very close to my heart and, when I given exposure front and center. My the beginning stages of dementia being seriously affected by this disease as a result, we made the decision is horrible to watch someone you deterioration of “self” and it has affected am thankful that my family has been decision and, when I say it takes us all mother has her good days and her only way we know how, and we’re brought us closer together and precious time is. I don’t know how (her mother lived until 96 and at least we know that she is safe Most importantly, she is not alone, some familiar faces around on the “bad”
are also experiencing what we are it is important that we, as careChatting with our editorial board quite a few have either cared for family members being cared for with Alzheimer’s) and am saddened by what
Detecting and Coding Elder Abuse
COVER FEATURE BY: Joy Rose, MSA, RHIA, CCS, CHA, CHPS, and Joanne Byron, BS, LPN, CCA, CHA, CHCO, CHBS, CHCM, CIFHA, CMDP, OHCC, ICDCT-CM/PCS of The American Institute of Healthcare Compliance. www.aihc-assn.org.
appears to be an uptick in the community. Is it just that they’re being diagnosed better/earlier or is it that more and more cases are happening? Other parts of the world refer to this family of diseases as type 3 diabetes, and the term “insulin resistance” is being mentioned more and more. It’s definitely something to think about, especially when our children are exposed to sugar, carbohydrates, and environmental toxins at earlier ages and larger quantities than my generation ever was. What does their future hold? I can’t help but wonder and pray that it will not be this disease or something along these lines. It’s sad to watch someone disappear like this and I don’t wish it on anyone. So, if you are helping a family member, please know that you are not alone. Reach out when those days get tough (and there are doozies sometimes!) and talk about it. There are several helplines and support groups out there, so get in touch before it gets too much.
Until next time. Storm Kulhan
M.A. editorial@billing-coding.com storm@billing-coding.com
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Detecting and Coding Elder Abuse
EXPERT Contributors this issue
Joanne Byron, BS, LPN, CCA, CHA, CHCO, CHBS, CHCM, CIFHA, CMDP, OHCC, ICDCT-CM/PCS, serves as Board Chair and Director at the American Institute of Healthcare Compliance. www.aihc-assn.org.
Sandy Coffta is VP of Client Services at Healthcare Administrative Partners. www.hapusa.com
Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, FAHIMA, is a past president and former interim CEO of AHIMA and recipient of AHIMA’s distinguished member and legacy awards. She is Chief Operating Officer of First Class Solutions, Inc., a healthcare consulting firm based in St. Louis, MO. First Class Solutions, Inc. assists healthcare organizations to enhance or transform their HIM operations, facility and physician office documentation, and revenue cycle performance, and provides coding support and coding audits. Rose is also the author of Libman’s HCC Fundamentals and Auditing programs. https://firstclasssolutions.com
Carrie Gluck, Chief Information and Security Officer at Rectangle Health, is an industry expert on various Information Security regulatory requirements, industry standards, and best practices. With more than 20 years of experience in Information Technology and Information Security, Carrie offers significant expertise in planning, developing, documenting, maintaining, and optimizing security and risk management processes. www.rectanglehealth.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
Regina Mixon-Bates is the CEO of the Physician Practice SOS Group based in Atlanta, GA. She has long been in high demand across the country for her unique style of working with healthcare executives, physicians, and their staff on topics that teach them how to make the most of their strengths and develop the creative innovation needed to succeed in management, compliance, and day-to-day operations. www.ppsosgroup.com
Sonal Patel, BA, CPMA, CPC, CMC, ICDCM, is CEO and Principal Strategist at SP Collaborative, LLC. www.spcollaborative.net
Joy Rose, MSA, RHIA, CCS, CHA, CHPS, is a member of the American Institute of Healthcare Compliance (AIHC) and serves as a subject matter expert on the AIHC Volunteer Education Committee. www.aihc-assn.org.
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
Austin Ward is Head of Growth at Fathom, the leader in autonomous medical coding. He oversees the company’s go-to-market efforts and client analytics. He brings broad experience in health systems, technology, and data science, and has worked at BCG, the Bill & Melinda Gates Foundation, and in venture capital. He holds an MBA from Stanford University, an MPA from Harvard University, and BAs from the University of Chicago. www.fathomhealth.com
NEWS
AMA Announces CPT Update for Avian Influenza Vaccines
The American Medical Association (AMA) recently announced an editorial update to Current Procedural Terminology (CPT®), the leading medical terminology code set for describing healthcare procedures and services, which includes a newly assigned provisional CPT code for vaccines to protect patients against the H5N8 strain of avian influenza (bird flu).
The provisional CPT code is effective for use on the condition the H5N8 influenza virus vaccine candidates receive emergency use authorization from the U.S. Food and Drug Administration (FDA). The AMA is publishing the CPT code update now to ensure electronic systems across the U.S. healthcare system are prepared in advance for the potential FDA authorization.
“The new CPT code is a vital preparatory step in response to the potential danger to humans from a highly infectious avian influenza disease,” said AMA President Bruce A. Scott, M.D. “A CPT code that clinically distinguishes the avian influenza vaccine allows for data-driven tracking, reporting, and analysis that supports planning, preparedness, and allocation of vaccines in case a public health response is needed for avian flu prevention.”
For quick reference, the new product code assigned to H5N8 influenza virus vaccines is:
90695: Influenza virus vaccine, H5N8, derived from cell cultures, adjuvanted for intramuscular use
The new CPT code for H5N8 influenza virus vaccines should be used with one of the following administration codes to report the work counseling patients or caregivers, administering the vaccine, and updating the medical record.
For children (through 18 years of age), the administration codes are:
90460: Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified healthcare professional; first or only component of each vaccine or toxoid administered
90461: Immunization administration through 18 years of age via
any route of administration, with counseling by physician or other qualified healthcare professional; each additional vaccine or toxoid component administered
For adults, the administration codes are:
90471: Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); one vaccine (single or combination vaccine/toxoid)
90472: Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid)
Changes to the CPT code set are considered through an open editorial process managed by the CPT Editorial Panel that collects broad input from the healthcare community and beyond to ensure CPT content reflects the coding demands of digital health, precision medicine, augmented intelligence, and other aspects of a modern healthcare system. This rigorous editorial process keeps the CPT code set current with contemporary medical science and technology so it can fulfill its vital role as the trusted language of medicine today and the code to its future.
Source: AMA – ama-assn.org
Many Patients Are Hit With Claims Denials. But Few Challenge the Decisions, Study Finds
A recent survey by the Commonwealth Fund reveals that nearly half of American adults have received a medical bill or copayment for services they expected to be covered by their insurance. Despite this, only a small fraction of individuals disputes these charges.
The survey, which included over 7,800 insured working adults, found that 45% had faced unexpected medical bills or copayments, while 17% experienced claim denials for services prescribed by their doctors. However, less than half of those affected took action to contest these costs.
The survey indicates that 54% of individuals did not challenge
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their bills or copayments because they were unaware of their right to do so.
Susan Collins, a co-author of the study and Vice President for Healthcare Coverage and Access at the Commonwealth Fund, commented, “When a significant number of insured individuals are confronted with unexpected bills and denied care that their doctors recommend, it underscores a failure in our healthcare system. This failure is largely due to convoluted billing practices and loopholes that diminish accountability for billing errors and unfair coverage denials.”
Collins added, “Patients deserve a better experience – they should not have to navigate a complex system to access the insurance and care they have paid for.”
The study also highlighted that uncertainty about challenging unexpected costs is more prevalent among low to moderate-income individuals, those under 50, and Hispanic adults. Notably, 60% of younger individuals, particularly those aged 19 to 34, were unaware of their rights to contest insurance decisions.
When patients do dispute claims or unexpected costs, they often achieve favorable outcomes. The survey found that 50% of those who challenged a denial managed to get some or all of the denied services approved, and 38% who disputed a bill succeeded in reducing or eliminating their charges.
Success rates were highest among Medicare recipients, with 61% achieving reduced or eliminated bills, followed by Medicaid enrollees at 46%.
The survey also revealed that 60% of individuals who faced coverage denials experienced delays in care, and 47% reported worsened health conditions as a result. Researchers suggest that these findings should encourage policymakers to enhance consumer protections. They recommend that the Department of Health and Human Services increase oversight of claims denials and impose stricter penalties on insurers who repeatedly deny coverage unfairly. Additionally, state and federal programs should improve efforts to educate consumers about their rights regarding billing disputes and claim denials.
Entering a Diagnosis and Procedure Code
The myth: Only physicians or other qualified healthcare professionals can enter or change the diagnosis and/or Current Procedural Terminology (CPT®) code(s) associated with an encounter,
procedure, or service.
Debunking the myth: While physicians and other qualified healthcare professionals are responsible for ensuring the use of the correct diagnosis and CPT codes, other appropriate individuals may physically enter or change the code when authorized. This should be done in consultation with the physician to ensure that any update reflects the service provided.
There is no federal regulation or CPT guidance mandating that only physicians or other billing healthcare professionals may enter or change diagnosis and procedure codes when the need arises either before a claim is submitted or after one has been denied and requires correction. Likewise, there is no federal regulation or CPT guidance prohibiting certified professional coders from reviewing diagnosis and procedure codes, respectively, for compliance with reporting guidelines and regulations.
The CMS E/M guidelines state that a billing specialist may review documentation before a claim is submitted or resubmitted. Additionally, the ICD-10-CM guidelines state, “A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses.” CPT guidance requires that the performing healthcare professional maintain responsibility for correct coding, so the collaborative relationship between physicians and coders is important to ensure that the appropriate diagnosis and procedure codes are used.
Background
In many healthcare settings, a procedure or service is reviewed by a certified professional coder or other billing specialist before being submitted as a claim to the payor. In some instances, CPT codes and/or the associated diagnosis codes need to be adjusted to match the service provided or corrected if the wrong code was selected by mistake. Some organizations require that these changes be made only by the physician or other qualified healthcare professional who performed the service, incorrectly assuming that billing and coding professionals are not permitted to make such changes.
Source: AMA – ama-assn.org
Gender-Based
A recent study highlights significant gender-based differences in practice patterns and reimbursement rates among various
surgical subspecialties serving Medicare patients, according to research published online on July 24 in JAMA Surgery.
Dr. Muhammad Musaab Munir and his team from The Ohio State University Wexner Medical Center investigated these disparities by analyzing publicly available Medicare Fee-for-Service Provider Utilization and Payment data. Their retrospective cross-sectional study covered 20,549 general surgeons (24.5% female, 75.5% male), 1,065 surgical oncologists (42.3% female, 57.7% male), and 1,601 colorectal surgeons (27.0% female, 73.0% male).
The findings revealed that female surgeons consistently billed fewer Medicare charges across all subspecialties, with differences of 30.1% for general surgeons, 27.5% for surgical oncologists, and 21.7% for colorectal surgeons. Moreover, they received significantly lower reimbursements – 29.0% less for general surgeons, 23.6% less for surgical oncologists, and 24.5% less for colorectal surgeons. Even after adjusting for variables, the reimbursement gap persisted: −$14,963.46 for general surgeons, −$8,354.69 for surgical oncologists, and −$4,346.73 for colorectal surgeons.
The study’s authors conclude, “These findings indicate that gender disparities in surgical practices, billing, and revenue continue to exist. To address these inequities, it is crucial to refine billing and coding practices to ensure fair compensation and create a more equitable environment for female surgeons to advance their clinical careers.”
CMA Urges Congress to Reform the Medicare Fee Schedule
The California Medical Association (CMA) and the American Medical Association (AMA) have called on Congressional leaders to advance five critical bills aimed at reforming the Medicare fee schedule due to increasing unsustainability in the current payment system. The letter highlights the urgent need for these reforms to maintain patient access and care quality.
Key Issues and Proposed Solutions
Medicare Economic Index (MEI) Inflation Update:
• Problem: CMS projects significant increases in MEI practice expenses for 2024 and 2025, yet physician payments have been reduced, leading to a 29% decline in Medicare physi-
cian payment since 2001. This could severely impact patient access to care.
• Solution: Passing H.R. 2474, the “Strengthening Medicare for Patients and Providers Act,” would provide a permanent annual inflation update tied to MEI, stabilizing physician payments.
Budget Neutrality Reform:
• Problem: The MPFS requires budget-neutral adjustments, causing overestimates in new service utilization and unnecessary payment reductions. Frequent redistributions negatively affect physician income.
• Solution: H.R. 6371, the “Provider Reimbursement Stability Act,” would require CMS to correct inaccurate utilization predictions and adjust the MPFS conversion factor, with a proposed amendment to exempt new benefits and technologies from budget neutrality.
Merit-Based Incentive Payment System (MIPS) Reporting Reform:
• Problem: Current MIPS reporting requirements are clinically irrelevant and disproportionately burden small and rural practices.
• Solution: Proposed legislation would freeze performance thresholds for three years, adjust bonuses, ensure CMS provides performance feedback, improve measurement accuracy, and reduce penalties for small and rural practices.
Alternative Payment Model (APM) Reform:
• Problem: The current APM bonus payment will expire, and the revenue threshold to qualify for bonuses will increase to 75%, which is challenging to meet.
• Solution: S. 3503/H.R. 5013, the “Value in Health Care (VALUE) Act,” aims to extend the 5% APM incentive payments and maintain the 50% revenue threshold for an additional two years.
The CMA and AMA stress that these reforms are crucial to ensuring a fair and effective Medicare payment system.
Source: AMA
Coding Rules of the Road for ICD-10-CM: Chapter 1
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-10-CM) 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 on-the-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. The last article highlighted the general ICD-10-CM coding guidelines. This article continues the discussion, moving on to Chapter 1: Certain Infectious and Parasitic Diseases (A00-B99), U07.1, and U09.9, and discusses some of the major guidelines.
SChapter 1 of the ICD-10-CM is dedicated to coding infectious and parasitic diseases, encompassing a wide range of conditions caused by bacteria, viruses, fungi, and parasites. The codes in this chapter are organized into various blocks, each representing a specific group of diseases.
Here’s a breakdown of the major blocks within Chapter 1:
• A00-A09: Intestinal infectious diseases
• A15-A19: Tuberculosis
• A20-A28: Certain zoonotic bacterial diseases
• A30-A49: Other bacterial diseases
• A50-A64: Infections with a predominantly sexual mode of transmission
• A65-A69: Other spirochetal diseases
• A70-A74: Other diseases caused by chlamydiae
• A75-A79: Rickettsioses
• A80-A89: Viral and prion infections of the central nervous system
• A90-A99: Arthropod-borne viral fevers and viral hemorrhagic fevers
• B00-B09: Viral infections characterized by skin and mucous membrane lesions
• B10-B19: Viral hepatitis
• B20-B24: Human immunodeficiency virus (HIV) disease
• B25-B34: Other viral diseases
• B35-B49: Mycoses
• B50-B64: Protozoal diseases
• B65-B83: Helminthiases
• B85-B89: Pediculosis, acariasis, and other infestations
• B90-B94: Sequelae of infectious and parasitic diseases
• B95-B97: Bacterial and viral infectious agents
• B99: Other infectious diseases
tructure of Chapter 1: ICD-10-CM
Specific Guidelines for Key Diseases
Human Immunodeficiency Virus (HIV) Infections
Code only confirmed cases of HIV infection/illness. The provider’s diagnostic statement is sufficient.
Selection and Sequencing of HIV Codes:
• Patient admitted for HIV-related condition: Use B20 as the principal diagnosis, followed by codes for all reported HIVrelated conditions.
• Patient with HIV admitted for unrelated condition: Code the unrelated condition first, followed by B20 and additional HIV-related conditions.
• Asymptomatic HIV: Use Z21 for patients listed as “HIV positive” without symptoms or HIV-related illnesses.
• Inconclusive HIV Serology: Use R75 for patients with inconclusive HIV serology without a definitive diagnosis.
• Previously Diagnosed HIV-Related Illness: Use B20 for any known prior diagnosis of an HIV-related illness.
• HIV in Pregnancy, Childbirth, and the Puerperium: Use O98.7- followed by B20 and codes for the HIV-related illnesses for symptomatic patients. For asymptomatic patients, use O98.7- and Z21.
• Encounters for HIV Testing: Use Z11.4 for screening and Z71.7 for HIV counseling if provided. Code signs and symptoms if present.
• HIV Managed by Antiretroviral Medication: Use B20 and Z79.899 for long-term antiretroviral therapy.
• Encounter for HIV Prophylaxis: Use Z29.81 for pre-exposure prophylaxis (PrEP).
Examples:
• A patient with HIV presents with Kaposi’s sarcoma of the skin. The correct codes are B20 (HIV disease) and C46.0 (Kaposi’s sarcoma of skin). The B20 code would be first-listed, followed by the HIV-related condition according to the guidelines.
Sepsis Infections
Sepsis and severe sepsis have separate codes:
• Sepsis: Sepsis is coded with a single code from category A41 (Other sepsis) unless the sepsis is specified as due to a specific organism, in which case a combination code for the specific infection should be used.
Example: A patient diagnosed with sepsis due to Staphylococcus aureus should be coded as A41.01 (Sepsis due to Methicillin susceptible Staphylococcus aureus).
• Severe Sepsis: Severe sepsis is coded with a combination of codes: one for the underlying systemic infection and another for the severe sepsis itself, along with any associated acute organ dysfunction. Use code R65.20 (Severe sepsis without septic shock) or R65.21 (Severe sepsis with septic shock) to indicate severe sepsis.
Example: A patient diagnosed with severe sepsis with acute kidney failure should be coded as A41.9 (Sepsis, unspecified organism) and R65.20 (Severe sepsis without septic shock), along with N17.9 (Acute kidney failure, unspecified).
When sepsis results from a postprocedural infection, a combination of codes should be used:
• One for the specific type of infection
• Another for the sepsis
Example: A patient develops sepsis after a surgical procedure due to a postoperative infection. The correct codes would be T81.40XA (Infection following a procedure, initial encounter) and A41.9 (Sepsis, unspecified organism).
If sepsis is due to a non-infectious process, the code for the non-infectious condition is:
• A patient with diabetes mellitus type II is seen for a routine follow-up visit. His diabetes is well-controlled with medication. It is also noted that the patient has AIDS. The appropriate codes are E.11.9 (type II diabetes mellitus without complications) and B20 (HIV disease). In this scenario, the B20 code is listed second as diabetes is not an HIV-related condition.
• Sequenced first
• Followed by the appropriate sepsis code
Example: A patient develops sepsis due to an 8% total body surface area (TBSA) burn injury. The correct codes would be the code for the specific burn injury (e.g., T31.0 for burns involving less than 10% of body surface) followed by A41.9 (Sepsis, unspecified organism).
Special considerations of sepsis include:
• Coding for Sepsis in Newborns: Sepsis in newborns is coded differently and requires codes from category P36 (Bacterial sepsis of newborn).
Example: A newborn diagnosed with neonatal sepsis due to E. coli should be coded as P36.4 (Sepsis of newborn due to Escherichia coli [E. coli]).
• Sepsis and Septic Shock: Septic shock is a severe and potentially fatal condition that can result from sepsis. It is coded using a combination of codes for the underlying sepsis and the septic shock.
Example: A patient diagnosed with sepsis and septic shock due to Streptococcus pneumoniae should be coded as A40.3 (Sepsis due to Streptococcus pneumoniae) and R65.21 (Severe sepsis with septic shock).
Coronavirus Infections
COVID-19:
• ICD-10-CM Code: U07.1 (COVID-19)
• Confirmed Only: This code is used for confirmed cases of COVID-19. A confirmed diagnosis does not require a positive test result; a provider’s diagnostic statement that the patient has COVID19 is sufficient.
Example: A patient is admitted with a confirmed diagnosis of COVID-19. The correct code is U07.1.
Encounters for Screening:
• ICD-10-CM Code: Z11.52 (Encounter for screening for COVID-19)
• Screening Only: Use this code when a patient is being screened for COVID-19 and does not exhibit symptoms or have a known exposure to the virus.
Example: A patient comes in for a routine COVID19 screening required by their workplace. The correct code is Z11.52.
Exposure to COVID-19:
• ICD-10-CM Code: Z20.822 (Contact with and [suspected] exposure to COVID-19)
• Suspected Only: Use this code when a patient is exposed to COVID-19 and is either asymptomatic or is being tested for COVID-19 but has not yet been confirmed to have the disease.
Example: A patient reports close contact with a confirmed COVID-19 case and is being tested for the virus. The correct code is Z20.822
COVID-19 in Pregnancy, Childbirth, and the Puerperium:
• ICD-10-CM Codes: O98.5- (Other viral diseases complicating pregnancy, childbirth, and the puerperium)
• Pregnancy/Childbirth/Puerperium Only: When COVID-19 complicates pregnancy, childbirth, or the puerperium, use codes from category O98.5along with U07.1.
Example: A pregnant patient in her second trimester is diagnosed with COVID-19. The correct codes are O98.512 and U07.1.
• In Addition-To: MIS is a condition that can occur after a COVID-19 infection. Use this code for patients diagnosed with this syndrome, and U07.1 if COVID-19 is still present.
Example: A child is diagnosed with multisystem inflammatory syndrome following a COVID-19 infection. The correct codes are M35.81 and U07.1 if the COVID-19 infection is still active. If COVID is still present, U07.1 would be coded first according to the guidelines.
• Post Only: This code is used for conditions that develop as a result of a previous COVID-19 infection. Do not use U09.9 during an active COVID-19 infection.
Example: A patient presents with fatigue and dyspnea months after recovering from COVID-19. The correct code is U09.9 for the post-COVID-19 condition, along with additional codes for the specific symptoms. U09.9 would be coded following the specific condition related to COVID-19, if known.
Special Considerations:
• Asymptomatic COVID-19: When a patient tests positive for COVID-19 but is asymptomatic, the code U07.1 should still be used.
Example: A patient tests positive for COVID-19 but does not exhibit any symptoms. The correct code is U07.1.
• Symptoms without a Confirmed Diagnosis: When a patient presents with symptoms of COVID-19 but no confirmed diagnosis, code the symptoms.
Example: A patient presents with fever, cough, and shortness of breath but has not been confirmed to have COVID19. The correct codes are R50.9 (Fever, unspecified), R05 (Cough), and R06.02 (Shortness of breath).
Conclusion
Accurate coding of ICD-10-CM is crucial for patient care, epidemiological tracking, and reimbursement. By adhering to the official guidelines and ensuring thorough documentation, medical coding professionals can contribute to effective management and reporting of cases. Continuous education and staying updated with evolving guidelines are essential for mastering the complexities of coding. In future issues, watch for these articles on other specific chapters of ICD-10-CM.
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
Navigating the Storm: Key Strategies for Effective Denials Management in Healthcare
In the intricate landscape of healthcare financing, denials management emerges as a formidable hurdle, especially amidst the surge in clinical and technical denials. These denials not only lead to payment delays but also set off a chain reaction of adverse financial ramifications, including increased labor or vendor expenses for appeal processes and heightened write-offs. Consequently, healthcare leaders find themselves compelled to embrace proactive measures to navigate these challenges and uphold financial stability.
Medical billing denials generally fit into two main types: hard denials and soft denials. Hard denials occur when claims are outright rejected, necessitating corrective measures for successful resubmission. Conversely, soft denials represent initial refusals that can often be resolved through clarification or the provision of additional information.
Essential Approaches for Managing Denials
Identify Root Causes: Conduct a thorough analysis to identify the root causes of denials, whether they stem from coding errors, billing inaccuracies, or documentation deficiencies. By pinpointing recurring issues, healthcare organizations can implement targeted solutions to prevent future denials.
Robust data analytics tools can help to identify patterns and trends in denials, whether they stem from billing
or clinical inaccuracies. By analyzing denial reasons, frequency, and payor-specific trends, managers can pinpoint areas of vulnerability and implement targeted interventions. Real-time data analytics enable proactive identification and resolution of denial issues, minimizing revenue leakage and optimizing cash flow.
Ensure that coding personnel receive thorough training and strictly follow coding guidelines set forth by regulatory entities like the American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS). This includes educating healthcare providers on proper documentation practices. Precision and compliance in coding are crucial for reducing denials stemming from coding inaccuracies. Clinical inaccuracies are a significant contributor to denials. Strengthening CDI programs can substantially reduce clinical denials by ensuring accurate and comprehensive documentation of patient care. Conducting regular audits and imple-
menting clinical decision support tools can enhance the accuracy and completeness of medical records. By capturing the complexity and severity of patient conditions, CDI programs not only reduce denials but also support appropriate coding, reimbursement, and compliance with regulatory requirements.
Open and Clear Communication: Encourage transparent communication among billing personnel, coding experts, healthcare providers, and insurance firms to expedite the prompt resolution of denials. Implement procedures for efficiently handling denials and elevate unresolved matters as required.
Streamlined Appeals Management Processes: The appeals process is often cumbersome and time-consuming, exerting additional strain on financial resources. To streamline appeals management, healthcare organizations should implement efficient workflows, leverage technology for automation, and standardize documentation requirements. Centralizing denials management functions and establishing clear escalation protocols can expedite the resolution of appeals, minimizing payment delays and reducing administrative burden. Furthermore, conducting root cause analysis of overturned denials can inform process improvements and prevent recurrence.
Payor Collaboration and Negotiation: Effective denials management necessitates collaboration and communication with payors to address underlying issues and prevent future denials. Healthcare financial leaders should engage in proactive dialogue with payors to understand their adjudication processes, policies, and coverage guidelines. By fostering transparent relationships and advocating for fair reimbursement practices, organizations can negotiate favorable contracts and reduce denial rates. Collaborative efforts such as joint operational meetings and performance scorecard reviews facilitate alignment between providers and payors, fostering a culture of mutual accountability and problem-solving.
Investment in Technology and Training: Technology plays a pivotal role in modern denials management, offering innovative solutions for detection, prevention, and resolution of denials. Implementing advanced revenue cycle management (RCM) systems equipped with artificial intelligence (AI) and machine learning capabilities can enhance claims accuracy, optimize
coding processes, and minimize denials. Additionally, investing in staff training programs ensures proficiency in denials management protocols, coding guidelines, and regulatory requirements. Continuous education empowers employees to navigate complex reimbursement landscapes effectively and adapt to evolving industry dynamics.
Conclusion
Effective denials management is imperative for healthcare organizations grappling with the rising tide of clinical and technical denials. By embracing a multifaceted approach encompassing data analytics, CDI programs, streamlined appeals processes, payor collaboration, and technological innovation, management can mitigate the financial impact of denials and safeguard revenue integrity. In an era of unprecedented challenges, proactive denials management emerges as a driving force for sustainable financial performance and optimal patient care delivery in healthcare.
Regina Mixon Bates CEO at The Physicians Practice S.O.S. Group
Regina Mixon Bates is the Director of The Physicians Practice S.O.S. Group®, a healthcare consulting and educational firm that provides services such as: longrange planning, IRO services, practice assessments, practice management, A/R management and oversight, new practice set up that includes facility design, auditing, and training to physicians and their staff. The company has helped healthcare providers across the country streamline their A/R process, improve patient flow, practice management, and compliance, and keep current with ever-changing state and federal guidelines. They provide extensive quantitative analysis that generates comprehensive reports to help identify the practice problem areas, as well as opportunities for expansion. Their consultants help the physicians and their staff to fully understand the data collected and implement sustainable solutions. In August of 2012, she franchised the company, the first of its kind in the country and offers franchise opportunities in 35 states.
www.ppsosgroup.com
The True Costs of Coding Errors: How AI Turns Challenges Into Opportunities
Accurate medical coding is a critical goal for health systems. Many strive for 95% overall coding accuracy, though true accuracy often falls short. With so many possible codes –for example, ICD-10 alone has about 70,000 diagnoses – it’s easy for mistakes to happen despite the best efforts of dedicated professionals. Unfortunately, inaccurate coding does more than cause administrative headaches – it exerts a financial toll on organizations in a myriad of ways.
Few providers fully comprehend the true enterprise-wide costs associated with coding inaccuracies. Aside from slowing down the revenue cycle, coding mistakes prevent proper reimbursement and result in inaccurate, incomplete patient records. But what options do providers have for reducing them?
One increasingly common choice is autonomous coding. Many organizations are turning to the latest generation of AI medical coding technology for its ability to markedly reduce errors, enhance accuracy, and improve financial outcomes.
However, before examining the role of AI in improving the accuracy of coding, it is crucial to understand how coding errors negatively impact an organization’s financial health and operational efficiency. This understanding illuminates the full scale of the problem and the stakes for implementing effective programs to improve accuracy.
The True Costs of Coding Errors
Coding errors have far-reaching consequences, but there are three major categories for providers to monitor: administrative burdens, lost revenue, and disrupted cash flow.
Administrative Burden
The costs of administrative tasks are shockingly high –in 2022, the healthcare system spent $82.7 billion on them alone, as reported by RevCycle Intelligence. When coding errors arise, they create administrative costs in at least four ways: labor time spent on review, managing denials, training, and clinician impact. First, catching and correcting coding errors requires close review by medical coders and administrative staff. Factor in the burden of managing coding-related denials – according to a
Premier survey, providers waste $10.6 billion yearly on fighting denials – and labor and administrative overhead continue to escalate.
Providers also have to invest sizable resources in ongoing training and education to keep coding staff up to date with guideline changes. On the clinician side, excessive administrative burden creates friction and contributes to burnout among staff, resulting in higher turnover rates with financial ramifications. When physicians are busy keeping up with administrative duties, they have less time to dedicate to patient care. In this way, coding errors amplify administrative costs and exacerbate staff stress, diverting attention from patient care and lowering service quality.
Lost Revenue
Coding errors are a major cause of denied claims, resulting in lost revenue, or otherwise leaving money on the table. The American Medical Association found that denials represented 11% of all claims in 2022, corresponding to 110,000 unpaid claims for an average-sized health system. While overcoding can contribute to coding-related denials, undercoding is a frequent behavior that causes providers to miss out on appropriate revenue.
For example, undercoding occurs when coding results understate the full extent of reimbursable services performed. Imagine that a physician conducts a comprehensive examination in the Emergency Department and manages multiple complex conditions, but the coding team only bills for a low-acuity evaluation and management (E/M) code. This behavior results in lower revenue than appropriate, as the claim fails to represent the totality of reimbursable services rendered according to E/M guidelines.
Cash Flow Disruption
Inaccurate coding disrupts cash flow, making it more difficult for provider organizations to manage their finances effectively. Reimbursement delays start to pile up when claims are fre-
quently denied or require resubmission due to coding errors. This backlog then strains the organization’s liquidity, pushing cash receipts further into the future. At the same time, increased working capital costs, exacerbated by recent interest rate conditions, put more pressure on finance teams. In this way, cash flow disruptions – stemming originally from coding errors – can severely impact operations.
Enhancing Accuracy With Autonomous Coding
Given the myriad ways that coding errors drive financial challenges for providers, how are forward-thinking leaders considering technology to help? Many executives are catching on to the benefits of AI for improving coding accuracy and other revenue cycle outcomes. For example, a Bain and KLAS survey found that 58% of healthcare leaders have either implemented an AI adoption strategy or are in the process of creating one.
In particular, Bain and KLAS found that revenue cycle management was the top priority for new technology. By improving accuracy, technology such as autonomous coding directly mitigates the financial repercussions of coding errors.
Here are four concrete ways in which autonomous coding enhances accuracy and, consequently, financial performance:
1. Reduced Costs: AI coding is significantly less expensive than manual coding (typically 30-50% lower cost on a per-encounter basis), even compared to off-shore operations, while delivering higher accuracy. The increased accuracy of AI coding – from training models on hundreds of millions of high-quality coded encounters – offers further cost savings by reducing time and effort spent on lengthy and complex corrections along with other forms of administrative overhead.
2. Improved Revenue Capture: Increased coding accuracy with AI is especially important for E/M coding, ensuring that all services rendered are appropriately documented and billed for proper acuity leveling. Autonomous coding technology
can also capture procedures that human coders might overlook. Both of these effects can lead to higher relative value units (RVUs), where appropriate. The quality of autonomous coding is particularly beneficial for physicians who are compensated based on RVUs, as accurate coding directly impacts their personal income.
3. Reduced Denials: Autonomous coding improves accuracy and compliance, consequently minimizing coding-related denials. Reducing denials makes the claims process run more smoothly and frees up resources, giving staff time to spend on managing high-value encounters. Shorter delays enhance RCM, leading to a more stable and predictable financial environment. Depending on the configuration, AI coding may also provide insights into common reasons for denials, empowering providers to address these issues upstream.
4. Enhanced Consistency and Continuous Improvement: AI coding approaches each encounter uniformly to ensure consistent application of coding guidelines across all cases, leading to more predictable and reliable outcomes for providers. One large advantage that autonomous systems have over human coders is the ability to instantly adapt to new coding guidelines, such as the latest CMS-HCC-V28 updates. Historically, guideline changes take months for revenue cycle and coding teams to adopt, increasing organizational training costs. But with autonomous coding, the technology immediately implements coding guideline updates and payor rules, helping providers to remain compliant and up to date.
These impacts are not theoretical. Take the example of ApolloMD, a nationwide physician group serving millions of patients at more than 100 hospitals and health systems across the US. By bringing on autonomous coding, the organization has improved coding accuracy and quality, reduced costs, and relieved
administrative burdens for clinicians. Many organizations are pursuing similar projects across medical specialties to reduce their enterprise-wide costs stemming from coding inaccuracies and to set themselves up for long-term financial and operational stability.
Turn Coding Challenges Into Opportunities
From an enterprise-wide perspective, the true costs of coding errors are undeniable: They result in administrative burdens for staff, lost revenue, and disrupted cash flow. Enhancing coding accuracy –reaching or exceeding the typical 95% goal – is a worthy initiative that delivers benefits across the organization.
To overcome the practical challenges that have historically impeded efforts at boosting accuracy, the latest generation of coding automation technology offers an exciting advantage. Providers incorporating autonomous coding into their revenue cycle organization solve the root causes of coding errors and thereby unlock reduced costs, improved revenue capture, and reduced denials. By implementing AI, billing and coding leaders turn coding challenges into opportunities for growth – bolstering their financial future.
Austin Ward is Head of Growth at Fathom, the leader in autonomous medical coding. He oversees the company’s go-to-market efforts and client analytics. He brings broad experience in health systems, technology, and data science, and has worked at BCG, the Bill & Melinda Gates Foundation, and in venture capital. He holds an MBA from Stanford University, an MPA from Harvard University, and BAs from the University of Chicago.
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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.
Safeguarding Your Practice from Cyberattacks:
A Provider’s Guide
Delivering effective and personalized care to healthcare patients relies on a robust, trusting, and collaborative patient-provider relationship. Yet, the recent rise of cyberattacks targeting all corners of the healthcare industry has adversely affected patient data security, provider care operations, and, ultimately, individual health outcomes.
While the recent announcement from the White House, Microsoft, and Google regarding their joint initiative to enhance security in rural healthcare organizations is certainly uplifting, cybersecurity should be a priority for all practices. As we’ve seen from multiple incidents and outages just this year, the current cybersecurity framework of the American healthcare system is a systemic vulnerability, and these attacks can happen to anyone.
Recent breaches have disrupted operations and, in many cases, forced a return to manual and paper-based processes. In other cases, they’ve negatively compounded already tedious tasks such as payment reconciliation, managing claims, and examining comprehensive patient data. As a result, staff morale, operational efficiency, and productivity are impacted, and it is essential for healthcare providers to implement technical measures to safeguard their patients, staff, and practice from potential cyber threats.
This article will delve into the common causes of cyberattacks, offering practical and effective strategies for staff to prevent and mitigate these threats. Additionally, it will outline proactive measures to ensure system integrity, secure patient data, and improve existing processes, ultimately fostering a resilient and successful practice.
How Do Cyber Breaches Happen?
The administrative arm of the healthcare industry remains under significant stress, intensifying the need for robust security measures. According to CDW’s recent Cybersecurity Report, only 14 percent of healthcare organizations report having fully staffed IT security teams, while around 30 percent of IT professionals indicate their organizations are significantly understaffed. This underscores the urgent cybersecurity needs within the healthcare sector.
The majority of cyberattacks, even those targeting major organizations, stem from systemic lapses in compliance
and cybersecurity protocols. Additionally, research from the American Hospital Association, FBI, and IBM found that stolen credentials are among the most common methods hackers use to gain access and are often obtained with minimal effort. Nefarious hackers frequently employ email phishing techniques targeting login and financial information through means such as sending fake invoices or impersonating close contacts. Providers should ensure that all staff are aware of and properly trained in identifying and avoiding phishing threats and that their administrative software requires strong, unguessable passwords.
While it is impossible to eliminate all threats, providers can take proactive measures to protect staff, patients, and data from external risks. Below are essential cybersecurity and compliance protocols that providers can implement to effectively safeguard their community and stakeholders.
Personalized, Actionable, and Data-Driven Compliance Tips
When evaluating and enhancing cybersecurity compliance and frameworks, providers and any external support they engage should approach this process with thoroughness and introspection. By utilizing up-to-date software to manage operations, providers can assess their current cyber readiness with personalized, data-driven insights. Most importantly, this high-quality, relevant data will offer staff actionable recommendations to protect their practice from cyberattacks.
Here are five best practices for achieving compliance:
1. Follow governmental and industry standard regulations. Following HIPAA and OSHA guidelines is required, and compliance can often feel stressful and tedious in the wake of managing burdensome administrative tasks and patient needs. Additionally, further guidelines such as HITRUST certification and PCI (payment card industry) are becoming necessities for providers managing their practices through increasingly digitalized mediums. While at first glance, these extra guidelines may seem even more burdensome and even costly, compliance solutions can help alleviate these feelings and quickly bring them into practice.
2. Implement thorough staff training on compliance, protocols, and communication. Staff should receive comprehensive training on compliance and protocols, emphasizing the principle of least privilege (PoLP). PoLP, a key IT security
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- 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.
concept, ensures that staff can only access the information and resources necessary for their specific roles, minimizing the risk of exposing sensitive patient or financial data. Additionally, staff training should cover phishing and social engineering and highlight the importance of communication. This enables employees to adhere strictly to protocols and inform patients about steps they can take to protect their personal information.
• 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.
3. Use Virtual Private Networks (VPNs) in remote work settings. As hybrid work and remote position offerings become the norm, provider organizations should acquire and require staff to use a VPN when working from home or in public places. Public Wi-Fi in places such as a coffee shop is usually unsecured, and employees working on these networks can expose their organization to session hijacking, eavesdropping, malware, and credential thefts.
• 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,
4. Require login protections. As previously discussed with email phishing, if employees properly fortify their logins, the practice has already taken a significant step in reducing cyberattack risk. Additionally, best-in-class compliance solutions offer proven methods for further fortification, including double encryption, multi-factor authentication, mandatory and time-based password resets, and complex password requirements.
will help to ensure that the practice is in full compliance.
Conclusion
While regularly conducting internal audits and assessments can feel tedious, stressful, and even costly, the benefits far outweigh the effects and amplified feelings brought on by cyber breaches and and integrating modern ing clear employee training and protocols enable providers patients, and sensitive information actors.
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
Ultimately, the surge in cyberattacks healthcare sector’s need oritize administrative systems enue diversification strategies. already in place, organizations one source of cash, such positioned to both navigate and build a thriving practice
Carrie Gluck, Chief
Payment Locality Reporting for Radiology Professional Services
5. Ensure operations-ready backup systems and/or protocols are in place. While cyberattacks frequently cause system and server outages, they can arise from various factors. In today’s environment, practices must have clearly trained and understood protocols in place for any system downtimes. Defined roles and communication channels should be established and comprehended in advance to help staff effectively navigate highly stressful and chaotic situations.
Industry-Wide Vulnerabilities Go Beyond Isolated Cyberattacks and Stolen Data
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
Information and Security is an industry expert on latory requirements, industry With more than 20 years Technology and Information nificant expertise in planning, maintaining, and optimizing processes. She also shares her diverse experience in a wide array of security technologies for authentication, encryption, monitoring, and management of systems. Carrie’s extensive education in Information Security includes a Master of Science in Information Security and Assurance from Norwich University, as well as ten industry-leading IS, risk, and IT audit certifications.
www.rectanglehealth.com
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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.
What the Strike Down of Chevron May Mean to HIM Professionals
On June 28, 2024, the Supreme Court unraveled the 1984 decision, Chevron v. Natural Resources Defense Council. Chevron has been one of the most cited decisions in American law, because it granted significant power to executive agencies that regulate many aspects of our lives and work.
The ruling will make it easier to challenge regulations across an array of issues, like keeping the water clean; ensuring car seats are safe; what Medicare covers including NCDs/LCDs; and CMS regulations related to billing and coding (for example, will we use ICD-9, 10, or 11?); and even regulations associated with EMTALA and utilization review.
Legal challenges at the federal levels have relied on Chevron to defuse and dismiss challenges to regulations. According to the precedent established in Chevron, if part of the law Congress wrote empowering a regulatory agency is ambiguous but the agency’s interpretation is reasonable, judges should defer to the agency.
In the New York Times, “How a Fishery Case Fits Into a Long-Game Effort to Sap Regulation of Business” (Jan. 17, 2024), Charlie Savage contends that critics of Chevron argue that Chevron put too much power in the executive branch when the courts are competent to interpret the law. Proponents of Chevron counter-argue that without the agency regulations, courts may be overwhelmed and dealing with many technical issues that judges have no expertise to resolve.
We need to make a distinction here. Regulations and interpretations are issued after a law or statute is established. Chevron and its demise are placing regulations and interpretations on the table for questioning.
Savage also reported that Jody Freeman, a Harvard University law professor who specializes in administrative and environmental law, suggested that the rejection of Chevron will create “a free-for-all for judges to dig into the nitty-gritty of everything agencies are doing” and “an invitation for interest-group lawyers to try to tie up the agencies in legal knots.” In contrast, as reported by the HFMA in “Supreme Court Ruling on Chevron Makes Regulations in Healthcare More Vulnerable to Legal Challenges” (June 28, 2024), the Supreme Court stated that “Courts must exercise their independent judgment in deciding whether an agency has acted within its statutory authority. Courts are in a better position to resolve the statutory ambiguities.”
One, if not the first, lawsuit was filed in Mississippi, with the court issuing an injunction on July 3, 2024, on behalf of 15 state Medicaid agencies, preventing the Biden administration from enforcing regulations expanding anti-discrimination gender specific protections in the Affordable Care Act (ACA). In this case, reported by the HFMA in “HHS Issues Regulations to Strengthen Anti-Discriminatory Protections in Healthcare” (July 3, 2024), according to the Mississippi Court, the relevant laws—that is, statutes—are Title 9 and ACA, and neither mentions gender identity.
Many agency interpretations could now be out and the courts’ decisions in, which means that statutes trump regulations.
Although not identical in nature, think about what has happened in the courts since Roe v. Wade was struck down. Now, let’s consider what the Chevron decision might mean for coding and billing guidelines that will be on the table for payors to litigate the validity of, and how the guidelines may be modified in each court. Could we end up with guidelines that are not just payor-specific but also state-specific?
John Hall, MD, JD, mentioned on Monitor Mondays (July 8, 2024) that we have 94 federal courts. Texas has four and could therefore have four different decisions on the same agency interpretation!
The HFMA shared a perspective that hospitals that disagree with CMS’s application of the market basket in its annual determination of Medicare payments or covers an item or service or not, could litigate and successfully argue the issue. Specifically, “There are thousands of pages of regulations and manuals containing agency interpretations of program requirements such as coding for risk adjustment payments, qualifications for disproportionate share hospital payments, [and] supervision requirements for use of physician extenders…”
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Within those stacks of agency interpretations and regulations will be such regulations as: coding for HCCs, what should be in an H&P, the two-midnight rule, billing rules, E/M requirements, what constitutes a complete record, and so on. Consider just the HIPAA requirements: Could attorneys litigate what is PHI and what isn’t, how much/if anything should be charged for copies, and who may access the record?
One suggestion offers a workaround employing negotiated rulemaking, a process in which a committee of agency experts and affected parties collaborates on proposed regulations. Reported by Polsinelli in “The Chevron Doctrine: Part 1” (May 2, 2024), “Although negotiated rulemaking is not appropriate for all regulations, advocates have felt the approach can speed rule development, reduce litigation, and generate more creative and effective regulatory solutions. Congress has sometimes mandated negotiated rulemaking and established specific procedures and time frames to follow.”
What actions should revenue cycle and health information professionals take?
1. Review and understand the rationale behind the specific coding rules that you may be using for appeals. Just citing agency interpretations and guidelines may no longer suffice and could be ignored by payors. If an appeal goes up the judiciary ladder, coding professionals and denial specialists will need to argue the rationale of the code applied and even the sequencing of those codes.
2. Capture and compare the application of payor coverage rules for similar patient populations and the payors’ billing requirements to define the industry norm. Again, payors may use the demise of the Chevron rule to apply their own billing requirements. In court, you and your attorneys may need to promote the norm and defend against using willy-nilly requirements. Imagine having to configure the organization or practice’s billing and edit systems for each payor’s application of the standard billing rules. Explaining the technological challenges to modify a billing system to accommodate rules that are unique to a single payor for the services being claimed for a commercial, Medicaid, or Medicare patient will benefit the organization should it file or
be a party to a lawsuit against a payor.
3. Proactively convene functional leaders from those functions that are substantially governed by agency regulations. This includes finance, compliance, health information, coding, revenue cycle, payroll, pharmacy, laboratory, etc. to forecast “what ifs” and identify issues that are controversial or vulnerable to litigation because they are based on agency rules, such as whether and how much you can charge for copies of records, what is considered protected health information for individuals participating in research, what needs to be in a compliance plan, what if the inpatient only list is challenged, should CISA requirements for cybersecurity protections be followed, and so forth. Any of these are possibilities now that Chevron has been struck down.
4. Communicate with our congressional members and encourage the use of negotiated rulemaking. And, at the same time, urge each of our professional associations (such as AHIMA, HFMA, HIMSS, and AAPC) to get involved now.
I encourage readers to review the articles that are cited herein as these authors provide great insight; another recommended resource is Adam Liptak’s “The Morning: A Landmark Case. How Much Power Should Government Experts Have?” (Jan. 18, 2024) in the New York Times.
To all of us: Be ready for the litigation heyday ahead.
Rose T. Dunn
MBA, RHIA, CPA, FACHE, FHFMA, FAHIMA, is a past president and former interim CEO of AHIMA and recipient of AHIMA’s distinguished member and legacy awards. She is Chief Operating Officer of First Class Solutions, Inc., a healthcare consulting firm based in St. Louis, MO. First Class Solutions, Inc. assists healthcare organizations to enhance or transform their HIM operations, facility and physician office documentation, and revenue cycle performance, and provides coding support and coding audits. Rose is also the author of Libman’s HCC Fundamentals and Auditing programs.
https://firstclasssolutions.com
• Imaging studies
- Ultrasound
- Abdominal CT scan (preferred)
Treatment depends on the type and severity of the patient’s appendicitis. Uncomplicated appendicitis may be treated with an antibiotic and/or surgery to remove the appendix laparoscopically. Complicated cases, especially those with severe infection like sepsis, require intravenous (IV) antibiotics and placement of a surgical drain to get the infection under control and remove the pus from the abdominal cavity. Once the infection is controlled, surgery can be planned to safely remove the ruptured appendix.
Documentation and Code Assignment
Documentation should identify the key details that allow for high-specificity code assignment, such as:
• Acute appendicitis
• With or without perforation
• With or without abscess
• With or without localized or generalized peritonitis
Acute appendicitis with localized peritonitis is reported with codes from K35.89- with the sixth character identifying the status of perforation, abscess, and gangrene.
The new codes, effective as of October 1, 2023, include:
• K35.200 - without perforation or abscess
• K35.201 - with perforation, without abscess
• K35.209 - without abscess, unspecified as to perforation
• K35.210 - without perforation, with abscess
• K35.211 - with perforation and abscess
• K35.219 - with abscess, unspecified as to perforation
• With or without gangrene
Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT, is a medical coding, billing, and auditing consultant, author, and educator with more than 30 years of clinical and administrative experience in healthcare, coding, billing, and auditing. Medicine, including coding and billing, is a constantly changing field full of challenges and learning and she loves both. Aimee believes there are talented medical professionals who, with proper training and excellent information, can continue to practice the art of healing while feeling secure in their billing and reimbursement for such care. www.findacode.com
Detecting and Coding Elder Abuse
Victimization and abuse of older adults is an important subset of crime.
Older adults experience the same crimes as the rest of the population, including financial victimization, neglect, and physical, sexual, or emotional abuse. However, older adults may be less likely to recover from their victimization and are often sought out because of their age and decreased likelihood of reporting.
According to the National Institute on Aging, an older adult is someone aged 65 or older. Abuse of older adults is an intentional act or failure to act that causes or creates a risk of harm to an older adult. The abuse occurs at the hands of a caregiver or a person that the older adult trusts.
Common types of elder abuse include the following:
• Physical abuse is when an older adult experiences illness, pain, injury, functional impairment, distress, or death as a result of the intentional use of physical force, and includes acts such as hitting, kicking, pushing, slapping, and burning.
• Sexual abuse involves forced or unwanted sexual interaction of any kind with an older adult. This may include unwanted sexual contact or penetration or non-contact acts such as sexual harassment.
• Emotional or Psychological Abuse refers to verbal or nonverbal behaviors that inflict anguish, mental pain, fear, or distress on an older adult. Examples include humiliation or disrespect, verbal and non-verbal threats, harassment, and geographic or interpersonal isolation.
• Neglect is the failure to meet an older adult’s basic needs. These needs include food, water, shelter, clothing, hygiene, and essential medical care.
• Financial Abuse is the illegal, unauthorized, or improper use of an older adult’s money, benefits, belongings, property, or assets for the benefit of someone other than the older adult.
Elder Abuse Is a Serious Problem
According to the Centers for Disease Control (CDC) and other government agencies (DOJ, FBI), elder abuse is a serious problem in the United States. The available information is an underestimate of the problem because the number of nonfatal injuries is limited to older adults who are treated in emergency departments.
The information does not include those treated by other providers or those that do not need or do not seek treatment. Additionally, many cases are not reported because older adults are afraid or unable to tell police, friends, or family about the violence.
Victims have to decide whether to tell someone they are being hurt or continue being abused by someone they depend upon or care for deeply.
The CDC reports that elder abuse is common. Abuse, including neglect and exploitation, is experienced by about 1 in 10 people aged 60 and older who live at home. From 2002 to 2016, more than 643,000 older adults were treated in the emergency department for nonfatal assaults and over 19,000 homicides occurred.
Some groups have higher rates of abuse than others:
• Compared with women, men had higher rates of both nonfatal assaults and homicides.
• The rate of nonfatal assaults increased by more than 75% among men (2002–2016) and more than 35% among women (2007–2016).
• The estimated homicide rate for men increased by 7% from 2010 to 2016.
• Compared to non-Hispanic whites, non-Hispanic black or African American persons, non-Hispanic American Indian/ Alaskan Natives, and Hispanic or Latino persons have higher homicide rates (2002–2016).
Overall, firearm-specific older adult homicide rates increased between 2014 and 2017, in which:
• Of the 6,188 victims, 62% were male.
• The perpetrator was an intimate partner in 39% of firearm homicides and 12% of non-firearm homicides.
• Common contexts of firearm homicides were familial/intimate partner problems, robbery/burglary, argument, and illness-related (e.g., the homicide was perpetrated to end the suffering of an ill victim, both victim and perpetrator had an illness, or the perpetrator had a mental illness).
Detecting Physical Abuse
Warning signs of physical abuse can present as:
• Bruises, black eyes, welts, lacerations, or rope marks
• Bone fractures, broken bones, or skull fractures
• Open wounds, cuts, punctures, untreated injuries in various stages of healing
• Sprains, dislocations, or internal injuries/bleeding
• Broken eyeglasses/frames, physical signs of being subjected to punishment, or signs of being restrained
• Laboratory findings of medication overdose or under-utilization of prescribed drugs
• An older adult’s report of being hit, slapped, kicked, or mistreated
• An older adult’s sudden change in behavior
• The caregiver’s refusal to allow visitors to see an older adult alone
Physical Abuse Stories of Older Adults Shared by the DOJ
• Abuse by Guardian/Conservator Blair, 65, had no close relatives. Because of early-onset dementia, he was placed in a nursing home and required guardianship. Chris, Blair’s guardian, came to Blair’s nursing home every few months to see how Blair was doing. During the last visit, Chris began slapping Blair to wake him up. Joan, a care attendant, rushed to the room when Blair began crying out for Chris to stop. Joan noticed marks on Blair’s face and asked what had happened. Blair was unable to tell Joan what had happened, and Chris quickly left the room. Joan reported the incident to her supervisors who helped her make a report to Adult Protective Services (APS). The report triggered involvement by the state Ombudsman and local law enforcement.
• Abuse by Long-Term Care Aide
Monica, 79, was placed in a long-term care facility when her ALS became severe, and her family could no longer care for her. Her family became concerned when they saw bruising on her arms and back. Monica was not able to speak and could not tell her family how she got the bruises. Monica’s family asked the staff about the bruising but was not satisfied with the explanation. The family also noticed that when a certain aide helped bathe her, Monica became upset and agitated. They suspected that the aide was hitting Monica and called local law enforcement.
• Abuse by Disabled Adult Son
When George, 79, lost his wife of 50 years to cancer, his son, Lawrence, came to live with him. Lawrence was on disability due to a traumatic brain injury. The brain injury caused
behavior changes, including difficulty with self-control and verbal and physical outbursts. The injury also caused violent mood swings. Occasionally, Lawrence went to a neighbor’s apartment and got drunk. One night when Lawrence returned home, George asked him if he was drunk. Lawrence yelled “No!” and punched his father in the face. Because George was afraid of further violence, he called 911 to get help from the police.
• Abuse by Adult Grandsons Katherine, 82, raised two grandsons, Joel and Kent. They had physically abused her since they were teenagers. After 12 years in prison, Joel returned to his grandmother’s home because he had nowhere to go. One night, Joel came home drunk. He banged on the door, but Katherine told Joel to go away. After he entered the house through a back window, Joel beat his grandmother. Katherine went to a neighbor’s house and called 911. Joel was arrested and Katherine was taken to the hospital. The police contacted Adult Protective Services.
• Abuse by Spouse
After 58 years of marriage, Virgil and Ella, both 83, knew each other’s habits well. Sometimes, when they argued, they became physically violent. Nevertheless, they said they loved each other and had never considered divorce. Violence was unfortunately a part of their relationship. As Ella aged, she developed osteoporosis. She began to worry that if she fell down when they were fighting each other, she might end up with a broken bone. She confided this to a friend, and her friend suggested calling the local domestic violence hotline to speak with a counselor.
Detecting Abandonment/Neglect
Warning signs of abandonment/neglect can present as:
• Dehydration, malnutrition, untreated bed sores, and poor personal hygiene
• Unattended or untreated health problems
• Hazardous or unsafe living conditions/arrangements (e.g., improper wiring, no heat, or no running water)
• Unsanitary and unclean living conditions (e.g., dirt, fleas, lice on person, soiled bedding, fecal/urine smell, inadequate clothing)
• An older adult’s report of being neglected
• The desertion of an older adult at a hospital, a nursing facility, or other similar institution
• The desertion of an older adult at a shopping center or other public location
• An older adult’s report of being abandoned
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Abandonment and Neglect Stories of Older Adults Shared by the DOJ
• Neglect by Daughter and Son-in-Law
Kofi, 84, was diagnosed with Alzheimer’s disease and moved in with his daughter’s family. Sometimes Kofi had trouble sleeping, had physical and verbal outbursts, and began dering. His daughter and son-in-law were afraid that Kofi might wander out of the house if they left him alone. They locked the doors to the house so that Kofi could not get out and wander around when they left for work. A neighbor noticed Kofi trying to get out of the house. She contacted the local police and Adult Protective Services.
• Neglect by Son and Daughter-in-Law
Tamara, 76, lived alone but had trouble getting around. Her son and his wife asked Tamara to move in with them. Tamara had her own bedroom on the second floor and stayed there most of the time. She could not use the stairs easily. Her son and daughter-in-law both traveled frequently for work and sometimes neglected to give her adequate food and water. They also failed to groom her or to clean her room consistently. One day Tamara became dizzy, weak, and disoriented, so her daughter took her to the hospital. The hospital staff discovered that she was dehydrated, disheveled, and obviously unwashed. They asked about care, but Tamara said she was well cared for. Nevertheless, as required by law, the hospital staff reported suspected neglect to Adult Protective Services.
• Neglect by Sons
Clarence, 79, invited his two adult sons to move in with him so he would not be alone after his wife died. The sons soon sent Clarence out to live in the shed and locked him out of the house. Sometimes his sons put food out for him. Occasionally, they gave him a basin of cold water with washcloth. When one of Clarence’s neighbors noticed that Clarence seemed to be living in the shed, she called Adult Protective Services anonymously and reported what she seen. She then decided Clarence may need immediate help, so she called the police to do a welfare check.
• Abandonment by Adult Daughter
Juliette, 87, lived with her daughter, Nanette, for the past three years. Nanette helped Juliette with daily activities, such as getting her meals, bathing, and cleaning the house. Nanette decided to move in with her boyfriend in another state and left her mother alone in the home. About a week later, Juliette’s niece happened to be in town and stopped to visit her aunt. She saw that the inside of the house was in bad condition and found Juliette in poor health. Juliette’s niece contacted Adult Protective Services and the State Agency on Aging.
bor might harm her if she told him to stop, Rosie contacted local law enforcement and filed criminal charges, as well as a petition for a civil restraining order. She also notified housing management.
• Psychological Abuse by Son Jane had not seen her friend Harry, 87, at Mass for weeks. This was not like her friend since Harry went to Mass almost every Sunday. Jane stopped by Harry’s house. Harry answered the door and Jane was shocked. Her friend had lost weight, looked terrible, and had obviously been crying. Harry told Jane in a hushed voice that since his son had moved in, he would not let him go to church, the senior center, or even out of the house. Harry said that his son was now controlling everything, including his money. Before Jane could say anything, Harry’s son started yelling and Harry quickly closed the door. Jane decided to make an anonymous report to Adult Protective Services.
• Psychological Abuse by Spouse Sarah, 75, had been married for over 50 years to Saul, who was abusive. The abuse had a pattern. Her husband would start following her around, watching her every move. Then he would make comments under his breath. Finally, he would start pointing his finger in her face and pushing her around. Since Saul’s retirement, this pattern seemed to be getting worse and happening more often. Sarah picked up a pamphlet on domestic violence at her synagogue and decided to make her first call for help. From her conversation with the domestic violence advocate, she learned about resources in her area and steps she could take to be safe.
• Psychological Abuse by Daughter Zoe, 79, was healthy, independent, and lived with her unmarried daughter, Trish, to share expenses. Zoe believed they had a good relationship. Nevertheless, Trish sometimes yelled at Zoe, calling her horrible names, and telling her she was worthless. Trish began threatening to put Zoe in a nursing home. Zoe tried to ignore these rants because she was grateful to live with her daughter. However, she thought she deserved to be safe from such comments. Zoe eventually told a close friend about Trish’s yelling and threats. The friend suggested that Trish and Zoe seek counseling and that Trish get respite help from a local Agency on Aging.
• Psychological Abuse by Guardian/Conservator Mark, 75, had Alzheimer’s disease and was beginning to have severe memory loss and trouble walking around the house. Mark’s paid caregiver, Yolanda, asked the court to appoint a guardian. Each time the guardian, Mrs. McKee, visited with Mark, she made fun of his memory problems and inability to remember where he was or even who Yolanda was. Yolanda became worried about Mark and the fact that Mrs. McKee, the court appointed guardian, did not seem to take Mark’s
condition seriously. Yolanda called Adult Protective Services and the probate court to review Mark’s guardianship.
Detecting Sexual Abuse
Warning signs of sexual abuse can present as:
• Bruises around the breasts or genital area
• Unexplained venereal disease or genital infections
• Unexplained vaginal or anal bleeding
• Changes in an older adult’s demeanor, such as showing fear or becoming withdrawn when a specific person is around
• Evidence of pornographic material being shown to an older adult with diminished capacity
• Blood found on sheets, linens, or an older adult’s clothing
• An older adult’s report of being sexually assaulted or raped
Sexual Abuse Stories of Older Adults Shared by the DOJ
• Sexual Abuse by Nursing Home Aide
Margaret, 77, lived in a nursing home that was known for good residential care. One day, a nursing aide noticed that Margaret appeared anxious, but Margaret would not explain why. While preparing her for a bath, the nursing aide saw multiple bruises on Margaret’s arms, neck, and back, and the aide asked what happened. Initially, Margaret did not say anything. Subsequently, the director of nursing learned from another resident that a new aide had sexually assaulted Margaret. As required by law, the director of nursing reported the sexual assault to Adult Protective Services, and APS initiated an investigation, involving the Ombudsman and local law enforcement.
• Sexual Abuse by In-Home Caregiver
Eduardo, 80, had a stroke. His family hired an in-home caregiver to assist with his daily needs, such as bathing and using the bathroom. One day, his daughter stopped by to visit her dad. As she helped him get dressed, he winced, and she noticed that his genital area was red and irritated. Her father started to cry and mumbled something about the caregiver hurting him there. The daughter immediately called Adult Protective Services to make a report. She also called the agency where the caregiver worked, made a complaint, and ended services. APS alerted law enforcement.
• Sexual Abuse by Family Member Pearl, 70, took her nephew in when his mother could not handle his behavior problems. The nephew started watching pornography on the TV that he shared with his aunt. Pearl was uncomfortable about this and told her nephew to stop. One day, the nephew came home and was high on drugs. He forced himself sexually upon his aunt. Pearl called 911 for
local law enforcement and went to the hospital where she met with a sexual assault victim specialist.
• Sexual Abuse by Guardian/Conservator
Angela, 71, required guardianship because of her continued alcohol and drug abuse. The court appointed Richard as her guardian. Soon after his appointment, he gave Angela more drugs, sexually assaulted her, and threatened her with prison for her drug use if she reported him. Angela summoned the courage to go to the local police and contacted a lawyer to obtain a new guardian.
Reporting Elder Abuse on the Claim
ICD-10-CM
Coding Rules for Elder Abuse
When it comes to medical coding, there are specific codes that cover many types of abuse and exploitation. These codes should always be assigned when appropriate.
As a medical coder, when reviewing the medical record for appropriate documentation, one can only assign the codes when they are documented by the patient’s provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis). Do not interpret the physician narrative without the physician’s confirmation.
Remember the axes of ICD-10? In coding abuse, the first axis is abuse, neglect, or other maltreatment of an adult, and whether the abuse is confirmed (category T74) or suspected (category T76). Only select these categories when it is documented by the patient’s provider in the record.
Code example of suspected elder financial abuse:
• A suspected case of adult financial abuse would start with the first axis, abuse, suspected – T76
• The fourth character would indicate the type of abuse, financial – T76.A
• The fifth character specifies adult as the victim – T76.A1
• The sixth character indicates suspected – T76.A1X
• The seventh character indicates the episode or encounter, in this case, initial – T76.A1XA
- For adult financial abuse, suspected, subsequent encounter – T76.A1XD
- For adult financial abuse, suspected, sequela – T76.A1XS
For confirmed cases of abuse, be sure to assign the appropriate external cause codes from the assault section (X92-Y09) to identify the cause of physical injuries. The perpetrator, when known, should also be added as a code from the Y07 category.
Look Up Convention for Abuse ICD-10-CM Codes
To find the code, use the search term “maltreatment,” “abuse,” or “exploitation” as a start. When using an encoder, it may provide a code when entering a full term, such as “financial abuse.”
Sequencing
Follow the coding guidelines for coding of injuries in Section 1, Chapters 19, 15, and 20, as well as the conventions of ICD10 in the codebook.
What About Suspected but Ruled Out Cases?
If suspected abuse is ruled out during a visit, assign code Z04.71, Encounter for examination and observation following alleged physical adult abuse, ruled out.
• The “Z” category codes for ruled out should be used, not a code from T76.
• If a suspected case of alleged adult rape or sexual abuse is ruled out during an encounter, code Z04.41.
• If a suspected case of forced sexual exploitation or forced labor exploitation is ruled out during an encounter, code Z04.81, Encounter for examination and observation of victim following forced sexual exploitation, or code Z04.82, Encounter for examination and observation of victim following forced labor exploitation.
Coding Scenario
An older woman presents at the emergency department for pain in her left wrist. Upon examination and X-ray, it is discovered that she has a closed radial styloid process fracture. She relates the story as her wrist being grabbed and twisted by
her adult daughter as the older woman attempted to keep the daughter from obtaining her debit card. The friend who brought the woman in witnessed the encounter and agrees with the story. A police report has been filed. The physician documents the abuse as confirmed.
The codes assigned based on documentation in the patient’s medical record would be:
• S52515A – Nondisplaced fracture of left radial styloid fracture, closed
• Y042XXA – Assault by strike against or bumped into by another person, initial encounter
• Y0744 – Child perpetrator of maltreatment and neglect
A coder should also code the social determinants of health for this encounter, if any. In this case, Z62820, Parent-biological child conflict, might be used.
Conclusion
As physical, sexual, and emotional/psychological abuse, neglect/ abandonment, and financial exploitation of older adults is prevalent, criminal, and affects a vulnerable population, it is important to be able to detect and code elder abuse appropriately to end the abuse and help victims recover and receive justice.
Joy Rose
MSA, RHIA, CCS, CHA, CHPS, is a member of the American Institute of Healthcare Compliance (AIHC) and serves as a subject matter expert on the AIHC Volunteer Education Committee.
Joanne Byron BS, LPN, CCA, CHA, CHCO, CHBS, CHCM, CIFHA, CMDP, OHCC, ICDCT-CM/PCS, serves as Board Chair and Director at the American Institute of Healthcare Compliance.
www.aihc-assn.org
Learning from Recent Technology Transgressions
Cyberattacks and the adverse impacts on businesses, governments, and consumers are now more prevalent and pernicious than ever.
To illustrate this point, here are three different types of breaches, which have resulted in reputational, financial, and legal consequences:
• A recent investigation of a cyberattack on AT&T confirmed that the breach resulted in cybercriminals “exfiltrating files” of “nearly all” of the company’s wireless customers.
• A recent class action case in the United States District Court for the Southern District of California, Julie Jones, et al. v. Peloton Interactive, Inc., Case No. 23-cv-1082-L-BGS, led to a motion to dismiss being denied related to a plaintiff’s claim arising from a “defendant’s use of third-party software called Drift which was embedded into the website chat feature [and is] automatically intercepted and recorded by Drift which creates transcripts of the conversations.”
• A False Claims Act settlement of $2.45 million against three labs that engaged in instructing workforce members on how to manipulate diagnosis codes and implement computer macros to stream-
line the process to achieve consistently miscoded false and fraudulent claims that were submitted to Medicare and Medicaid for higher reimbursement, in United States, et al. ex rel. Balbina Castillo v. Vista Clinical Diagnostics, LLC, et al., Case No. 6:20-cv00617 (M.D. Fla.) (hereinafter “Vista”).
These are all examples of significant technology transgressions. To avoid a similar fate, companies and individuals alike should learn from these events and take time to assess their cybersecurity risk management and compliance programs.
Technology Transgression: Vista Clinical Diagnostics’ False Claims Act Settlement
On February 22, 2024, the United States Department of Justice (DOJ) released its annual report for fiscal year 2023, “False Claims Act Settlements and Judgements Exceed $2.68 Billion in Fiscal Year 2023.” In the related press release, the DOJ stated, “The recoveries in fis-
cal year 2023 also reflect the department’s focus on key enforcement priorities, including fraud in pandemic relief programs and alleged violations of cybersecurity requirements in government contracts and grants.” Notably, healthcare also topped the list again as the sector leading False Claims Act settlements and judgments. It’s with this backdrop in mind that we consider the allegations in the Vista case, as well as how certain aspects translate to generative AI transgressions that could easily lead to the knowing submission of false and fraudulent claims under the False Claims Act.
On April 9, 2020, a complaint was filed under seal by a whistleblower, also known as a relator, alleging a scheme known as “upcoding” or, in this case, referred to as “code jamming,” whereby there is inadequate documentation to substantiate medical necessity and is “not provided by the patient’s physician when ordering the lab work.” Here, the defendants used “macros, which are a saved sequence of commands or keyboard strokes that can be stored and then recalled with a single command or keyboard stroke and have been created in-house, to add diagnosis codes to a large number of their patients’ submissions strictly to assure reimbursement will be made by Medicare and/ or Medicaid and/or to assure a higher reimbursement will be forthcoming from Medicare and/or Medicaid. A specific macro is added to billings based on what CPT code has been ordered by the beneficiary’s physician.” Additionally, in Vista, the defendants also engaged in violations of the Federal Anti-Kickback Statute.
Now, take the use of macros and imagine a similar concept being applied to a generative AI algorithm. As the U.S. Food and Drug Administration published in its October 22, 2020, “Executive Summary for the Patient Engagement Advisory Committee Meeting Artificial Intelligence (AI) and Machine Learning (ML) in Medical Devices”:
“Systems that imitate human intelligence are also integral to healthcare. AI is being used to detect eye conditions, recognize certain cell types, and evaluate human behaviors
associated with mood disorders. Modern automated external defibrillators that can detect abnormal heart rhythms by analyzing heart waveforms and deliver the needed electrical charge have been in use since the 1970s, with continually improving performance. They have been designed and implemented to use the same process for detection as has been done by physicians. Compared to these technologies that aim to mimic the human decision process, modern AI technologies are data-driven in that they analyze large volumes of complex data in novel ways; discover new relationships between the information entered and the desired results from the available data; and can adapt their reasoning based on new data. In recent years, there has been an increased use of AI/ML in medical devices, especially for tasks that require the analysis of large volumes of data or the interpretation of complex information.”
Devices that utilize AI/ML are considered Software as a Medical Device (SaMD). As defined by the International Medical Device Regulators Forum (IMDRF), SaMD is “software intended to be used for one or more medical purposes that perform these purposes without being part of a hardware medical device.” The same concerns that the Federal Trade Commission raised in its July 2022 Report to Congress – inaccuracy of the algorithm and the outcomes, bias, and privacy - are just as applicable to medical devices and other healthcare applications as they are to online harms. Similarly, the safeguards, including human monitoring and evaluation, are just as important, especially because a skewed algorithm can result in a medically unnecessary diagnosis, wrong diagnosis, and/or wrongful prescribing of a drug or medical device because of a skewed result. In turn, like in Vista but with the application of generative AI, the knowing submission of a false and fraudulent claim under the False Claims Act could occur, as well as the residual liability.
The area of algorithmic discrimination giving rise to the Fair Housing Act is an area that we have already seen play out in United States of America v. Meta Platforms, Inc., f/k/a Facebook, Inc., Case No. 22-cv-05187 (S.D.N.Y. 2022),
which required Meta to pay the maximum penalty under the Fair Housing Act, remove targeting options for housing advertisers that directly describe or relate to FHA-protected characteristics, and to develop a new algorithm, as well as the related private action settlement National Fair Housing Alliance et al. v. Facebook, Inc., Case No. 18-cv-2689 (S.D.N.Y).
Due to the potential for fraud, discrimination, and cyberattacks, healthcare organizations and health sector participants of all sizes should take proactive compliance measures to mitigate risk.
Compliance Conclusion
I have to admit, I love Peloton and utilize it religiously. From the outset, I also adhered to my own policy of not engaging in chats, blinding my information from public view, and enabling all safeguards, including blocking my contacts from being imported.
Similarly, when conducting risk analyses with my clients, I ask:
• What third-party software is being utilized?
• What particular data is being collected?
• How is the data being utilized?
• Are appropriate business associate agreements in place?
• Has patient consent been obtained in order to avoid a HIPAA sales and marketing violation?
• What other technical safeguards are in place?
As for the allegations in the Vista case, when applied to generative AI, the potential for the submission of false and fraudulent claims becomes even greater. In speaking with reputable healthcare institutions who are piloting the use of generative AI technology in coding and claims submissions, their approaches are prudent and align with the five principles espoused in the White House Office of Science and Technology’s “Blueprint for an AI Bill of Rights.”
The AI Bill of Rights focuses on:
• Safe and Effective Systems
• Algorithmic Discrimination Protections
• Data Privacy
• Notice and Explanation
• Human Alternatives, Consideration, and Fallback
Additionally, utilizing a prevention, detection, and correction approach to cybersecurity risk management, as set forth in the National Institute of Standards and Technology (NIST) Cybersecurity Framework (CSF) 2.0, which added “governance” to the previous version, is essential to mitigating legal, reputational, financial, and operational risks for companies, as well as their boards of directors and executives. The NIST AI Framework is equally important. Notably, the frameworks are meant to be general guideposts, while the NIST special publications are more detailed and are referenced in a variety of laws including the Federal Acquisition Regulations (FAR).
Finally, as set forth in 42 CFR § 483.85, as well as in the evolving technical and administrative safeguards to implement in relation to cybersecurity in healthcare, any person who is in the healthcare sector that creates, receives, maintains, or transmits either patient protected health information or consumer individually identifiable health information, should ensure that compliance programs are comprehensive and up to date, as well as having adequate training, encryption, and conducting a requisite HIPAA risk analysis annually that looks at both traditional technologies and evolving technologies such as generative AI. Failing to do so can lead to significant breaches and government enforcement actions, as well as costly class actions and False Claims Act matters.
Rachel V. Rose
JD, MBA (Houston, Texas), advises clients on compliance, transactions, government administrative actions, and litigation involving healthcare, cybersecurity, corporate, and securities law, as well as False Claims Act and Dodd-Frank whistleblower cases. Ms. Rose represented the whistleblower in the DOJ’s first settlement under its Civil Cyber Fraud Initiative. She also teaches bioethics at Baylor College of Medicine in Houston. Rachel holds a variety of leadership positions within the FBA, including serving on its National Board of Directors and can be reached through her website: www.rvrose.com
Our Team Will:
• Identify Areas of Risk Leading to Over or Under-coding
• Ensure Coding Practices are Compliant with Regulations by Private and Government Payors
• Teach Providers and Staff How to Use Documentation to Maintain Compliance and Proper Reimbursement
Our team of experts at DoctorsManagement conduct reviews of coding and documentation procedures closely simulating actual carrier audits - regardless of the specialty or practice type. From determining the sample size selection to providing a concise report of findings, to providing customized education for providers and staff. Let us customize a plan for you.
Medicare Proposed Rule Again Cuts Radiology Reimbursement in 2025
The Centers for Medicare and Medicaid Services (CMS) has issued its proposal for payments in 2025 under the Physician Fee Schedule (PFS), and it contains an across-the-board 2.8% cut from the current 2024 payment rate. This reduction in payments continues a trend that has seen the Medicare fee schedule reduced nearly 10% over the past 10 years. Last year’s proposed rule (for 2024) contained a 3.36% cut that ended up being a 1.77% cut after Congressional intervention in March, and it is possible that similar action will occur again. The Conversion Factor (CF) in the 2025 Proposed Rule is $32.3562, compared with the $33.2875 currently in use.
The published CMS estimates indicate that most of radiology will be minimally impacted (0%) by the PFS rule, but interventional radiology would see a 2% decrease. However, those calculations do not take into account the Congressional adjustment to the 2024 fee schedule.
Our estimate of the actual impact is as follows:
See Table 1 Below.
Some Positive News
CMS has proposed that CT Colonography (CTC) would become a covered service for Medicare beginning in
Table 1
2025. The American College of Radiology (ACR) reports in their “Preliminary Summary of Radiology Provisions in the 2025 MPFS Proposed Rule” that “CMS is using statutory authority under the Balanced Budget Act of 1997 for the Secretary to add additional colorectal cancer screening tests and procedures to its definition of screening tests to propose coverage of CTC for Medicare beneficiaries. The rule points out that the U.S. Preventative [sic] Services Task Force (USPSTF) included CTC as a CRC screening method in their June 2016 revised Final Recommendation Statement and again in its May 2021 guideline update.” At the same time, the proposed rule would remove coverage of the double-contrast barium enema, which has mostly been replaced by CTC for colorectal cancer screening.
Direct supervision of certain procedures will continue to be allowed via two-way audio/video communications technology through December 31, 2025. This has been a temporary modification of Medicare rules since 2020, but CMS has failed to make it permanent as they continue to evaluate additional information regarding potential patient safety and quality of care concerns.
Quality Payment Program
In addition to fee schedule changes, the Medicare PFS covers rules that govern the Quality Payment Program (QPP). Radiology practices often participate in the QPP through the Merit-based Incentive Payment System (MIPS). Changes in MIPS scoring for 2025 could have a positive effect for radiology practices.
MIPS Value Pathways (MVPs) have not been available to radiology due to a lack of applicable measure sets. “CMS proposes to develop MVPs based on existing Specialty Measure Sets, which would act as a bridge until new measures are available to support the creation of individual MVPs [for radiology],” according to the ACR.
Under current MIPS rules, there is a cap of seven (7) points on any Quality Category measure that is part of a specialty, such as radiology, with a limited number of measures available for use. CMS is proposing to remove that cap, which means that such measures would receive the full ten (10) points. Diagnostic radiology measures 360, 364, 405, and 406 would be included in this provision.
Measure #436, Radiation Consideration for Adult CT – Utilization of Dose Lowering Techniques, was previously finalized for removal in 2025, to be replaced by Measure #494, Excessive Radiation Dose or Inadequate Image Quality for Diagnostic CT in Adults.
The Improvement Activities Category has had two levels of measures, medium-weight and high-weight, with the goal of reaching 40 points by submitting from two (2) to four (4) activities.
The proposed rule would eliminate the weighting system, as follows:
• Small practices, non-patient facing, and rural/health professional shortage practices would attest to one (1) activity. This would include many radiologists.
• All other practices would attest to two (2) activities.
• Practices reporting under MVPs would attest to one (1) activity.
Many aspects of the MIPS rules will remain unchanged for 2025, including:
• The MIPS Performance Threshold will remain at 75 points. It had originally been scheduled to move up to 82 points in 2024 and beyond.
• The 75% data completeness criteria will be maintained through the 2028 performance year.
• For practices where performance categories are not reweighted, the category weights remain at:
- Quality – 30%,
- Improvement Activities – 15%
- Cost – 30%
- Promoting Interoperability – 25%
• For practices where Promoting Interoperability and Cost are not a factor, the standard reweighting will be 85% Quality and 15% Improvement Activities (or 50% each for Small Practices).
• • The Small Practice bonus will be retained at 6 points in the Quality Category.
Conclusion
The Proposed Rule is usually a pretty good indicator of what the Final Rule will contain when it is issued later in the year. The CF typically changes slightly due to final calculations being applied, but there should be no significant difference. Although many had hoped for legislative correction, such as H.R. 2474 to improve the MPFS rate-setting methodology, it does not appear to be likely in 2024. As mentioned above, the Consolidated Appropriations Act, 2024, provided some relief for part of the current year, and any hope of avoiding the 2.8% cut will likely come in a similar fashion for 2025.
We will provide our analysis of the Final Rule when it is issued.
Sandy Coffta is
VP of Client Services at Healthcare Administrative Partners. Radiology Billing & Coding Experts - 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
MONTHLY SPOTLIGHT ON
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.
Wellesley Psychiatrist Sentenced to Over Eight Years in Prison for $19 Million Insurance Fraud Scheme; Billed Insurance Companies for Thousands of Services He Never Provided
Early June saw a Wellesley psychiatrist sentenced for billing Medicare and private insurance companies for over $19 million in treatments he did not provide and obstructing justice in an attempt to conceal his crimes.
This man was sentenced by the U.S. District Court Judge on the case to 99 months in prison, followed by three years of supervised release. He was also ordered to pay restitution and forfeiture in an amount to be determined at a later hearing. In October 2023, following a jury trial, he was convicted of seven counts of wire fraud, six counts of false statements relating to healthcare matters, and one count of obstructing a criminal healthcare investigation.
He was a licensed psychiatrist who owned and operated Advanced TMS Associates, located in Massachusetts. Among other services, he offered transcranial magnetic stimulation (TMS) therapy and psychotherapy to patients suffering from depression. TMS therapy is a noninvasive method of brain stimulation that uses rapidly alternating or pulsed magnetic fields to induce electrical currents directed at a patient’s cerebral cortex.
Between January 2015 and December 2018, he engaged in a variety of fraudulent billing schemes in which he sought and received reimbursement for $19 million in services he did not render. For example, he billed Medicare and private insurers $10.6 million for thousands of TMS sessions he never provided, including over 8,000 sessions he claimed were provided to 74 patients who, in fact, never received a single session of the therapy. He also billed Medicare and private insurers for millions of dollars’ worth of psychotherapy sessions he never provided, including over 900 face-to-face sessions
he falsely claimed he provided while he was on vacation in locations like the Bahamas, the Dominican Republic, and the Czech Republic. On 382 days, he billed Medicare and private insurers for having provided more than 24 hours’ worth of psychotherapy services in a single day, including one day in July 2017 when he claimed he had provided hour-long psychotherapy sessions to 70 different patients – all while outside the United States on vacation. With the proceeds of his fraud, he paid off a $1.8 million home in Wellesley, purchased over $600,000 in jewelry from Cartier, Van Cleef, and Tiffany’s, and purchased a $2.1 million vacation home in Nantucket.
To further his fraudulent billing scheme, he made numerous false statements to his patients, the billing company he worked with, and the insurers to whom he submitted claims seeking reimbursement. When Medicare and private insurers sought records from him to justify his exorbitant claims, he took steps to conceal his fraud by creating, and forcing his employee to create, fake patient records to send to Medicare and private insurers. He continued his obstructive behavior when, in response to a July 2018 subpoena from the Department of Health and Human Services Office of Inspector General, he created and produced additional fake patient records purporting to show patients had received dozens of treatments that never happened, and which falsely represented that the condition of those patients was improving.
Source: Wellesley Psychiatrist Sentenced to Over Eight Years in Prison for $19 Million Insurance Fraud Scheme; Billed Insurance Companies for Thousands of Services He Never Provided (2024, June 7). www.justice.gov.
Founder/CEO and Clinical President of Digital Health Company Arrested for $100M Adderall® Distribution and Healthcare Fraud Scheme
This is the Justice Department’s first criminal drug distribution prosecution case related to a digital health company that distributed controlled substances via telemedicine.
The founder and CEO of a California-based digital health company, Done Global Inc., and its clinical president were arrested in connection with their alleged participation in a scheme to distribute Adderall® over the internet, conspire to commit healthcare fraud in connection with the submission of false and fraudulent claims for reimbursement for Adderall® and other stimulants, and to obstruct justice.
According to court documents, the men allegedly conspired with others to provide easy access to Adderall and other stimulants in exchange for payment of a monthly subscription fee. The indict-
ment alleges that the conspiracy’s purpose was for the defendants to unlawfully enrich themselves by, among other things, increasing monthly subscription revenue and thus increasing the value of the company. Done Global, an online telehealth website, allegedly arranged for the prescription of over 40 million pills of Adderall® and other stimulants and obtained over $100 million in revenue.
The pair allegedly obtained subscribers by targeting drug seekers and spending tens of millions of dollars on deceptive advertisements on social media networks. They also allegedly intentionally structured the Done Global platform to facilitate access to Adderall® and other stimulants, including by limiting the information available to Done Global prescribers, instructing Done Global prescribers to take Adderall® and other stimulants even if the Done member did not qualify, and mandating that initial encounters would be under 30 minutes. To maximize profits, the CEO allegedly put in a place an “auto-refill” function that allowed Done Global subscribers to elect to have a message requesting a refill be auto-generated every month. The CEO wrote that Done Global sought to “use the comp structure to dis-encourage follow-up” medical care by refusing to pay Done Global prescribers for any medical visits, telemedicine consultation, or time spent caring for patients after an initial consultation, and instead paying solely based on the number of patients who received prescriptions.
The duo allegedly persisted in the conspiracy even after being made aware that material was posted on online social networks about how to use Done Global to obtain easy access to Adderall® and other stimulants, and that Done Global members had overdosed and died. They also allegedly concealed and disguised the conspiracy by making fraudulent representations to media outlets to forestall government investigations and action and induce third parties to continue doing business with Done Global.
The indictment also alleges that both men conspired to obstruct justice after a grand jury subpoena was issued to another telehealth company and in anticipation of a subpoena being issued to Done Global, including by deleting documents and communications, using encrypted messaging platforms instead of company email, and ultimately failing to produce documents in response to a subpoena issued to Done Global by a federal grand jury.
If convicted, the men each face a maximum penalty of 20 years in prison on the conspiracy to distribute controlled substances and distribution of controlled substances counts.
An indictment is merely an allegation. All defendants are presumed innocent until proven guilty beyond a reasonable doubt in a court of law.
Source: Founder/CEO and Clinical President of Digital Health Company Arrested for $100M Adderall Distribution and Health Care Fraud Scheme (2024, June 13). www.justice.gov.
DOJ and Evergreen Treatment Services Settle Allegations Regarding Double Billing of Government Health Programs
The U.S. Department of Justice resolved double billing allegations against Evergreen Treatment Services. The settlement is on behalf of the U.S. Department of Health and Human Services (HHS) which runs the Medicare program and other government health plans. Evergreen Treatment Services will pay the government $1,453,982 to resolve the matter.
According to the settlement agreement, in January 2020, Medicare began paying for drug treatment services including medically assisted treatment. Evergreen, a non-profit based in Seattle, submitted claims in 2020 for the period January 1, 2020, to July 2020 and those claims were paid. The claims are paid weekly, and services are bundled: Medications, counseling, therapy, toxicology testing, intake activities, and periodic assessments are billed under one billing code.
Evergreen then knowingly resubmitted bills that had already been paid. This conduct continued from January 8, 2021, to February 26, 2021. Evergreen was improperly reimbursed for these services. These double billings totaled $726,991.
Of the $1,453,982 settlement, $726,991 is restitution and the rest is a penalty under the False Claims Act.
Source: DOJ and Evergreen Treatment Services Settle Allegations Regarding Double Billing of Government Health Programs (2024, June 13). www.justice.gov.
Averhealth to Pay Over $1.3 Million to Resolve False Claims Act Allegations Related to Drug Tests Used in Michigan’s Children’s Protective Services and Foster Care Programs
Avertest, LLC, a forensic drug testing company based in Virginia, and which does business nationwide under the name Averhealth, has agreed to pay $1,344,621 to settle allegations that it knowingly violated the False Claims Act (FCA) by submitting to the Michigan Department of Health and Human Services (MDHHS) improper claims for payment for drug tests.
In 2019, Averhealth began performing drug screening and confirmation testing for the State of Michigan’s Children’s Protective Services and Foster Care programs under a contract with MDHHS. To pay for these services, MDHHS utilized funds from the Social Services Block Grant, which provides annual federal assistance to states to support social services programs and is administered by the U.S. Department of Health and Human Services Administration for Children and Families.
The settlement resolves allegations that from May 15, 2019, through November 30, 2020, Averhealth violated the FCA when it knowingly submitted, or caused the submission of, claims for payment to MDHHS, and knowingly made statements material to those claims, which concerned positive drug test results for oral fluid samples that were not confirmed using a mass spectrometric method analytically different from the screening method, and did not conform to the terms of the contract between Averhealth and MDHHS.
The civil settlement includes the resolution of claims brought by a female physician under the qui tam or whistleblower provisions of the False Claims Act. These provisions allow a private party, known as a relator, to file an action on behalf of the United States and receive a portion of any recovery. She will receive $228,586 as part of the settlement.
The claims resolved by the settlement are allegations only and there has been no determination of liability.
Source: Averhealth to Pay Over $1.3 Million to Resolve False Claims Act Allegations Related to Drug Tests Used in Michigan’s Children’s Protective Services and Foster Care Programs (2024, June 20). www. justice.gov.
Sonal Patel
BA, CPMA, CPC, CMC, ICDCM, is CEO and Principal Strategist at SP Collaborative, LLC. She 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. www.spcollaborative.net
2025 ICD-10-CM Updates Released: Explore the 252 New Codes and 36 Deleted Codes
The 2025 ICD-10-CM updates have been officially released, introducing a range of modifications for the upcoming fiscal year. The new updates encompass changes across the Index, Tabular List, Neoplasms, and External Causes sections. Key highlights include 252 new codes, 36 deletions, 13 revisions, and a total of 74,260 codes, all effective from October 1, 2024.
For access to the 2025 Code Tables, Tabular, and Index files, as well as the Coding Guidelines and Present on Admission (POA) Exempt Code List, please visit the Centers for Medicare & Medicaid Services (CMS) website or the CDC/NCHS website.
2025 ICD-10-CM Guidelines Overview
The ICD-10-CM guidelines for 2025 show only minor adjustments. Here is a summary of the key changes:
Chapter 2: Neoplasms - Addition and Clarification: Updates in sections I.C.2.s and I.C.2.t regarding Breast Implant Associated Anaplastic Large Cell Lymphoma and Secondary Malignant Neoplasm of Lymphoid Tissue.
Chapter 4: Endocrine - New Code Description: Introduction of a code for Presymptomatic Type 1
Diabetes Mellitus in section I.C.4.a.1) (a).
Chapter 9: Circulatory - Clarification : Section I.C.9.e.5) now includes the phrase “if applicable” for Other Types of Myocardial Infarction.
Chapter 21: Factors Influencing Health Status - Addition: Section I.c.21.c.3) now includes “and other hormones and factors” to the Z17 Estrogen Receptor Status.
Appendix I - Update: The link to the POA indicator exempt list has been revised.
2025 ICD-10-CM New Codes Summary
Here’s an overview of notable new codes for 2025:
• Chapter 2: 63 codes for lymphoma, including identifiers for “in remission.”
• Chapter 3: 1 code for Fanconi anemia.
• Chapter 4: 16 codes covering Presymptomatic Type 1 DM, hypoglycemia levels, and obesity classifications.
• Chapter 5: 26 codes for classifications related to anorexia, bulimia, and binge-eating disorders.
• Chapter 6: 7 codes for KCNQ2, a common neonatal-onset epilepsy syndrome.
• Chapter 9: 4 codes for cement or fat embolism of the pulmonary artery.
• Chapter 10: 7 codes for nasal valve collapse.
• Chapter 11: 27 codes for anal fistula classifications by site and type.
• Chapter 12: 8 codes for cholestatic pruritus and specific alopecia types.
• Chapter 13: 33 codes for discogenic low back pain and related conditions.
• Chapter 17: 4 codes for congenital malformations of the aortic and mitral valves.
• Chapter 18: 1 code for anosognosia.
• Chapter 19: 30 codes addressing adverse effects of immune checkpoint inhibitor (ICI) immunotherapy and gastrointestinal tract anastomosis disruptions.
• Chapter 21: 25 codes for estrogen and other hormones and factors receptor status, sepsis aftercare encounters, social determinants of health, Duffy phenotype, pediatric obesity body mass index, family history of familial adenomatous polyposis, and personal history of colon polyps.
Tips: Many of the files listed on this page can be found in the linked folders on our FTP site. Some large files are provided in ZIP format for easy downloading.
ICD-10-CM Fiscal Year Releases
The federal government’s fiscal year runs from October 1 through September 30 of the next year.
The fiscal year is named for the calendar year in which it ends.
October 1, 2024, ICD-10-CM release:
• ICD-10-CM FY25, October 1, 2024.
• FY25 ICD-10-CM codes should be used for healthcare services provided from October 1, 2024, through September 30, 2025.
• This release replaces the FY24, April 1, 2024, release.
The latest CMS code, G2211, is here, which means we need to implement internal policies, train our coders/auditors, educate our physicians, and closely focus on documentation. While it may still be rescinded, let’s prepare for success!
NAMAS has been working hard to create a FREE DOWNLOADABLE reference card that is comprehensive and informative. The front of the card helps physicians identify patients who qualify for the G2211 complexity service and provides appropriate documentation to support the service’s work. The back of the card includes reference information on terms used to describe the services provided by G2211.
Coding Notes Pocket Coach for Medical Coding 3rd Edition
Your professional coding coach at your fingertips. Increase your confidence with the expert guidance you’ll find in the 3rd Edition of this easy-to-use guide. Here’s all of the information you need to understand medical billing and coding procedures…in a snap! It’s your one-stop source for commonly used codes and categories that don’t change frequently and ICD-10 references for locating codes that do. It’s like having a master coder by your side showing you how to use the coding reference manuals to increase your efficiency and accuracy.
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.
Medical Billing & Coding Mastery in 4 Months: The All-Inclusive Guide for Aspiring Professionals with Interactive Training, Exam Strategies, and Proven Job-Hunting Tactics
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.
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