a patient comes into the office to review their own medical record information and they begin taking pictures or writing notes from their medical record information, how can you make that work logistically, as far as internal workflow process is concerned?
In conclusion, privacy and security for our medical practices should be a vital part of what you’re doing as far as your overall business operations are concerned. Conduct risk assessments and do whatever you need to do to mitigate your levels of exposure. Then, make the appropriate changes when updated requirements are released, train staff members on those new guidelines, and monitor your processes. This will help ensure HIPAA compliance readiness.
For more information, visit the Practice Management Institute (pmimd.com) to view the in-depth session (three hours), titled, “HIPAA Guidance for the Medical Practice.”
Disclaimer: Audrey Coaxum and Practice Management Institute assume no liability for the information contained herein, nor provide any expressed or implied warranty regarding the content of this article. Any opinions expressed or educational material supplied in conjunction with the same. Furthermore, this program does not constitute legal advice and should not be used as a substitute for seeking legal counsel.
Audrey E. Coaxum, CHC, CPC, CEMC, CMC, CMIS, CMOM, CMCO, is an Instructor/Consultant with Practice Management Institute. She is an influential leader with more than twenty-five years of relevant experience involving many facets of healthcare operations. Audrey has a sterling reputation across the healthcare community as a customer-service oriented strategic problem solver and trusted advisor. www.pmimd.com
Revenue Cycle Management Mastery
Created and taught by Revenue Cycle Management Thought Leaders Taya (Shawntea) Moheiser, EMBA, CMPE, CMOM, and Kem Tolliver, CMPE, CPC, CMOM
Authors of:
Revenue Cycle Management: Don't Get Lost In The Financial Maze Published by the Medical Group Management Association (MGMA)
This comprehensive training will help you achieve:
Higher payment approval rates
Faster receipt of payments
Reduction in claim denials
Practice Management
Empowering Healthcare Staff with Comprehensive Training
In the field of healthcare, the importance of a well-trained and skilled workforce cannot be overstated. As the backbone of medical practices, healthcare staff members hold the key to delivering quality patient care and ensuring smooth operations. Comprehensive training programs play a critical role in empowering healthcare staff, equipping them with the knowledge, skills, and confidence to excel in their roles. In this article, we will explore the significance of healthcare staff training and its impact on practice efficiency.
What Is the Value of Healthcare Staff Training?
Healthcare staff training goes beyond basic orientation and job shadowing. It encompasses ongoing education and development initiatives designed to enhance skills, update knowledge, and address emerging industry trends. Training programs provide staff with the tools and resources they need to perform their roles effectively, resulting in improved patient care, increased job satisfaction, and enhanced practice efficiency.
What Are the Benefits of Comprehensive Training?
• Enhanced Patient Care: Well-trained healthcare staff members possess the necessary knowledge and proficiency to deliver high-quality care to patients. Training programs focus on clinical skills, patient communication, empathy, and best practices, ensuring that staff members are equipped to handle a wide range of patient needs. Improved patient care leads to increased patient satisfaction and better health outcomes.
• Increased Efficiency: Comprehensive training programs impart operational knowledge and
workflows to healthcare staff, enabling them to navigate through complex administrative tasks and utilize technology effectively. Staff members are trained on time-saving techniques, optimizing processes such as appointment scheduling, medical billing, and electronic health records (EHR) management. This leads to streamlined operations, reduced bottlenecks, and improved practice efficiency.
• Consistency and Standardization: Training programs provide a standardized approach to tasks and procedures within a medical practice. This ensures that all staff members are equipped with the same knowledge and follow consistent protocols, resulting in a cohesive and efficient workflow. Consistency in processes helps minimize errors, reduces rework, and enhances overall practice productivity.
• Adaptation to Industry Changes: The healthcare industry is constantly evolving, with new regulations and advancements in technology. Comprehensive training programs keep healthcare staff updated on the latest industry changes, ensuring compliance with regulations and fostering a culture of continuous improvement. Staff members become proficient in utilizing new technologies, which can lead to improved patient outcomes and enhanced practice performance.
How Can Businesses Implement Comprehensive Training Programs?
To maximize the benefits of healthcare staff training, medical practices should consider the following key elements while developing their programs:
• Needs Assessment: Assess the specific training needs and skill gaps within the practice. This can be done through feedback surveys, performance evaluations, and staff discussions.
• Curriculum Development: Design a comprehensive curriculum that encompasses clinical skills, communication techniques, customer service, and practice-specific workflows.
• Multimodal Approach: Utilize a mix of training methods, such as classroom sessions, e-learning modules, role-playing exercises, and hands-on practical experiences. This ensures a well-rounded learning experience.
• Ongoing Evaluation: Continuously assess the effectiveness of training programs through staff feedback, performance metrics, and patient satisfaction surveys. Adjust programs as needed to address emerging needs and ensure sustained improvement.
Conclusion
Comprehensive training programs empower healthcare staff by providing them with the knowledge, skills, and confidence necessary to excel in their roles. By enhancing patient care, increasing practice efficiency, ensuring consistency, and promoting adaptability, these programs contribute to the overall success of medical practices. Investing in the comprehensive training of healthcare staff not only fuels continuous improvement but also enables practices to deliver exceptional care and build a positive reputation in today’s ever-evolving healthcare landscape.
Ranadene (Randi) Tapio, MBA, CMRS, CCES, CS, CHM, CHBP, is the Owner/CEO of MedCycle Solutions based in St. Cloud, MN.
Randi Tapio founded MedCycle Solutions, creating revenue cycle solutions for healthcare practices that will improve efficiencies, maximize reimbursements, and help clients get paid faster.
Randi is an experienced healthcare revenue cycle professional with more than 20 years of experience in various healthcare roles, including revenue cycle, administration, and consulting. As an experienced revenue consultant, she has a long history of cultivating strong working relationships with providers, ancillary staff, and healthcare executives. Randi concentrates her efforts in working with independent and hospital-based physician groups to improve revenue by increasing productivity and office efficiency, as well as billing and coding compliance. She has guided many practices, successfully streamlining their revenue cycle processes by working with clients to ensure accurate workflows are in place, adapting to the specific needs of each practice. In her own communities, Randi has been named to the “5 Under 40” list, has been the keynote speaker at local RHIT graduations, was named “Woman of the Year” by Beta Sigma Phi, and presented for local AAPC and AHIMA chapters.
If you’re looking to implement a comprehensive training program tailored to your practice’s needs, reach out to the MedCycle team of experts today. Empower your healthcare staff and unlock the full potential of your practice.
https://medcyclesolutions.com
Navigating the Impact of Private Equity on Healthcare for Physician Groups
As a society, we should all be concerned about the increasing rate at which private equity firms are acquiring physician groups. Over the last decade, private equity firms have invested nearly $1 trillion in approximately 8,000 healthcare deals, encompassing a wide spectrum of medical services, from fertility clinics to neonatal care, primary care to cardiology, hospices, and everything in between.
The consequence? Healthcare has shifted toward a profit-driven model where physicians have minimal influence on the treatment plans for their former patients. Instead, decisions are made by profit-focused administrators, neglecting patient outcomes. A tragic example is the case of Zion Gastelum in Yuma, Arizona. Two-year-old Zion Gastelum tragically passed away shortly after
undergoing root canals and crowns on six baby teeth at a clinic associated with a private equity firm.
His parents filed a lawsuit against the Kool Smiles dental clinic in Yuma, Arizona, and its private equity investor, FFL Partners. They alleged that these procedures were performed unnecessarily, driven by a corporate strategy to maximize profits by overtreating children from
lower-income families enrolled in Medicaid. Zion’s demise was attributed to “brain damage caused by a lack of oxygen,” per the lawsuit.
A recent investigation by Kaiser Health News has shed light on the detrimental impact of private equity in healthcare. As private equity delves deeper into the healthcare sector, mounting evidence suggests that this penetration has led to higher costs and reduced quality of care. Companies owned or managed by private equity firms have been obligated to pay fines exceeding $500 million since 2014 to settle at least 34 lawsuits under the False Claims Act, a federal law penalizing fraudulent billing submissions to the federal government. In most cases, private equity owners have managed to evade liability.
One might argue that physicians are to blame for selling their practices. In reality, health insurance payors have compelled physician groups to sell their practices due to inadequate reimbursement rates. Unlike other businesses, medical practices cannot simply raise their prices; they must negotiate with health insurance companies—a daunting task. The American Medical Association has revealed that the primary reason physicians sell their practices to any entity is the need for higher reimbursement rates to sustain financial viability. Isolated, they struggle to effectively negotiate these rates with insurers.
Private equity often portrays itself as a savior, luring physicians with promises of reduced workload, higher earnings, and improved work-life balance. However, physicians frequently encounter increased burnout, akin to employed hospital physicians. They are excluded from clinical decisions and referrals and are pressured to utilize unnecessary ancillary services. Most physicians ultimately leave after three to five years, which coincides with the typical length of these buyout contracts.
Many physicians also discover that the promised pay increases fail to materialize. Health insurance companies are aware that negotiating with private equity firms leaves them with limited leverage, leading to reluctance. Insurance companies understand that this consolidation can result in private equity dictating healthcare service prices, further dissuading negotiations. Consequently, physicians are left with practices they no longer own, corporate control over medicine, reduced clinical outcomes, and often, the same or lower pay than before they sold their practice. In this situation, the sole beneficiary is typically the private equity firm, aligning with their primary objective.
So, what can physician groups do? The most critical step is to regularly negotiate reimbursement rates. If you haven’t negotiated these rates in the last three years, you’re already facing a 15% or even higher deficit, depending on local inflation rates. Insurance payors count on these groups not to negotiate, using it as a cost-saving strategy while they increase premiums significantly beyond inflationary rates.
After initial rate negotiations, practices should review these rates annually and request yearly cost-of-living increases. This approach eliminates the need to fight for a 15% increase three years down the line, allowing for smaller raises over three years with less effort.
Insurance payors are becoming more discerning about private equity’s influence and are reevaluating their support for private practices. Some payors are increasingly willing to assist private practices and raise rates if the physician group is not backed by private equity. More insurance payors are demanding disclosures of ownership to determine if a practice has private equity involvement. While this development is promising, physician groups must still take the initiative to negotiate. The process has become challenging, and we encourage physician groups to seek the assistance of consultants or companies with expertise in this endeavor.
Private equity’s presence is undeniable and rapidly reshaping our healthcare landscape. Physician groups must respond effectively. Many physicians end up regretting selling to private equity once they witness the cutthroat business tactics employed by these companies—disrupting and profiting from an industry. Private equity’s primary aim is to maximize profits, not forge partnerships, even if it means sacrificing physician groups and the quality of care. As stakeholders in healthcare, physician groups and others must take a stand and adopt measures to safeguard against this corporate-owned healthcare approach.
Nathaniel Arana is a nationally recognized healthcare business consultant and CEO of NGA Healthcare. NGA Healthcare works with practices to negotiate reimbursement rates and help physicians remain autonomous. Over the last 10 years, NGA Healthcare has negotiated millions of dollars back into physician pockets with the goal of supporting small to medium-sized physician practice groups.
https://www.ngahealthcare.com
Coming Soon to a Federal Register Near You: Changes to the FTC’s Health Breach Notification Rule
On April 26, 2024, the Federal Trade Commission (FTC) announced changes to its Health Breach Notification Rule, 16 CFR Part 318 (HBNR). The effective date is 60 days after its publication in the Federal Register (https://www.ftc.gov/system/files/ftc_gov/pdf/hbnr_final_rule_04_25.pdf for the pre-publication version).
Initially promulgated as a result of the American Recovery and Reinvestment Act of 2009, Pub. L. 111-5 (2009), Section 13407 “created certain protections for ‘personal health records’ or ‘PHRs,’ electronic records of PHR identifiable health information on an individual that can be drawn from multiple sources and that are managed, shared, and controlled by or primarily for the individual.” Notably, the HBNR applies to per-
sons not under the umbrella of the Health Information Portability and Accountability Act of 1996, Pub. L. 104191 (1996) (HIPAA) and is broader in scope because it affects consumers’ PHR while HIPAA impacts patients protected health information. The initial HBNR (“2009 Final Rule”) was published in the Federal Register on August 25, 2009, and became effective February 22, 2010. 74 Fed. Reg. 42962 (Aug. 25, 2009) applied only to
breaches of unsecured health information and does not apply to covered entities or business associates as defined by HIPAA.
Although the HBNR has been in effect since February 2010, the FTC’s initial enforcement actions did not occur until 2023. The first enforcement action involved digital health company, GoodRx Holdings, Inc. (United States v. Good Rx Holdings, Inc., No. 23-cv460 [N.D. Cal. Feb. 17, 2023]). The second involved “Premom,” an ovulation tracking app developed by Easy Healthcare, Inc. (United States v. Easy Healthcare Corp., No. 1:23-cv-3107 [N.D. Ill. June 22, 2023]).
The purpose of this article is to highlight some of the key aspects of the changes to the HBNR, as consumer privacy and security, especially in relation to health records, will remain a top enforcement priority.
Highlights
In the FTC’s April 26, 2024, press release, “FTC Finalizes Changes to the Health Breach Notification Rule – Final Rule Underscores Its Application to Health Apps and Similar Technologies Not Covered by HIPAA” (https://www.ftc.gov/news-events/news/ press-releases/2024/04/ftc-finalizes-changes-health-breach-notification-rule), the FTC specifically highlighted the following items:
• Revising Definitions: The Commission revised several definitions to underscore the final rule’s application to health apps and similar technologies not covered by HIPAA. This includes modifying the definition of “PHR identifiable health information” and adding two new definitions for “covered healthcare provider” and “healthcare services or supplies.”
• Clarifying Breach of Security: It clarifies that a “breach of security” under the final rule includes an unauthorized acquisition of identifiable health information that occurs as a result of a data security breach or an unauthorized disclosure.
• Revising Definition of PHR Related Entity: The definition of “PHR related entity” has been revised in two ways that pertain to the rule’s scope. The revised definition makes clear
that the final rule covers entities that offer products and services through the online services, including mobile applications, of vendors of personal health records. It also makes clear that only entities that access or send unsecured PHR identifiable health information to a personal health record— rather than entities that access or send any information to a personal health record—qualify as PHR related entities.
• Clarifying Multiple Sources of PHR Identifiable Health Information: The final rule clarifies what it means for a personal health record to draw PHR identifiable health information from multiple sources.
• Expanding Use of Electronic Notification: The final rule authorizes the expanded use of email and other electronic means of providing clear and effective notice to consumers of a breach.
• Expanding Consumer Notice Content: The final rule expands the required content that must be provided in the notice to consumers. For example, the notice would be required to include the name or identity (or, where providing the full name or identity would pose a risk to individuals or the entity providing notice, a description) of any third parties that acquired unsecured PHR identifiable health information as a result of a breach of security.
• Changing Timing Requirement: The final rule modifies when the FTC must be notified under the rule. For breaches involving 500 or more individuals, covered entities must notify the FTC at the same time they send notices to affected individuals, which must occur without unreasonable delay and in no case later than 60 calendar days after the discovery of a breach of security.
• Improving Readability: The final rule also includes changes to improve the rule’s readability and promote compliance.
Table 1 provides specifics of the FTC’s aforementioned highlights.
See table 1
In order to make the verbiage digestible for consumers, 16 CFR 318(2)(c), “Clear and conspicuous means that notice is reasonably understandable and designed to call attention to the nature and significance of the information in the notice” (p. 96 of unpub-
Item
PHR Identifiable Health Information
Covered Healthcare Provider
New Language or Modifications
16 CFR 318.2(i) – Means information that (1) Relates to the past, present, or future physical or mental health or condition of an individual, the provision of healthcare to an individual, or the past, present, or future payment for the provision of healthcare to an individual; and (i) identifies the individual; or (ii) with respect to which there is a reasonable basis to believe that the information can be used to identify the individual; and (2) Is created or received by a: (i) covered healthcare provider; (ii) health plan (as defined in 42 U.S.C. 1320d(5)); (iii) employer; or (iv) healthcare clearinghouse (as defined in 42 U.S.C. 1320d(2)); and (3) With respect to an individual, includes information that is provided by or on behalf of the individual.
16 CFR 318.2(f) - Means a provider of services (as defined in 42 U.S.C. 1395x(u), a provider of medical or other health services (as defined in 42 U.S.C. 1395x(s)), or any other entity furnishing healthcare services or supplies (p. 98 of unpublished Final Rule). As stated in the Final Rule, “The Commission is modifying the proposed definition of ‘healthcare provider’ to ‘covered healthcare provider’ to distinguish that term from interpretations of the term ‘healthcare provider’ in other contexts, which may be more limited in scope. As commentators requested, the Commission affirms that its definition of ‘covered healthcare provider’ is unique to the Rule; it does not bear on the meaning of ‘healthcare provider’ as used in other regulations enforced by other government agencies” (p. 26 of unpublished Final Rule).
Healthcare Services or Supplies
16 CFR 318.2(e) - Means any online service such as a website, mobile application, or internet-connected device that provides mechanisms to track diseases, health conditions, diagnoses or diagnostic testing, treatment, medications, vital signs, symptoms, bodily functions, fitness, fertility, sexual health, sleep, mental health, genetic information, diet, or that provides other health-related services or tools (p. 98 of the unpublished Final Rule).
Third Party Service Provider 16 CFR 318.2(l) – Means an entity that: (1) Provides services to a vendor of personal health records in connection with the offering or maintenance of a personal health record or to a PHR related entity in connection with a product or service offered by that entity; and (2) Accesses, maintains, retains, modifies, records, stores, destroys, or otherwise holds, uses, or discloses unsecured PHR identifiable information as a result of such services.
Breach of Security 16 CFR 318.2(a) – Means, with respect to unsecured PHR identifiable health information of an individual in a personal health record, acquisition of such information without the authorization of the individual. Unauthorized acquisition will be presumed to include unauthorized access to unsecured PHR identifiable health information unless the vendor of personal health records, PHR related entity, or third party service provider that experienced the breach has reliable evidence showing that there has not been, or could not reasonably have been, unauthorized acquisition of such information. A breach of security includes an unauthorized acquisition of unsecured PHR identifiable health information in a personal health record that occurs as a result of a data breach or an unauthorized disclosure.
PHR Related Entity
Drawing PHR Identifiable
Information From Multiple Sources
16 CFR 318.2(j) – Means an entity, other than a HIPAA-covered entity or an entity to the extent that it engages in activities as a business of a HIPAA-covered entity, that: (1) Offers products or services through the website, including any online service, of a vendor of personal health records; (2) Offers products or services through the websites, including any online service, of HIPAA-covered entities that offer individuals personal health records; or (3) Accesses unsecured PHR identifiable health information in a personal health record or sends unsecured PHR identifiable health information to a personal health record (p. 100 of unpublished Final Rule).
Vendor of Personal Health Records
Expanding the Use of Electronic Notification of a Consumer Breach
Expanding Breach Notice Content
Reporting Requirement Change
16 CFR 318.2(j) – Means an entity, other than a HIPAA-covered entity or an entity to the extent that it engages in activities as a business associate of a HIPAA-covered entity, that offers or maintains a personal health record.
16 CFR 318(5) – This section is lengthy and needs to be parsed out.
16 CFR 318.3. This section is lengthy and relates to §318.4 (Timeliness of notification), §318.5 (Methods of notice), and §318.6 (Content of notice).
16 CFR § 318.4(a) In general. Except as provided in paragraph (d) of this section (Law enforcement exception), all notifications required under §318.3(a)(1) (required notice to individuals), § 318.3(b) (required notice by third party service providers), and § 318.3(a)(3) (required notice to media) shall be sent without unreasonable delay and in no case later than 60 calendar days after the discovery of a breach of security.
NOTE: For breaches of less than 500 individuals, “All logged notifications required under §318.5(c) (Notice to FTC) involving the unsecured PHR identifiable health information of fewer than 500 individuals may be sent annually to the Federal Trade Commission no later than 60 calendar days following the end of the calendar year.”
lished Final Rule). Section 318(2)(c) further elucidates in subsequent subsections what “reasonably understandable,” “designed to call attention,” and “notice” means.
Finally, for the purposes of this article, 16 CFR 318(2)(m), “unsecured” means PHR identifiable information that is not protected through the use of a technology or methodology specified by the Secretary of Health and Human Services in the guidance issued section 13402(h)(2) of the American Reinvestment and Recovery Act of 2009, 42 U.S.C. 17932(h)(2).
In light of these changes, any person who falls under the scope of the definitions mentioning supra should take immediate steps to assess its current compliance program, including training and policies and procedures, as well as outward facing language to consumers, consent language, and contractual language. Failing to do so may lead to increased fines and penalties by the FTC and other government agencies, who may become involved.
Conclusion
It has never been riskier to take a lackadaisical approach to privacy and security, especially in relation to individuals and their health information, as defined in either the HBNR or HIPAA. Appreciating the enhanced requirements now can save potential financial, legal, and reputational harm in the long run.
Rachel V. Rose, JD, MBA, has a unique background, having worked in many different facets of healthcare throughout her career including: work in acute care hospitals including the operating room and dietary department; consultative work as a top performing representative for the pharmaceutical and medical device industry; work for the Chairman of the Reform and Oversight Committee on Capitol Hill; intern at the Department of Health and Human Services; and compiling policy papers at the Royal College of Nursing in London. She has worked on Wall Street and at one of the Big Four consulting firms.
Coding Rules
of the Road for ICD-10-CM
Medical coding is a critical component of the healthcare industry, providing a standardized system for classifying diseases, diagnoses, and medical procedures. The adoption of the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10CM) has brought significant changes to medical coders. Whether you are new to coding or an experienced professional, mastering the rules of the road for ICD-10-CM is essential for accurate and efficient coding. Sometimes, new coding professionals receive onthe-job training and aren’t given the time to study the guidelines. And more experienced coding professionals sometimes fall into the trap of “I know how to code for XYZ” and don’t study the updates when they come out. In this article, some key principles and guidelines to help new and experienced coders navigate the complexities of ICD-10-CM will be addressed.
Understand the Structure of ICD-10-CM
Understanding the structure of ICD-10-CM codes is important for accurate coding.
Here’s a breakdown of each character:
• Character 1: Represents the category of the disease or condition.
• Characters 2 and 3: Further specify the etiology, anatomical site, severity, or other clinical details.
• Characters 4 to 6: Provide additional information regarding the cause, manifestation, or site.
• Character 7: Indicates the episode of care (initial, subsequent, or sequela).
Follow Official Coding Guidelines
The ICD-10-CM coding guidelines provide instructions and conventions that coding professionals must follow to ensure consistency and accuracy in coding. Understanding and adhering to these guidelines is fundamental for both new and experienced coders. The chapter-specific guidelines will be covered in future issues of BC Advantage. For this first article in the series, the guidelines from Section IV, Diagnostic Coding and Reporting Guidelines for Outpatient Services, will be reviewed, by section.
A. Selection of First-Listed Condition
In outpatient settings, the term “first-listed diagnosis” is used instead of “principal diagnosis.” The determination of the first-listed diagnosis is guided by the coding conventions of ICD-10-CM, as well as general and disease-specific guidelines, which take precedence over outpatient guidelines. Often, diagnoses are not immediately established during the initial encounter; it may require multiple visits for confirmation. The key rule is to initiate the code search using the Alphabetic Index, avoiding starting directly from the Tabular List to prevent coding errors.
1. Outpatient Surgery: For patients undergoing outpatient surgery (commonly known as same-day surgery), the reason for the surgery is coded as the first-listed diagnosis, irrespective of whether the surgery is performed due to a contraindication.
2. Observation Stay: When a patient is admitted for observation due to a medical condition, the code for that medical condition is assigned as the first-listed diagnosis. In scenarios where a patient initially presents for outpatient surgery but develops complications necessitating admission for observation, the reason for the surgery is coded as the first-listed diagnosis (reason for the encounter), followed by codes for the complications as secondary diagnoses.
B. Codes From A00.0 Through T88.9, Z00-Z99, U00-U85
When documenting diagnoses, symptoms, conditions, problems, complaints, or reasons for an encounter or visit in outpatient settings, utilize the appropriate codes from A00.0 through T88.9, Z00-Z99, and U00-U85. These codes provide a comprehensive framework for accurately identifying and recording various healthcare-related issues, ensuring thorough and standardized documentation.
C. Accurate Reporting of ICD-10-CM Diagnosis Codes
Precision in reporting ICD-10-CM diagnosis codes hinges on documentation that thoroughly describes the patient’s condition. This entails employing terminology that encompasses specific diagnoses, symptoms, problems, or reasons for the encounter. Fortunately, the ICD-10-CM coding system offers a comprehensive array of codes tailored to capture each facet of the patient’s healthcare status, ensuring thorough and accurate representation.
D. Codes That Describe Symptoms and Signs
When a definitive diagnosis has not yet been confirmed by the healthcare provider, it’s permissible to use codes that
CONSULTING SOLUTIONS
CHCS offers a variety of customized consulting solutions, depending on your specific needs.
• Compliance Program Evaluation, Denials Review, Payor Audit Rebuttal, General Office Practice Assessment, Shadowing Service
EDUCATION SOLUTIONS
Educational Services elevate your organization through targeted learning experiences that drive compliance, enhance coding accuracy, and improve overall operational efficiency.
Our comprehensive audit services are tailored to the unique demands of the health care sector.
• Audit Subrscription, One-Time Audit Service
CODING TOOLS
CHCS offers its suite of E/M coding tools designed to support your practice in achieving flawless coding outcomes. From robust physical tools to versatile digital solutions, we provide the resources your team needs to ensure accurate E/M service levels are consistently applied.
• Physical Coding Tools, Digital eTools
Betty A. Hovey is a seasoned healthcare professional with over three decades of experience in the field. She has extensive experience conducting audits for medical practices and payors. She specializes in educating various groups including coding professionals, auditors, doctors, APPs, payors, and others on coding, billing and related topics. Betty is a highly sought-after speaker and has co-authored manuals on ICD-10-CM, ICD-10-PCS, E/M, and various CPT specialty areas.
describe symptoms and signs for reporting purposes. For example, if a physician believes a patient has pneumonia due to fever, cough, and shortness of breath, he gives the patient an order for a chest X-ray to rule out pneumonia, which the patient goes over to the diagnostic center to have performed. For the E/M visit, pneumonia should not be coded. Rather, the fever, cough, and shortness of breath would be coded.
Chapter 18 of ICD-10-CM, Symptoms, Signs, and Abnormal Clinical and Laboratory Findings Not Elsewhere Classified (codes R00-R99), encompasses a wide range of codes specifically designed for this purpose. It’s important to note that while many symptoms are covered within this chapter, it may not encompass all potential symptoms. For example, back pain is coded to M54.9.
E. Encounters for Circumstances Other Than a Disease or Injury
ICD-10-CM offers a comprehensive set of codes to address encounters involving circumstances beyond diseases or injuries. The Factors Influencing Health Status and Contact with Health Services codes (Z00-Z99) are specifically designated to handle instances where diagnoses or issues recorded involve factors other than diseases or injuries like personal and family history of diseases. These codes play a crucial role in accurately documenting various healthcare encounters, ensuring comprehensive and detailed medical records.
F. Level of Detail in Coding
1. Variability in ICD-10-CM Code Length: ICD-10-CM codes are structured with three, four, five, six, or seven characters. Initially, codes with three characters serve as the category headings, which can be refined through the addition of fourth, fifth, sixth, or seventh characters to offer increased specificity.
2. Complete Utilization of Characters: A three-character code should only be used when further subdivisions are unnecessary. Failure to utilize the full number of characters required for a code renders it invalid, including the application of the seventh character where applicable.
3. Pursuit of Specificity: It’s important to code to the
G.
highest level of specificity supported by the medical documentation present in the record.
ICD-10-CM Code for the
Diagnosis, Condition, Problem, or Other Reason for Encounter/Visit
When documenting medical encounters, prioritize listing the ICD-10-CM code corresponding to the diagnosis, condition, problem, or primary reason for the visit as indicated in the medical record. This code should primarily reflect the service provided. Additionally, include supplementary codes for any coexisting conditions identified.
Occasionally, the first-listed diagnosis may pertain to a symptom, especially when a definitive diagnosis has not yet been confirmed by the provider.
H. Uncertain Diagnosis
When documenting diagnoses, avoid coding terms such as “probable,” “suspected,” “questionable,” “rule out,” “compatible with,” “consistent with,” or “working diagnosis,” as these indicate uncertainty. Instead, code the condition(s) to the highest degree of certainty for that encounter or visit, focusing on symptoms, signs, abnormal test results, or other reasons for the visit.
It is important to note that this approach differs from the coding practices used in short-term acute care, long-term care, and psychiatric hospitals.
I. Chronic Diseases
Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s).
J. Code All Documented Conditions That Coexist
When coding documented conditions, include all those that coexist at the time of the encounter or visit and that require or influence patient care, treatment, or management. Do not code conditions that have been previously treated and no longer exist. However, history codes (categories Z80-Z87) may be used as secondary codes if the historical condition or family history impacts current care
or influences treatment.
K. Patients Receiving Diagnostic Services Only
For patients receiving diagnostic services only during an encounter or visit, first sequence the diagnosis, condition, problem, or other reason for the encounter as documented in the medical record that is chiefly responsible for the outpatient services provided. Codes for other diagnoses, such as chronic conditions, may be sequenced as additional diagnoses.
For encounters for routine laboratory or radiology testing without any signs, symptoms, or associated diagnosis, assign Z01.89, Encounter for Other Specified Special Examinations. If routine testing is performed during the same encounter as a test to evaluate a sign, symptom, or diagnosis, assign both the Z code and the code for the non-routine test.
For outpatient encounters where diagnostic tests have been interpreted by a physician and the final report is available at the time of coding, code any confirmed or definitive diagnoses documented in the interpretation. Do not code related signs and symptoms as additional diagnoses.
Note: This practice differs from hospital inpatient coding regarding abnormal findings on test results.
L. Patients Receiving Therapeutic Services Only
For patients receiving therapeutic services only during an encounter or visit, first sequence the diagnosis, condition, problem, or other reason for the encounter as documented in the medical record that is chiefly responsible for the outpatient services provided. Codes for other diagnoses, such as chronic conditions, may be sequenced as additional diagnoses. The only exception to this rule is when the primary reason for the admission or encounter is chemotherapy or radiation therapy. In such cases, the appropriate Z code for the service is listed first, followed by the diagnosis or problem for which the service is being performed.
M. Patients Receiving Preoperative Evaluations Only
For patients undergoing preoperative evaluations only, first sequence a code from subcategory Z01.81, Encounter for PreProcedural Examinations, to describe the preoperative consultations. Additionally, assign a code for the condition that
necessitates the surgery as a secondary diagnosis. Also, code any findings related to the preoperative evaluation.
N. Ambulatory Surgery
For ambulatory surgery, code the diagnosis that prompted the surgery. If the postoperative diagnosis differs from the preoperative diagnosis at the time of confirmation, use the postoperative diagnosis for coding, as it provides the most definitive information.
P. Encounters for General Medical Examinations With Abnormal Findings
The subcategories for encounters for general medical examinations (Z00.0-) and routine child health examinations (Z00.12-) include codes for both with and without abnormal findings. If a general medical examination reveals an abnormal finding, the code for a general medical examination with abnormal findings should be assigned as the primary diagnosis. An examination with abnormal findings refers to a newly identified condition or a change in the severity of a chronic condition (such as uncontrolled hypertension or an acute exacerbation of chronic obstructive pulmonary disease) discovered during a routine physical examination. Additionally, a secondary code for the abnormal finding should be assigned.
Conclusion
For both new and experienced coders, mastering the rules of the road for ICD-10-CM is essential for accurate and efficient coding. Adhering to the official coding guidelines, understanding the coding structure, staying updated on annual revisions, and leveraging coding software and resources are some essential strategies to ensure success in the world of medical coding. By continually improving your knowledge and skills, you’ll become a proficient medical coder capable of providing accurate coding and contributing to the overall efficiency and effectiveness of the healthcare industry.
Betty Hovey, CCS-P, CDIP, CPC, COC, CPMA, CPCD, CPB, CPC-I, is the Senior Consultant/Owner of Compliant Health Care Solutions, a medical consulting firm that provides compliant solutions to issues for all types of healthcare entities.
Chcs.consulting
Artificial Intelligence: Resources to Technology Governance
This article introduces Artificial Intelligence (AI), large multimodal models (LMMs), and the impact on healthcare. This information is not intended as legal or consulting advice. Please utilize the resources provided within this article for more information.
During the design and development of machine-learning models (aka general-purpose foundation models), the responsibility rests with the developers.
A general-purpose foundation model can be used by a third party (a “provider”) through an active programming interface for a specific purpose or use. Governments bear the responsibility to set laws and standards to require or forbid certain practices. Another aspect to consider is compliance with national and state security standards. In the United States, America’s cyber defense agency is CISA (Cybersecurity and Infrastructure Security Agency).
“Secure by Design” means building cybersecurity into the manufacturing of the technology.
International Governance
International governance is necessary to ensure that all governments are accountable for their investments and participation in the development and deployment
of AI-based systems and that governments introduce appropriate regulations that uphold ethical principles, human rights, and international laws. International governance can also ensure that companies develop and deploy LMMs that meet adequate international standards of safety and efficacy and uphold ethical principles and human rights obligations. Governments should also avoid introducing regulations that provide a competitive advantage or disadvantage for either companies or themselves.
Published in September 2023 by Oxford Academic, “The Global Governance of Artificial Intelligence: Next Steps for Empirical and Normative Research” discusses the international impact of AI technology posing a global governance challenge. The first section of the article explains why AI is now a global governance concern:
“Why does AI pose a global governance challenge? In this section, we answer this question in three steps. We begin by briefly describing the spread of AI technology
in society, then illustrate the attempts to regulate AI at various levels of governance, and finally explain why global regulatory initiatives are becoming increasingly common. We argue that the growth of global governance initiatives in this area stems from AI applications creating cross-border externalities that demand international cooperation and from AI development taking place through transnational processes requiring transboundary regulation.”
NIST – The National Institute of Standards and Technology
Published in January 2023, NIST’s “Artificial Intelligence Risk Management Framework” (AI RMF) guidance targets mitigating risk while cultivating trust in AI technologies.
“This voluntary framework will help develop and deploy AI technologies in ways that enable the United States, other nations, and organizations to enhance AI trustworthiness while managing risks based on our democratic values,” said Deputy Commerce Secretary Don Graves. “It should accelerate AI innovation and growth while advancing—rather than restricting or damaging— civil rights, civil liberties, and equity for all.”
On March 30, 2023, NIST launched the Trustworthy and Responsible AI Resource Center, which will facilitate implementation of, and international alignment with, the AI RMF.
As the United States and other governments regulate foundation models, new legal definitions have emerged. The World Health Organization (WHO) is weighing-in with free resources related to healthcare.
World Health Organization and the Governance of Generative Artificial Intelligence (AI) Technology
The six core AI principles identified by WHO are:
1. Protect autonomy.
2. Promote human well-being, human safety, and the public interest.
3. Ensure transparency, explainability, and intelligibility.
4. Foster responsibility and accountability.
5. Ensure inclusiveness and equity.
6. Promote AI that is responsive and sustainable.
In January 2024, the World Health Organization posted new guidance regarding AI ethics and governance guidance of large multimodal models.
This is an update to the previous June 2021 publication, “Ethics and Governance of Artificial Intelligence for Health,” and used by WHO to offer a free 3.5 hour online introductory course designed for policymakers, AI developers, designers, and healthcare providers involved in the design, development, use, and regulation of AI technology for health. Go to https://openwho.org/courses/ ethics-ai for more information.
Multimodal language models are considered the next steps toward artificial general intelligence. A large multimodal model is an advanced type of artificial intelligence model that can process and understand multiple types of data modalities. These multimodal data can include text, images, audio, video, and potentially others.
As reported by WHO, LMMs have been adopted faster than any consumer application in history, with several platforms—such as ChatGPT, BARD, and BERT—entering the public consciousness in 2023. GPT-4, the latest iteration in the GPT series of models maintained by OpenAI, can respond to multimodal queries. Multimodal queries use text and images.
The new WHO guidance outlines five broad applications of LMMs for health:
• Diagnosis and clinical care, such as responding to patients’ written queries;
• Patient-guided use, such as for investigating symptoms and treatment;
• Clerical and administrative tasks, such as documenting and summarizing patient visits within electronic health records;
• Medical and nursing education, including providing trainees with simulated patient encounters; and
• Scientific research and drug development, including identifying new compounds.
Recommendation
Read additional free articles on artificial intelligence and healthcare posted to the American Institute of Healthcare Compliance Blog.
AIHC Volunteer Education Committee. AIHC is a non-profit organization. We value our members, credentialed professionals, and greatly appreciate the talents offered by our member volunteers! aihc-assn.org
Mastering Time Management: Essential Strategies for Physicians
As a physician, balancing patient care, administrative duties, and personal time can be incredibly challenging. Effective time management is key to maintaining this balance, ensuring that you can provide the best care for your patients while also taking care of yourself. Here are some essential strategies to help you optimize your schedule and reduce stress.
By adopting systematic approaches to organizing tasks, leveraging technology, and setting clear priorities, physicians can navigate the complexities of their roles more effectively. These strategies not only alleviate the pressures of the profession but also foster a more sustainable and rewarding career in medicine.
Prioritize Tasks with the Eisenhower Matrix
In the fast-paced world of healthcare, managing a mul-
titude of tasks efficiently is essential. The Eisenhower Matrix, also known as the Urgent-Important Matrix, is a powerful tool that helps physicians prioritize their responsibilities by categorizing them based on urgency and importance. By systematically evaluating tasks using this method, you can focus on what truly matters, delegate or eliminate less critical activities, and ensure that your time and energy are directed toward the most impactful areas.
Here’s how you can implement the Eisenhower Matrix to
optimize your workflow:
• Urgent and Important: Tasks that require immediate attention, such as critical patient care.
• Important but Not Urgent: Tasks to be scheduled, like routine check-ups and professional development.
• Urgent but Not Important: Tasks to delegate, such as administrative paperwork.
• Not Urgent and Not Important: Tasks to eliminate or minimize, like unnecessary meetings.
Use Technology Wisely
In the digital age, technology offers powerful tools that can transform how physicians manage their time and workload. By effectively leveraging these technologies, you can enhance your efficiency, streamline processes, and improve patient care. From electronic health records to telemedicine, the right technological solutions can help you focus more on patient interactions and less on administrative tasks.
Here’s how you can make the most of the available technological advancements:
• Electronic Health Records (EHRs): Use a streamlined, user-friendly EHR system and invest time in mastering it.
• Scheduling Software: Implement advanced scheduling tools to manage appointments and cancellations.
• Telemedicine: Integrate telemedicine for follow-ups and minor consultations, saving time for in-person visits.
Delegate and Collaborate
Effective delegation and collaboration are essential for managing time efficiently and ensuring comprehensive patient care. By strategically distributing tasks and fostering teamwork, physicians can focus on their core responsibilities while leveraging the skills and expertise of their colleagues. This approach not only frees up valuable time but also enhances the overall workflow and quality of care.
Here are some key strategies for delegation and collaboration:
• Nurses and Physician Assistants: Delegate routine tasks and patient educaWEBINAR -
Practical HIPAA Compliance Advice
Presenter: Myson L. Joseph, MHA/INF, RHIA, CSSWB, PMEC, Consultant at MLJ Consultancy LLC, brings over 11 years of Health Information Management leadership experience, within different healthcare settings.
Time: 50.26 minutes
Description: Myson Joseph with MLJ Consultancy LLC delivers practical HIPAA compliance advice, walking you through the HIPAA compliance journey to help you better understand how to achieve and maintain HIPAA compliance in your healthcare organization.
tion to your trained staff.
• Administrative Staff: Assign non-clinical tasks such as billing and scheduling to administrative personnel.
• Team Meetings: Hold regular, focused team meetings to align patient care plans and streamline workflows.
Optimize Your Clinic Workflow
Streamlining your clinic workflow is essential for enhancing efficiency and ensuring that both you and your patients have a positive experience. By refining and organizing your processes, you can minimize delays, reduce stress, and improve the overall quality of care.
Here are some strategies to optimize your clinic workflow:
• Standardize Processes: Develop standard operating procedures for common tasks to reduce decision fatigue.
• Time Blocking: Allocate specific times for patient consultations, administrative tasks, and breaks.
• Batching: Group similar tasks together to maintain focus and reduce transition times.
Setting Boundaries
Setting boundaries is indeed essential for maintaining a healthy balance between work and personal life.
Here are some strategies for setting boundaries in the areas mentioned:
• Work Hours: Determine your ideal work hours based on your peak productivity and personal commitments. Communicate these hours clearly to colleagues, clients, and supervisors. Try to stick to these hours as much as possible and avoid taking work-related tasks outside of them unless necessary.
• Patient Appointments: Set realistic time limits for patient consultations based on the nature of the appointment and your capacity to provide quality care. Clearly communicate these time limits to patients and politely enforce them when necessary to ensure that appointments stay on schedule. Implement strategies such as scheduling buffer times between appoint-
ments to accommodate unexpected delays without compromising other patients’ time slots.
• Email and Calls: Establish specific times during the day dedicated to checking and responding to emails and returning phone calls. This allows you to focus on your tasks without constant interruptions while still being responsive to inquiries. Consider setting up an auto-reply message during off-hours to manage expectations and provide alternative contact information for urgent matters.
Remember that setting boundaries is not only about protecting your time and energy but also about fostering respect for your professional and personal well-being. It may take some time for others to adjust to your boundaries, but consistency and clear communication will help reinforce them over time.
Prioritize Self-Care
Taking care of yourself is crucial for maintaining both productivity and overall well-being.
Here are some ways to prioritize self-care:
• Breaks: Incorporate regular breaks into your workday to rest and recharge. Short breaks throughout the day can help prevent burnout and improve focus and productivity. Use this time to stretch, take a short walk, or engage in activities that relax and rejuvenate you.
• Healthy Lifestyle: Pay attention to your diet, exercise, and sleep habits. Eating nutritious meals, staying physically active, and getting enough sleep are fundamental components of self-care. Consider meal prepping to ensure you have healthy options readily available, schedule regular exercise sessions, and aim for a consistent sleep schedule to support your overall health and well-being.
• Mindfulness and Stress Management: Incorporate mindfulness practices or stress management techniques into your daily routine. This could include meditation, deep breathing exercises, journaling, or engaging in hobbies that promote relaxation and stress relief. These practices can help you stay grounded, manage stress more effectively, and maintain mental
clarity amid life’s challenges.
Remember that self-care is not selfish—it’s essential for sustaining your well-being and enabling you to perform at your best in both your personal and professional life. Prioritize self-care as you would any other important task, and don’t hesitate to seek support or resources if you need help implementing or maintaining healthy habits.
Continuous Improvement
Continuous improvement is essential for refining your time management skills and maximizing productivity.
Here’s how you can incorporate it into your routine:
• Feedback Loop: Actively seek feedback from colleagues, patients, and other stakeholders to gain insights into your time management effectiveness. Encourage open communication and constructive criticism to identify areas for improvement. Consider implementing feedback mechanisms such as surveys, suggestion boxes, or one-on-one discussions to gather valuable input.
• Professional Development: Commit to ongoing professional development to stay abreast of the latest medical practices and time management techniques. Attend workshops, conferences, or online courses relevant to your field to expand your knowledge and skill set. Additionally, seek out resources such as books, podcasts, or reputable websites that offer insights into effective time management strategies tailored to healthcare professionals.
• Reflect and Adjust: Set aside time regularly to reflect on your time management strategies and assess their effectiveness. Identify what’s working well and areas that need improvement. Be honest with yourself about any challenges or shortcomings you encounter. Based on your reflections, make necessary adjustments to your approach, whether it’s tweaking your scheduling methods, adopting new tools or technology, or refining your communication practices.
By actively engaging in a feedback loop, prioritizing professional development, and consistently reflecting on and adjusting your time management strategies, you can contin-
uously refine your approach and achieve greater efficiency and effectiveness in your professional endeavors.
Conclusion
Implementing these time management strategies can help physicians enhance their efficiency, improve patient care, and achieve a better work-life balance. Remember, time management is not just about doing more in less time; it’s about making thoughtful decisions to use your time effectively. By prioritizing tasks, leveraging technology, delegating, optimizing workflows, setting boundaries, taking care of yourself, and continuously improving, you can create a more manageable and fulfilling professional life.
Trevor McElhaney, JD, Director of Consulting
Trevor McElhaney is the Associate Director of Consulting at the firm’s Knoxville, Tennessee office. His focus areas include feasibility studies for potential ventures, practice startups, strategic planning for growth-stage practices, transactional advisory, and succession planning. His extensive knowledge and experience across primary care and specialty practices allow him to structure each engagement to the individual needs and goals of each client.
Prior to joining DoctorsManagement, he worked as a senior valuation consultant at a national consulting firm, advising clients in the areas of Stark Law and Anti-Kickback Statute compliance in connection with physician compensation arrangements, professional services agreements, and call pay arrangements. In addition, Trevor assisted with due diligence reviews in connection with large, multiparty mergers and acquisitions, joint ventures, reorganizations, and affiliations.
Trevor holds a Doctorate of Jurisprudence with a Concentration in Business Transactions from the University of Tennessee College of Law and a Bachelor of Science in Business Administration with a major in finance and minor in economics from the University of Tennessee College of Business.
https://www.doctorsmanagement.com/
Coding For Enhanced Interventional Radiology Reimbursement
The importance of accurate and complete coding cannot be overemphasized for any area of radiology, but the complexity of interventional radiology (IR) coding makes it even more critical for optimal reimbursement. The prerequisite for complete coding is thorough documentation that includes all of the required elements, along with a coding team that is highly trained in IR.
The Coding Team
There are specialty credentials for IR coding, and your team should consist of IR specialists just as you have specialty-trained IR physicians. The American Academy of Professional Coders (AAPC) issues the Certified Interventional Radiology Cardiovascular Coder (CIRCC) designation, and the Radiology Business
Management Association (RBMA) issues the Radiology Coding Certification in Interventional Radiology (RCCIR) credential. Just as physicians undergo continuing medical education, your coders should also be updated annually and have reference materials available to them. Webinars are frequently made available by both credentialing organizations mentioned.
Coding involves not only procedural (CPT) but also diagnosis (ICD) coding. These code sets include vast amounts of information, and your coding team should have readily available, annually updated reference material. The use of both internal and external audits will serve to reinforce training and provide assurance to the practice that the team is performing optimally. External audits are done less frequently and will include a full cross section of the practice’s procedure mix. Internal audits can target specific areas of concern, such as high-dollar or complex procedures, as well as the work of coders who are new to the practice.
It is essential that coders have the availability of a system that allows them to send any report back to the physician with questions or to supply missing information. This not only assures accurate coding of the specific patient procedure but it provides feedback to the physicians so they can improve their documentation. An administrator should monitor the system to ensure that requests are addressed in a timely manner. It is especially important to monitor the documentation provided by physicians new to the practice. A review of new physicians can be the subject of a targeted internal audit.
As the coding team receives its annual education, they must pass along any changes to coding or documentation requirements to the physicians and to the team responsible for insurance authorization. Bundling of procedures can change quarterly and those changes must be analyzed to determine whether they will have an impact on reimbursement.
Complete and Comprehensive Coding
We recommend coding a procedure as completely and accurately as possible, without regard to whether a particular payor will provide reimbursement for certain codes. The data provided on non-payment can be used in future contract negotiations with the payor. In addition, payors sometimes change their edits without notification, and a completely coded claim will have the opportunity for payment immediately if that occurs. Thoroughly coded claims also capture the full value of wRVU (work Relative Value Units) that are used to measure a physician’s productivity within the practice.
When using modifiers that allow two codes to be used together, it is vital that the documentation supports the reason for both codes. Frequent use of modifiers can trigger a payor audit that requests documentation, with potential penalties for inappropriate use.
Physician Bonuses and Compensation Landmines to Avoid
Presenter:
Rachel Rose, JD, MBA
Description:
This past year witnessed a leap in artificial intelligence (AI) technology, making various AI engines accessible to consumers. While these engines possess a core set of ethics, there’s potential for compromise or the creation of customized AI tailored for cybercrime. This webinar discusses how to maintain data privacy and compliance throughout the advancement of AI in healthcare.
Complete diagnosis coding is as important as complete procedure coding. Certain primary diagnoses are only payable with an acceptable secondary diagnosis. As an example, “diabetic ulcer” must have both ICD codes E11.621 (Type 2 diabetes mellitus with foot ulcer) and L97.523 (Non pressure chronic ulcer of other part of the left foot with necrosis of muscle) in order to comply with payor policies. Providing the highest level of specificity is always preferred. Some payors have announced that they will deny payment for claims where the laterality of the diagnosis is not specified.
Considerations for the Quality Payment Program (QPP)
While coding for Medicare’s Merit-based Incentive Payment System (MIPS) is not unique to interventional radiology, it is critical to receiving the maximum reimbursement. Unless the practice is a member of an Accountable Care Organization (ACO) or other Alternative Payment Model (APM), reporting under MIPS is essential in order to avoid a 9% payment penalty from Medicare.
The challenge for IR is to find measures that apply to their procedures as the number of available measures has continued to decrease over recent years. One solution is to consider reporting through a Quality Clinical Data Registry (QCDR) such as the one maintained by the American College of Radiology (ACR). QCDRs offer more measures that are tailored to a particular specialty. This is especially attractive to large practices of 16 or more eligible clinicians.
The Top Three Under-Documented IR Procedures
Thorough documentation is the basis for maximal coding and reimbursement. When we audit documentation for interventional radiology, there are certain procedures where we consistently see deficiencies. Without correction, those procedures would represent lost revenue from the failure to bill for all of the possible procedure codes, as well as opening the practice up to the possibility of a compliance risk if the codes were billed without supporting documentation.
Vascular Ultrasound Guidance
A complete report includes evaluation of the potential access sites, documentation of selected vessel patency, concurrent real-time ultrasound visualization of vascular
needle entry, and permanent recording and reporting. In the example that follows, the inadequate report does not document that the images were permanently stored in the patient’s record.
See Table 1.
Fluoroscopic Guidance
Fluoroscopic guidance is often used for placement, replacement, or removal of central vascular devices, and is increasingly bundled with a variety of IR services. In the example that follows, the inadequate report does not contain documentation of the follow-up imaging that is required to verify the catheter tip position.
See Table 2.
Moderate Sedation
While each individual case is not highly reimbursed, over many procedures, billing for moderate sedation can add up to a significant amount. Complete reporting must include both the start and stop times, including the total procedure time, affirmation that the radiologist provided direct supervision, and the medications administered. In the example that follows, the inadequate report does not document the medications administered.
See Table 3.
Conclusion
The recipe for IR revenue cycle success comes down to four essential ingredients:
• Education, including an awareness of payor policies, coding and documentation guidelines, and other factors that impact reimbursement.
• Communication, ensuring that all providers and staff understand their role in assuring compliance and maximizing revenue.
• Attention to detail, avoiding incomplete documentation, missing codes, or applying incorrect codes.
• Follow through, to be sure denials are handled promptly, and that all internal audits and monitoring processes take place according to the practice’s policies and procedures.
Adequate Documentation
A localizing sonographic evaluation of the right neck was performed. Images were saved as part of the patient’s permanent medical record. Localizing sonographic evaluation demonstrated the right internal jugular vein to be patent and normally compressible. There was no intraluminal thrombus. Under ultrasound guidance and using a micropuncture needle, the right internal jugular vein was accessed with ultrasound imaging showing needle positioning within the vein.
Inadequate
Documentation
History: Venous access requirement.
Technique: The left arm was prepped and draped in the usual sterile manner. Scout sonographic evaluation of the left arm was performed.
Images demonstrated a patent brachial vein. Under aseptic conditions, local anesthesia, and ultrasound guidance, the vein was accessed with a micropuncture kit, and a 5 French catheter was placed. The catheter was secured in place and flushed.
Findings: Patent right brachial vein.
Adequate Documentation
Under fluoroscopic guidance, the catheter was trimmed to an appropriate length and placed through the peel-away sheath. The distal catheter tip was positioned at the upper right atrial level. Follow-up fluoroscopic imaging demonstrates appropriate port catheter positioning with the distal catheter tip positioned at the upper right atrium. There were no kinks along the catheter course.
Inadequate Documentation
The catheter was trimmed to appropriate length and placed into the vein under fluoroscopic guidance via a peel-away sheath.
Adequate Documentation
Intravenous conscious sedation was administered by the nurse and supervised by Dr. Smith. The patient was independently monitored by an RN assigned to the department of radiology using automated blood pressure, EKG, and pulse oximetry equipment. The detailed conscious sedation record is permanently stored in the health information system. The following is the conscious sedation medication record, including start and end times: 50 mcg of fentanyl and 1 mg of versed were administered intravenously from 1035 until 1214 hours.
Inadequate
Documentation
SEDATION: Medications were administered and monitored by the radiology nursing staff with my direct supervision. The moderate sedation was started at 9:30 and given in divided doses throughout the procedure and ended at 10:15.
Erin Stephens, CPC, CIRCC, is the Sr. Client Manager of Education at Healthcare Administrative Partners. Healthcare Administrative Partners (HAP) provides revenue cycle management, clinical analytics, and comprehensive practice management solutions for radiology practices. We also provide coding services for multispecialty practices. HAP produces results, not promises. Our key to optimizing your success is to aggressively improve all areas of your practice’s financial health - maximizing reimbursements and accelerating cash flow while reducing cost and compliance risk. www.hapusa.com
Table 1
Table 2
Table 3
Leadership:
One of the Most Important Attributes of Success
Upon meeting a manager, one of my favorite questions to ask is: What is the greatest challenge facing you on a daily basis? By far, the most common response is: Trying to keep employees motivated.
Many managers think that today’s employees are just not motivated the way they were a few decades ago. In reality, the problem may originate with the manager. While it may be true that you cannot truly motivate someone, an untrained manager who lacks the necessary leadership skills certainly can de-motivate an employee.
There are many fallacies relating to the art of management. Yes, management and leadership talents are an art, not a science; however, the more we learn various techniques and skills, the more effective and successful we can be as leaders.
The following are some important leadership concepts to keep in mind:
• Leaders are not born; they are made.
• Leadership cannot be taught, but it can be learned.
• You manage projects, but you must lead people.
• Communication with employees should always be a conversation, not a confrontation.
• You can’t tell employees what to do, you must sell them on what to do.
Hundreds of excellent books have been written on leadership, so why not make it a habit to read at least one each quarter? As leaders, we do not gain knowledge by osmosis; we need to read or listen to successful leaders who are willing to share their best practices and proven concepts with us. Exposing yourself to the wisdom of other leaders is a fast-track method to improving your own skills.
I recently read an article about successful leaders who work in Fortune 500 companies. They had several traits in common:
• High Energy. It is true that if you want something
done, give it to a busy person. Effective leaders must have the stamina to preserve and stick with projects until they are completed.
• Interpersonal Skills. It is hard to lead if you cannot communicate your vision to others and get them to buy in. The easiest way to demonstrate excellent interpersonal skills is to have a sincere interest in others. Always respect others’ points of view and solicit their input in any decision. Remember, people do not care how much you know unless they know how much you care.
• Delegation. Today’s hectic world generates too much activity for top leaders to do it all by themselves. A leader must be able to get things done through others. A good rule of thumb is to delegate everything you can, but make sure you follow up before the person you delegated to has a chance to fail.
• Feedback. How do you expect others to succeed if you do not guide them on the right path? Feedback, both positive and negative, is imperative in helping others grow. Praise is the best type of feedback and, keep in mind when praising someone, you must be specific, sincere, and timely. Make sure you also know that person’s preferences—does he or she like to receive praise in public or privately?
• Set Goals. Keep in mind that setting goals is a great idea, but developing your goals is only part of the process. You must also develop and implement a strategic plan that will allow you to reach those goals. A goal
without an accompanying action plan is ineffective. It is like putting a cake in the oven but failing to turn it on.
While it may be true that our society seems to be losing some of the fundamental virtues, such as accountability and responsibility, it is still our duty as leaders to reflect those values and try to instill them in others. I hope that in my lifetime, teamwork and leadership classes will be part of the core curriculum in every elementary, middle, and high school throughout our country. Many students are ill-prepared for the issues they will face in the real world. However, until that day comes, you are not excused from becoming a lifelong student of leadership.
It is inappropriate for anyone in a leadership role to collect a paycheck and not invest in themselves to become an excellent leader. Seniority alone should not be a qualification of ascension to a leadership position. Leaders earn their positions because they have learned and continue to learn the intricacies of what makes a leader successful.
David Jakielo. Sign up for Dave’s FREE weekly success tips at www.Davespeaks.com, and if you have any questions or comments about this article, you can contact Dave at Seminars & Consulting, 86 Hall Avenue, Pittsburgh, PA 15205 or at 412-921-0976 or via e-mail at Dave@ Davespeaks.com.
Monthly Spotlight on Fraud, Waste, and Abuse
The following cases highlight fraud, waste, and abuse (FWA) and serve as a reminder to uphold high ethical standards when providing patient care and services.
Elara Caring Hospice Agrees to Pay $4.2 Million to Settle False Claims Act Allegations That It Billed Medicare for Ineligible Hospice Patients
Early May saw the hospice and its five wholly owned subsidiaries agreeing to pay $4.2 million to resolve allegations that they violated the False Claims Act by knowingly submitting false claims and knowingly retaining overpayments for the care of hospice patients in Texas who were ineligible for the Medicare hospice benefit because they were not terminally ill.
The settlement resolves allegations that the Elara Caring’s hospice’s Texarkana, Texas, location, which previously operated as CIMA Hospice under a different name, knowingly submitted false claims for hospice services provided to patients who were ineligible for the hospice benefit because they were not terminally ill. The patients at issue in the settlement were at the Texarkana location between 2014 and 2020. The settle-
ment also resolves allegations regarding two patients at other Texas locations between 2015 and 2021. The settlement further resolves allegations that the hospice knowingly and improperly concealed or avoided obligations to repay overpayments for these patients.
The civil settlement resolved a lawsuit filed under the qui tam or whistleblower provision of the False Claims Act, which permits private parties to file suit on behalf of the United States for false claims and share in a portion of the government’s recovery. The qui tam lawsuit was filed by a former Elara Caring hospice employee.
The claims resolved by the settlement are allegations only. There has been no determination of liability.
Source: Elara Caring Hospice Agrees to Pay $4.2 Million to Settle False Claims Act Allegations That It Billed Medicare for Ineligible Hospice Patients (2024, May 1). www.justice. gov.
Former VA Psychologist Sentenced to Prison for Submitting False Medical Documents, Healthcare Fraud
Here, a district judge sentenced a Herrin woman, formerly employed in southern Illinois as a psychologist with the Department of Veterans Affairs, to 10 months imprisonment after she admitted to submitting false medical documents, obstructing justice, and committing Medicare fraud.
This woman pleaded guilty in October 2023 to one count of concealing a material fact by trick, scheme, or device; three counts of making or using a false writing or document; one count of obstruction of justice; and one count of healthcare fraud. Her conduct involved a multi-faceted scheme that impacted her employment at the VA, fraudulent billing to Medicare, and the obstruction of a federal civil lawsuit in the Southern District of Illinois.
This woman, a licensed clinical psychologist, was employed by the Marion VA Medical Center. According to court documents, between November 2016 and August 2020, she submitted fraudulent medical documentation in the name of real and fake medical providers as part of the approval process for reasonable accommodations and medical leave, including FMLA leave. She admitted to submitting false medical documents with forged signatures of two legitimate medical providers, one of whom is local to the southern Illinois area.
In addition to her submission of fraudulent medical documents, she engaged in a scheme to defraud Medicare and obtain payment for psychiatric services that she did not provide to residents of a southern Illinois nursing home between May 2016 and January 2018. In addition to her full-time job at the VA, she owned a company through which she claimed to provide psychotherapy sessions to patients at a nursing center in Herrin, Illinois. She billed Medicare for more than 400 claims—worth more than $54,000—for services that she did not provide. She billed for at least some of the services on days she was on approved medical leave from the VA. In addition to her term of imprisonment, she was ordered to repay $35,795.94 in restitution to the Centers for Medicare & Medicaid Services as repayment for her fraudulent claims.
She also admitted to obstructing justice in a civil proceeding in federal court by submitting fraudulent medical documentation to her attorney—the contents of which were used to seek a continuance of the judicial proceeding. In April 2020, she filed a dis-
crimination complaint in U.S. District Court against the Secretary of Veterans Affairs. Rather than proceeding with the case, she submitted a letter impersonating a real physician who had practiced in Anna, Illinois, but had never treated her. Her lawsuit was ultimately dismissed by the judge.
Source: Former VA Psychologist Sentenced to Prison for Submitting False Medical Documents, Health Care Fraud (2024, May 1). www. justice.gov.
Glastonbury Psychologist Sentenced to Prison for Defrauding Medicaid of More Than $1.6 Million
The Connecticut psychologist was sentenced to 27 months of imprisonment, followed by three years of supervised release, for defrauding Medicaid of more than $1.6 million.
According to court documents and statements made in court, he is a psychologist who owned and operated his own independent practice, located in Glastonbury. He provided psychotherapy to young children, adolescents, and adults, and he was enrolled individually as a Behavioral Health Clinician provider in the Connecticut Medicaid Program.
Between January 2017 and October 2023, he submitted and caused to be submitted fraudulent claims to Medicaid for psychotherapy services that were purportedly provided to his Medicaid clients. Specifically, he submitted claims for dates of service when no services of any kind had been provided to the Medicaid clients identified in the claims, including when he was traveling, on vacation, recovering from surgery, or otherwise not working. He also submitted claims when an appointment had been canceled, when the claimed client was in the hospital, when he had stopped treating the claimed client, and when the claimed client had never been his client. In addition, when he treated multiple Medicaid clients in the same family at the same time, he billed Medicaid for the group visit as multiple individual claims, a practice that he knew was not permitted by Medicaid.
The investigation revealed that he used his business bank account for numerous personal expenditures.
Through this scheme, he defrauded Medicaid of $1,617,679. The judge on the case ordered him to make full restitution. He also forfeited 16 pieces of jewelry, which he paid for using his business bank account, with an appraised replacement value of $67,685.
On January 31, 2024, he pleaded guilty to healthcare fraud.
He was released on a $250,000 bond and is required to report to prison on June 24, 2024.
Source: Glastonbury Psychologist Sentenced to Prison for Defrauding Medicaid of More Than $1.6 Million (2024, May 10). www.justice.gov.
Hospice Owner Sentenced to 240 Months Imprisonment and Ordered to Repay $42,000,000 for Defrauding Medicare
A U.S. District Judge on the case sentenced this Louisiana hospice owner to 240 months of imprisonment, three years of supervised release, and $2,300 in mandatory special assessment fees, in relation to an extensive healthcare fraud scheme he orchestrated. In November 2023, a federal jury convicted the man of all 23 counts of his underlying indictment. He owned and oversaw the day-to-day operations of Canon Healthcare, LLC, a hospice facility with offices in the New Orleans area, Baton Rouge, Covington, and Gulfport, Mississippi.
At sentencing, the Court found that between January 2013 and December 2019, the hospice billed Medicare approximately $84 million in fraudulent claims and was paid approximately $42 million relating to these fraudulent claims. The Court ordered that the hospice owner repay the $42 million of fraudulent proceeds back to Medicare.
On November 6, 2023, a jury convicted him on all 23 counts of healthcare fraud charged in the indictment relating to overbilling for hospice patients for expensive General Inpatient (GIP) services and for multiple counts related to manipulating Medicare billing codes, known as Common Procedural Terminology (CPT) codes despite such services being medically unnecessary, or despite their inclusion in the daily hospice benefit the hospice already received for its patients.
Source: Hospice Owner Sentenced to 240 Months Imprisonment and Ordered to Repay $42,000,000 for Defrauding Medicare (2024, May 16). www.justice.gov.
DOJ Resolves Allegations Tacoma Spine Surgeon Billed for Unnecessary Surgeries
Here, there is resolution of a False Claims Act qui tam matter alleging a Tacoma physician billed government insurance programs for medically unnecessary spinal surgeries. CHI Franciscan Health and St. Joseph Medical Center will pay $745,654 to resolve the matter and the former Orthopedic Surgeon will pay $197,054 to resolve the case.
According to the settlement agreement, on May 21, 2018, another surgeon filed a qui tam lawsuit alleging the spine surgeon in this case had been performing medically unnecessary spinal surgeries, among other allegations. One health system resolved claims that the hospital billed for the spine surgeon’s performance of spinal surgery at more spinal levels than necessary and medically unnecessary spinal fusions at another Tacoma’s St. Joseph Hospital health system. The spine surgeon resolved claims pertaining to his performance of allegedly medically unnecessary spinal surgeries. Between January 1, 2013, and June 30, 2018, these surgeries were billed to government health programs when they were not medically necessary. The surgeries were billed to Medicare, TRICARE, and Veterans Affairs.
In resolving the case, neither the doctor nor the hospital and other health system are admitting wrongdoing. Each is paying the government health programs the amount that was improperly billed and additional penalties. Additionally, the other whistle-blowing surgeon, as the relator who reported the false claims, will receive 22% of the payments to the government health programs.
The spine surgeon in this case retired in 2018 and surrendered his physician license in 2019.
The settlement resolved a lawsuit filed under the qui tam, or whistleblower, provisions of the False Claims Act, which permit private parties known as relators to file suit on behalf of the government for false claims and to share in any recovery.
Source: DOJ Resolves Allegations Tacoma Spine Surgeon Billed for Unnecessary Surgeries (2024, May 7). www.justice.gov.
Sonal Patel, BA, CPMA, CPC, CMC, ICDCM, is CEO and Principal Strategist at SP Collaborative, LLC.
Sonal has over 13 years of experience understanding the art of business medicine. She is a nationally recognized thought-leader, speaker, author, creator, and consultant.
As the CEO & Principal Strategist of SP Collaborative, LLC, she serves as a partner to healthcare organizations, medical practices, physicians, healthcare providers, vendors, consultants, medical coders, auditors, and compliance professionals in working together to elevate coding compliance education for the business of medicine.
https://spcollaborative.net
New product discounts and Reviews
E/M Definitions – Digital Download
Where: https://elearning.chcs.consulting/product/em-definitions-digital-download/ Your Price: $4.99
Publisher: Compliant Health Care Solutions
Wish you had the E/M definitions at your fingertips without needing the CPT book? The Definitions Electronic Tool (E Tool) contains all of the definitions from the E/M section separated by MDM element (Problem Addressed, Data, Risk) for easy reference.
All E/M tools have been updated to align with the 2024 E/M guidelines.
2025 Provider Coding Bundle Digital Format
Where: https://www.pmiconline.com/product-page/2025-digital-coding-bundle-with-cpt-plus Your Price: $182.85 Sale Price (Hurry - Limited offer)
Publisher: PMICOnline
The best offer you will find for 2025 core coding products in digital format. The 2025 Provider Coding Bundle Digital Format includes one copy of each of the following references:
• CPT Plus 2025 Digital Format (November)
• ICD-10-CM 2025 Digital Format (August)
• HCPCS 2025 Digital Format (December)
Digital books, also known as electronic books or “e-Books,” are perfect for those who prefer reading on a screen rather than using traditional paper books. These e-books can be accessed on your PC, laptop, or tablet with just a click.
How to Handle Negative Patient Reviews and Unlock Adding 5 Star Reviews
Nearly three-quarters of internet users say they search online for health-related information or for a doctor or health professional near them who could best treat their symptoms. This presentation covers the importance of online reviews to today’s patients and doctors, including how to handle negative reviews and propel your practice forward.
Avoiding Balance Billing and the Waiving Copays and Deductibles Liability
Routinely writing off out-of-network or government program co-payments or deductibles, without meeting individual financial hardship exceptions, will most certainly land you in hot water-unless you know exactly how to comply with the fraud, waste, and abuse laws. In this webinar, Rachel Rose, Attorney at Law, helps you recognize these legal requirements and monitor your waivers to avoid compliance violations and penalties.
Practical HIPAA Compliance Advice
Myson Joseph with MLJ Consultancy LLC delivers practical HIPAA compliance advice, walking you through the HIPAA compliance journey to help you better understand how to achieve and maintain HIPAA compliance in your healthcare organization.
