BC ADVANTAGE - January/February 2024 | Issue 19.1

Providing resources for medical practices and the people behind them

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Celebrating 19 Over 500,0 Years in Print 00 CEUs P rovided www.billingcoding.com

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2024

Medicare Physician Fee Schedule Final Rule:

January / February 2024 | Issue 19.1

Includes Payment Reductions for Radiology

Updated ICD-10-CM Codes for Appendicitis The Impact and Challenges of Sequencing Z Codes for Reimbursement Not All Time-Based Billing and Coding Rules Are Created Equally Optimizing HCC Coding for Accurate Reimbursement

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CEO Letter I hope you all are staying warm where you are. We recently moved our head office to the mountains of North Carolina and are enjoying all that a higher elevation during winter can bring.

Snow, cold winds, all-encompassing clouds, and icy roads are all now part of our daily life. I have enjoyed having four seasons in South Carolina but am now feeling this fourth season up here a lot more! Mind you, the winter outdoor activities of sledding and skiing make it worth it, and the other seasons are just wonderful here, too. I am so happy to escape the summer humidity of South Carolina and leave the air conditioning and bugs behind but am fully aware that this opinion may change come the end of February—so watch this space!

in these areas. We have other articles that cover this, as well, so be sure to read about how data analytics can help power smarter revenue cycle management and about how time-based billing and coding rules are not created equally. Another article of interest, written by Aimee Wilcox from Find-A-Code, attends whether the symptoms or confirmed diagnosis should be reported for testing. Rachel Rose has written about data use agreements and has also presented webinars recently about several important topics, so be sure to head over to the webinar section online and take a listen. We also have an article about evolving trends in healthcare specialty training, and we wrap up the issue with some cautionary tales of fraud, waste, and abuse cases.

Let’s move on to the issue. We have familiar faces (and one or two new ones) in this issue and thank all of them for providing such a range of diverse topics to share with you all as we start this new year.

Enjoy your issue!

Until next time, Storm

Storm Kulhan

Sandy Coffta from HAP has written about the 2024 Medicare Physician Fee Schedule and how it includes payment reductions for radiology. This is the cover story for this issue, as being informed about these changes as we start the new year is vital for those affected by these changes.

Speaking of being informed, the NAMAS team has written about the impact and challenges of sequencing Z codes for reimbursement, particularly Z08 and Z09 for 2024. We have two articles on HCC coding in this issue, which I believe you will find helpful.

Nobody wants to leave money on the table but instead wants to be reimbursed fully for services rendered, so accuracy is critical

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CONTENTS MAGAZINES | CEUS | WEBINARS

JANUARY / FEBRUARY 2024 - ISSUE 19.1

28

2024

Medicare Physician Fee Schedule Final Rule: Includes Payment Reductions for Radiology

OTHERS

FEATURES 10: Updated ICD-10-CM Codes for Appendicitis 12: The Impact and Challenges of Sequencing Z Codes for Reimbursement 16: Unlocking Revenue Potential: How Data Analytics Powers Smarter Revenue Cycle Management 20: Not All Time-Based Billing and Coding Rules Are Created Equally 24: Optimizing HCC Coding for Accurate Reimbursement 4

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34: Data Use Agreements: Utilization and Distinguishing from Business Associate Agreements 38: Should I Report the Symptom or Confirmed Diagnoses for Testing?

42: Tomorrow’s Doctors: Evolving Trends in Healthcare Specialty Training 46: Missing HCC Codes Leave Money on the Table 48: Monthly Spotlight on Fraud, Waste, and Abuse

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6. News / Updates 50. Reviews - HIPAA: A Practical Guide to the Privacy and Security of Health Data - 2024 E/M Bell Curve Sourcebook - Uniform Billing Editor (Binder)

EXPERT Contributors this issue AQuity Solutions - In a span of about two years, AQuity found clients an additional 770,000+ ICD-10-CM codes and was able to assign more than 244,000 HCC codes. This brought the average HCC score from 0.7 to 1.3. Learn more at https://aquitysolutions. com/solutions or call 866-542-7253.

Sandy Coffta is Vice President, Client Services - Healthcare Administrative Partners. In this role, Sandy oversees the team responsible for achieving and maintaining the company’s consistently high retention and referral rates. Ms. Coffta has over 17 years of experience in client relationship management, including reimbursement analysis, workflow optimization, and compliance education. www.hapusa.com Toni Elhoms, CCS, CPC, CPMA, CRC, is an internationally known speaker and recognized subject matter expert on medical practice management, coding, reimbursement, revenue cycle management, compliance, and fee analysis. She is the Founder and CEO of Alpha Coding Experts, LLC (ACE).

Teri Gatchel-Schmidt is Vice President, Consulting & Business Development. Teri brings over 28 years of experience in the health care industry as a practice administrator, operational leader, and revenue cycle optimization consultant to large health systems and physician organizations. Ms. Schmidt has worked during the past 18 years consulting extensively with health care systems to enhance their financial performance in academic and physician ambulatory based settings.

Eric McGuire is Senior Vice President, Medical Coding and CDI Service Lines and Corporate Strategy, AGS Health. AGS Health is more than a revenue cycle management company–they are a strategic partner for growth. By blending technologies, services, and expert support, https://www.agshealth.com NAMAS is a division of DoctorsManagement, LLC, a premier full-service medical consulting firm since 1956. With a team of experienced auditors and educators boasting a minimum of a CPC and CPMA certification and 10+ years of auditing-specific

experience, NAMAS offers a vast range of auditing education, resources, training, and services.

Sonal Patel, BA, CPMA, CPC, CMC, ICDCM, is CEO and Principal Strategist at SP Collaborative, LLC. Sonal has over 13 years of experience understanding the art of business medicine. 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 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 Randi Tapio, MBA, CMRS, CPCS, CHM, CHBP, is the Owner/CEO of MedCycle Solutions, creating revenue cycle solutions for healthcare practices that improve efficiencies, maximize reimbursements, and help clients get paid faster. As an experienced revenue consultant with over 20 years’ experience, she has a long history of cultivating strong working relationships with providers, ancillary staff, and healthcare executives. www.medcyclesolutions.com 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. www.findacode.com Providing resources for medical practices and the people behind them

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We are always interested in hearing from any industry experts who would like to get published in our national magazine. Email us at editorial@billing-coding.com to request a copy of our editorial guidelines and benefits.

BC Advantage Magazine

November / December 2023 | Issue 18.6

BECOME PART OF SOMETHING BIGGER

ICD-10-CM Code Changes Pediatric Craniosynostosis Coding in ICD-10-CM Whistleblowers and Company Data: To Collect or Not to Collect Missing HCC Codes Leave Money on the Table Why Support for H.R. 2474 Is Important to Your Radiology Practice

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ICD-10 Codes - Look Up NCHS ICD-1O Code Browser

Offered by the National Center for Health Statistics (NCHS), this online tool can provide you with an ICD-10 code when you input a diagnosis (such as “skin allergy”) into the “Enter Search Terms” field.

You can then click on the ICD-10 category on the results page (like “dermatitis and eczema”) to find the exact ICD-10 code for the condition you experienced (such as “allergic contact dermatitis due to metals”).

The NCHS tool also allows you to input an ICD-10 code in the “Find Code in Tabular” field to check if the code submitted by your healthcare provider is the correct one.

Link: https://icd10cmtool.cdc.gov/?fy=FY2024

Nym Meets Growing Demand For Autonomous Medical Coding With Expansion Into Inpatient Care Settings Nym, a leader in autonomous medical coding, recently announced that it has added new capabilities to its revenue cycle management (RCM) solution, enabling hospitals and health systems to automate medical coding for inpatient care. With an established footprint in outpatient settings, such as emergency medicine, radiology, and outpatient surgery, Nym has taken the next step in its expansion and is now offering professional (Profee) coding for inpatient, observation, and skilled nursing facility encounters.

Profee coding is used to bill professional services rendered by a physician during a patient’s stay in an inpatient, observation, or skilled nursing facility setting. Typically, hospitals and health systems have a large volume of inpatient encounters that require profee coding, and, in today’s climate, limited coders to handle that volume. This combination of high coding volume and staffing shortages can increase the administrative burden for coders,

drive higher costs, and potentially put healthcare organizations at risk of coding backlogs and delayed payments. For many inpatient providers, continuing to work in tandem with these challenges is unsustainable both operationally and financially.

“We’ve heard about the frustrations associated with manual inpatient profee coding and the need for better solutions from many of Nym’s customers. It’s conversations like these that have driven us to prioritize inpatient coding for this next expansion of our engine’s capabilities,” said Or Peles, Nym’s CEO. “We are proud to be able to solve our customer’s most pressing challenges and are thrilled to bring our autonomous coding solution, which has consistently been delivering value in the outpatient setting, to inpatient care.”

Nym’s inpatient profee offering includes diagnosis coding, evaluation and management (E/M) coding, bedside procedures coding, modifiers, and provider attribution.

Leveraging clinical expertise, computational linguistics, and explainable AI, Nym’s engine deciphers physician notes in patient charts and accurately assigns ICD-10 and CPT codes for medical billing. Nym codes patient charts within seconds with over 95 percent accuracy and zero human intervention, enabling healthcare providers to optimize resource allocation and reduce coding costs, the risk of denials, and missed revenue. Additionally, the Nym engine is automatically updated as new guidelines are released, and it produces audit-ready, traceable documentation for every code it generates.

Please visit: https://nym.health/

AGS Health-HFMA Survey Finds Healthcare Finance Professionals Have High Expectations for, Limited Understanding of Autonomous Coding Autonomous coding enjoys a high level of trust among healthcare finance professionals who use or plan to use the technology, with 45 percent indicating it often works well and 16 percent placing complete trust in it. Yet despite its emergence as a powerful tool for streamlining and improving error-prone manual coding processes, autonomous coding suffers from an awareness problem, with 52 percent saying they do not know what it is.

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Those are the findings of a new survey from the Healthcare Financial Management Association (HFMA) on behalf of AGS Health, a leading provider of tech-enabled revenue cycle management (RCM) solutions and strategic growth partner to healthcare providers across the U.S. More than 450 healthcare finance professionals were surveyed during the 2023 HFMA Annual Conference on their knowledge of and value expectations for autonomous coding, including 60 percent that use or plan to use autonomous coding.

• • •

coding for the greatest reimbursement.

Just over 23 percent said it would improve patient satisfaction.

More than 22 percent said it would improve patient care.

“Autonomous coding is a rapidly maturing solution for many of the most significant pain points plaguing the healthcare revenue cycle, and we are already seeing its impact with productivity increasing by 20-35% on average.”

View results at: https://www.agshealth.com/ More than half (52%) of respondents said they don’t know what autonomous coding is and 30 percent either did not or were unsure if it could be trusted.

“Despite high expectations around its potential to increase coder productivity and coding accuracy, reduction in denials, missed charges and low-risk scores, and accelerated provider decision-making, autonomous coding suffers from a knowledge gap that must be closed if we are to see broader adoption.”

“Despite high expectations around its potential to increase coder productivity and coding accuracy, reduction in denials, missed charges and low-risk scores, and accelerated provider decision-making, autonomous coding suffers from a knowledge gap that must be closed if we are to see broader adoption,” said Thomas Thatapudi, CIO of AGS Health. “Until we can fully educate finance leadership on the potential autonomous coding holds for improving the healthcare revenue cycle, we are unlikely to see an acceleration in use cases for AI-powered technology which includes autonomous coding.”

American Institute of Healthcare Compliance offers FREE $150 MEMBERSHIP* to *Veterans and Active Military Veterans and Active Military* can get a free membership by applying coupon code VET2023 at payment time, which will give you a 100% discount. This is offered to non-members who are currently serving in the U.S. military and veterans.

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Among the key benefits of autonomous coding is its ability to eliminate the potential for human errors that result in missed reimbursement opportunities, backlogs, delays, and claims errors, and its ability to push accuracy levels to near perfect percentages. All of which can be achieved in near real time with the right integration pipelines. Autonomous coding is also faster than its human counterparts – it can complete charts in seconds – yet it also understands what it does not know, flagging it for human review.

What your free annual membership will provide:

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• • • •

Nearly 67 percent believed it would accelerate the revenue cycle.

63 percent said it would improve coding accuracy.

More than 59 percent indicated it would reduce the need for human intervention.

Nearly 56 percent said it would lower overall costs to the healthcare provider.

More than 48 percent responded that it would optimize

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Free continuing education videos and articles on various healthcare compliance topics available to members only (after log in).

Members-Only pricing and discounts - visit the Certifications Store and the Short Courses Store!

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Coding

Updated ICD-10-CM Codes for Appendicitis According to JAMA, there are approximately 250,000 cases of appendicitis diagnosed annually in the United States. Appendicitis can quickly spiral out of control when a perforation of the appendix occurs, and a patient becomes septic. Understanding the language used in medical documentation helps with the proper assignment of ICD-10-CM codes and supports testing and treatment.

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he appendix is a finger-shaped pouch that protrudes from the colon, near the cecum, located in the lower right quadrant of the abdomen. Appendicitis is diagnosed when the appendix becomes inflamed, which may be caused by an infection, tumor, or an appendicolith (a buildup of calcified feces within the appendix itself). Appendicitis occurs in men and women, almost equally, and most often between the ages of 10 and 30 years old.

in peritonitis, an infection of the peritoneum or the lining of the abdominal cavity and abdominal organs.

Peritonitis is either localized (the infection is walled off by organs limiting the spread of the infection to a specific location) or generalized (diffuse) where the infection spreads throughout the entire peritoneal cavity and lining of all the abdominal organs. Left untreated, a complicated case of appendicitis can turn septic and deadly.

Uncomplicated vs. Complicated Appendicitis

Diagnosis and Treatment

An uncomplicated case usually consists of an inflamed but not ruptured appendix, treatable with antibiotics and, if needed, surgery. However, a complicated case of appendicitis can be deadly if not aggressively treated right away. As the appendix ruptures, it leaks pus and bacteria into the abdominal cavity, which can result

After a patient history and examination have been completed, diagnosis may be done through additional testing, such as:

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•

Blood tests to check the white blood cell count, which, if high, indicates an active infection

•

Imaging studies - Ultrasound - Abdominal CT scan (preferred)

Acute appendicitis with localized peritonitis is reported with codes from K35.89- with the sixth character identifying the status of perforation, abscess, and gangrene.

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.

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

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 With or without gangrene

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ICD-10-CM of New Codes: Bumper Crop Team Intimidate CDI Codes Needn’t

2022 Acup

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uncture

2022 | / April March 2022 | Issue 17.4 July / August

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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

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Coding

The Impact and Challenges of

Sequencing Z Codes for Reimbursement Every year, we get updates to the Official Guidelines for Coding and Reporting, and this year, for reporting year 2024, we received an update regarding Chapter 21 for follow-up codes Z08 and Z09.

The accurate sequencing of these Z codes was emphasized in the guideline update by reminding us that they can be used for both medical and surgical treatment. There are times when another surgical treatment follow up can only be described by using Z08 or Z09. But be cautious with these codes because the key word used is “completed” treatment. There are times when a patient may be following up on various conditions and treatment has not been completed yet. Reimbursement can be impacted if we do not understand the basic requirements of using these codes and other Z codes that trigger reimbursement. Let’s look at the various Z codes and their impact.

P

urpose of Z Codes

The purpose of Z codes is outlined in Chapter 21 of ICD-10-CM, “Factors Influencing Health Status and Contact with Health Services” section (Z00Z99) of the ICD-10-CM coding manual. They are used to provide medical necessity for various factors that influence an individual’s health status and encounters with the healthcare system. Unlike codes used for specific diseases, injuries, or external causes, Z codes are applied

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in circumstances where the primary focus is on health status, preventive care, and reasons for seeking healthcare services that may not be related to a specific illness or injury.

Primary Diagnosis Requirements As you know, reimbursement hinges on the triggering of payment based on the reason for the encounter or the primary diagnosis in many cases, which makes it imper-

ative that we understand which Z codes can serve as primary and which cannot. The guidelines specify encounter scenarios where Z codes should be used as primary diagnoses, such as general examinations, screening, and encounters for specific procedures like antineoplastic therapy.

Aftercare Encounters Aftercare encounters, especially in the realm of orthopedics, introduce a layer of complexity to coding practices. The guidelines highlight instances where aftercare codes can be used as primary or secondary, with variances such as indicating a follow up for a healing fracture with the 7th character of the appropriate fracture code from Chapter 19 of ICD-10-CM. So, in some cases, if you wish to report that a condition other than a healing fracture is being followed up on, you would use a code from the Z47 category that has very specific reasons for the aftercare follow up, such as explanations of a joint prosthesis or for after an amputation. It can be easy to think that since they completed the treatment, you can just use trusty old Z09 but, remember, if another code exists that more accurately describes the scenario, we should be using it.

If you work in orthopedics, I strongly encourage you to read all the language and coding conventions in the Z47 category that will impact your proper coding and reporting.

Here is an overview for reference: • • • • • • • • •

Z42 - Encounter for plastic and reconstructive surgery following medical procedure or healed injury Z43 - Encounter for attention to artificial openings Z44 - Encounter for fitting and adjustment of external prosthetic device Z45 - Encounter for adjustment and management of implanted device Z46 - Encounter for fitting and adjustment of other devices Z47 - Orthopedic aftercare Z48 - Encounter for other postprocedural aftercare Z49 - Encounter for care involving renal dialysis Z51 - Encounter for other aftercare and medical care

Status and History Codes Status codes are important because they convey the ongoing story of a patient’s condition or procedure. While not recommended as primary codes, their accurate use is needed for further detail that adds medical necessity. They should not be used when their description is already inherent to another code from another chapter of ICD-10, such as subcategory T86.2, Complications of heart transplant, where it would not be necessary to also report the status of a heart transplant with Z94.1. For history codes, it is very important to identify a historical condition that is clinically relevant to the present encounter. Per ICD-10-CM Guideline Section I.C.20.c.4, we are to sequence a primary “encounter for” code before including a history code, ensuring the logical flow of information.

WEBINAR - CEU Approved FY 2024 ICD-10-CM code changes Presenter: Leigh Poland, RHIA, CCS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, Vice President Coding Services Line – AGS Health Objectives: Get an overview of the 395 new diagnosis codes, 25 deletions, and 13 revisions for the fiscal year (FY) 2024 ICD-10-CM code set announced by the Centers for Medicare and Medicaid Services (CMS), finalized to take effect on October 1 st , 2023.

Review key diagnosis code changes such as Parkinson’s Disease, chronic migraines, sickle cell disease, and external cause of morbidity and mortality codes.

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Social Determinants of Health: A Missed Opportunity?

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The healthcare industry is witnessing a shift toward value-based care, emphasizing data collection to show patient well-being. Despite the availability of codes in the Z55-Z65 range for reporting social determinants of health (SDOH) since 2015, there remains an underutilization of this valuable information. Financial factors, a prominent SDOH, significantly impact patient populations, yet the direct link between reporting these codes and reimbursement incentives remains elusive.

clinical, procedural, and social aspects, to enhance the quality of care provided and ensure a fair and just reimbursement system.

Here is an overview of the categories available:

2.

• • • • •

3.

• • • • •

Z55 - Problems related to education and literacy Z56 - Problems related to employment and unemployment Z57 - Occupational exposure to risk factors Z58 - Problems related to physical environment Z59 - Problems related to housing and economic circumstances Z60 - Problems related to social environment Z62 - Problems related to upbringing Z63 - Other problems related to primary support group, including family circumstances Z64 - Problems related to certain psychosocial circumstances Z65 - Problems related to other psychosocial circumstances

Here are some tips to improve revenue and communication across teams: 1.

4.

5.

6.

Revenue Impact of SDOH While SDOH codes might not directly result in a reimbursement triggering event, recent developments underscore their influence on reimbursement. Evaluation and Management (E/M) updates have in recent years recognized SDOH reporting under the moderate level of risk, which highlights the potential impact on reimbursement for chronic conditions managed at this level. Accurate documentation is vital for revealing the true cost and resources a patient is expected to consume by utilizing these codes. Data tracked by zip code, and other factors that are reported such as their age, disability status, and the severity of their chronic conditions, like diabetes, hypertension, and CKD, will impact their ability to receive care. If a patient does not seek care due to a financial hardship, their condition will worsen, especially if they stop rationing medication to pay a utility bill or buy food. If they get sicker, then it becomes more costly to treat them, resulting in higher costs to the health system and the ripple effects continue.

Conclusion Let us focus on telling the complete story, putting together the

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7.

Provider Education Educating providers ensures understanding Z codes’ role in comprehensive documentation.

Clear Documentation Guidelines Regularly review the guidelines that will help your care teams apply Z codes accurately during different encounter types.

Integration Into EHR Optimization and integration prompts providers to use Z codes appropriately in electronic health records.

Regular Audits and Feedback Audits identify areas for improvement, and feedback reinforces accurate Z code usage.

CDI Programs Clinical Documentation Improvement programs will enhance collaboration and accuracy.

Updates on Coding Guidelines Regular communication keeps providers informed about evolving coding standards. Now is a great time to review any changes for 2024 and any that may have been missed in previous years.

Provider and Staff Engagement A culture of engagement promotes open communication on the importance of Z codes. Remember that ICD-10-CM official guidelines advise coders and physicians to have a collaborative relationship.

NAMAS is a division of DoctorsManagement, LLC, a premier full-service medical consulting firm since 1956. With a team of experienced auditors and educators boasting a minimum of a CPC and CPMA certification and 10+ years of auditing-specific experience, NAMAS offers a vast range of auditing education, resources, training, and services. As the original creator of the now AAPC-affiliated CPMA credential, NAMAS instructors continue to be the go-to authorities in auditing. From DOJ and RAC auditors to CMS and Medicare Advantage Auditors to physician and hospital-based auditing professionals, NAMAS’ team has educated them all. NAMAS is proud to have helped so many grow and excel in the auditing and compliance field.

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Practice Management

Unlocking Revenue Potential: How Data Analytics Powers Smarter Revenue Cycle Management In today’s ever-evolving healthcare landscape, the pursuit of unlocking the full revenue potential of healthcare organizations stands as a paramount objective. With healthcare costs rising and the intricacies of medical billing becoming increasingly complex, the need for precision and insight in managing revenue has never been more critical. Data analytics has the transformative power in revenue cycle management to shed light on the strategies, tools, and real-world successes that can guide healthcare providers toward financial clarity and success.

T

he Power of Data Analytics in Revenue Cycle Management

Data analytics, often described as the linchpin of this transformation, brings precision and insight that has historically been elusive in healthcare financial management. At its core, data analytics serves as a powerful tool for identifying revenue leakage points within healthcare organizations. This process involves a nuanced understanding of the intricate workings of data

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analytics.

Precision Through Data-Driven Methodologies and Innovative Technologies Leveraging data-driven methodologies and innovative technologies, healthcare providers can systematically pinpoint inefficiencies, streamline processes, and optimize revenue streams. This strategic approach bolsters their financial health and empowers them to thrive in a

challenging fiscal landscape.

• Real-World Success Stories - Tangible Metrics Illuminate the Path To illustrate the transformative power of data analytics in revenue cycle management, let’s delve into a real-world success story: the case of Berenson Oncology. These narratives are replete with tangible metrics, underscoring how healthcare providers have achieved unparalleled clarity in their financial operations. Case studies serve as our guideposts, illustrating the substantial improvements in revenue generation and cost containment that result from a strategic embrace of data analytics.

•

•

standing in A/R, ensuring a consistent cash flow.

Poor Visibility into RCM Processes: Introduced transparency into revenue cycle management processes, providing Berenson Oncology with clear insights.

Cash Flow Forecasting: Robust cash flow forecasting reports enabled Berenson Oncology to troubleshoot issues impacting collections.

Poor Customer Service: Improvements in customer service practices bolstered relationships and satisfaction levels.

The Results The results of this transformation were remarkable:

The Challenge • Berenson Oncology, a private practice specializing in Hematology/Oncology in West Hollywood, California, faced a set of daunting challenges. These included cash flow issues, decreasing revenue, and a troubling increase in accounts receivables.

Faced with these hurdles, Berenson Oncology sought a benchmarking assessment of its revenue cycle processes.

• • •

The Solution With a comprehensive implementation strategy to revamp Berenson Oncology’s revenue cycle management, including daily benefits verification, daily claims submission, timely collection follow-ups, a robust document management system, cash flow forecasting reports, weekly progress reports, monthly revenue analysis reports, quarterly drug analysis, best practices recommendations, participation in the PQRS initiative, and real-time analytics reports through Doctrix. Notably, weekly drug cost analysis played a vital role in controlling expenses.

The Challenges Addressed •

•

•

Coding and Documentation: Comprehensive coding and documentation practices were implemented to improve claims accuracy and reimbursement rates.

Reimbursements for Unclassified Drugs: Strategies were devised to navigate reimbursement challenges related to unclassified drugs.

Increasing Days in Accounts Receivables (A/R): A targeted approach was adopted to reduce the number of days out-

•

•

Improvement in 90+ Insurance A/R: Berenson Oncology witnessed significant improvements in their accounts receivables with improvements in 90+ insurance AR. Consistent Cash Flow: Cash flow forecasting reports ensured consistent financial stability.

Better Working Capital Management: Efficient revenue cycle management led to enhanced working capital management.

Best-in-Class and Compliant Business Processes: Compliance was ensured through best practices and the business processes to ensure improved levels of efficiency.

100% Transparency into RCM Processes: Berenson Oncology gained a near real-time view into the KPIs impacting their revenue cycle performance.

Improved Payment Rates: Payment rates soared to an impressive 98% to 99%, reflecting the effectiveness of the transformation.

The Berenson Oncology case study exemplifies how data analytics, coupled with strategic implementation, can rejuvenate revenue cycle management for healthcare organizations. This real-world success story demonstrates that with the right tools and expertise, healthcare providers can achieve financial clarity and success, even in the face of significant challenges.

Sample Key Performance Indicators (KPIs) - Empowering Proactive Revenue Management In the realm of healthcare revenue cycle management, the role of Key Performance Indicators (KPIs) cannot be overstated. These metrics provide crucial benchmarks for assessing the perfor-

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mance of various revenue cycle functions.

Let’s explore a selection of these KPIs and understand their profound impact on proactive revenue management: 1.

Appointment No-Shows & Cancellation % (Scheduling/ Orders): KPI Impact: No-shows and cancellations may appear as minor inconveniences, but their repercussions run deep.

When these occurrences rise, the scheduling team is compelled to invest additional time in rescheduling patients.

Furthermore, the practice may lose out on billable time, directly affecting revenues. Monitoring this KPI is essential to optimize scheduling efficiency.

Time of Service Collections (Pre and Time of Service): KPI Impact: The efficiency of upfront or time of service collections is a pivotal factor in maintaining healthy cash flow. It also presents an opportunity to educate patients about their overall financial responsibilities. A high or increasing Time of Service Collections KPI indicates effective patient communication, trust-building, and early revenue collection in the revenue cycle management process. It mitigates the risk of aging Accounts Receivable (AR).

Denial Rate Percentage (Billing): KPI Impact: The journey from patient information intake to the conclusion of a care encounter is rife with opportunities for claims to be denied. The Denial Rate percentage serves as a guiding star, helping your practice identify potential issues that could lead to denied claims. Proactive management in this area is paramount to minimizing revenue loss.

Net Collection Rate (Payment): KPI Impact: Maximizing revenue requires collecting everything owed to your practice. The Net Collection Rate KPI allows you to gauge your collection performance based on contractual agreements with payers. It also serves as a measure of how effectively your team captures “collectable dollars.” Monitoring this KPI ensures that you’re not leaving potential revenue on the table.

Days in AR (Payment): KPI Impact: Timely payments and efficient revenue are the lifeblood of any healthcare practice. The Days in AR KPI helps identify delays in patient or insurance reimbursements, providing critical insights for your revenue cycle team. By promptly addressing issues indicated by this KPI, your team can focus their efforts where they will have the most significant impact, ensuring a streamlined revenue

2.

3.

4.

5.

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cycle.

These KPIs can serve as essential tools in proactive revenue management. They enable healthcare organizations to pinpoint areas of concern, make data-driven decisions and take corrective actions to optimize revenue performance.

Uncovering Strategies and Tools for Future Success Ultimately, our journey is leading us to uncover the strategies and tools that can unlock the full revenue potential of healthcare organizations. These insights are designed to ensure longterm financial vitality of unprecedented change and complexity.

As the healthcare landscape evolves, data analytics will remain a cornerstone in the quest for financial clarity and success, providing the guidance and precision necessary to navigate these challenging waters.

Teri Gatchel-Schmidt is Vice President, Consulting & Business Development.

Teri Gatchel-Schmidt, MBA, CPC, brings over 28 years of experience in the healthcare industry as a practice administrator, operational leader, and revenue cycle optimization consultant to large health systems and physician organizations. Ms. Schmidt has worked during the past 18 years consulting extensively with healthcare systems to enhance their financial performance in academic and physician ambulatory based settings.

As Vice President of Consulting, Ms. Schmidt is responsible for helping organizations reach their strategic, operational performance and financial goals through technology-led revenue cycle transformation. Her extensive hands-on knowledge of end-to-end revenue cycle processes gives her the ability to identify workflow redesign and overall performance improvement opportunities with an eye toward financial improvement and increased efficiency. Her past experiences include executive leadership roles at Change Healthcare, Optum, and MedSynergies. Prior to this, she spent 10 years at the University of Texas Southwestern Medical Center, where Ms. Schmidt held the position of Director of Operations for the departments of Otolaryngology and Oral and Maxillofacial Surgery. She holds an undergraduate degree in business/finance from Texas Wesleyan University and a Master of Business/Health Care Administration from the University of Dallas. www.synergenhealth.com

Coding

Billing

Management

Compliance

Auditing

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Billing / Coding

Not All Time-Based Billing and Coding Rules

Are Created Equally

On countless occasions, I have heard physicians and healthcare providers balk at the notion of learning how to level their Evaluation and Management (E/M) services based on Medical Decision Making (MDM), and some will even go as far as to say things like, “I don’t have time to bother with all that MDM stuff and prefer to only bill based on the time,” or, “I’ll just throw a time statement macro in the note to cover my bases since MDM is too subjective.” As compliance auditors and professionals, we see the results of this mentality in clinical documentation day in and day out with antiquated macros and note-bloat-heavy templates.

I

still see “greater than 50% of the face-to-face time was spent in counseling/coordinating care” almost daily, even though E/M services are no longer calculated based on this criterion. If this isn’t a case of “kicking the can down the road,” I don’t know what is! To make a bad situation even worse, these myopic sentiments are often paired with ineffective operations leadership and support staff who refuse to confront these issues and further enable this poor

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decision making. We, as compliance professionals, must remain diligent and peel back the curtain on all these decisions to assess the situation for potential compliance risk exposure.

While time-based billing for E/M services is permitted, let us not forget that not all time-based billing rules in CPT are created equally, which often results in conflating rules across different service categories. Within CPT

coding, we have service-based CPT codes and time-based CPT codes.

Categories of Time-Based Services There are certain services (e.g., Chronic Care Management [CCM], Principal Care Management [PCM], and Remote Patient Monitoring [RPM]) that require a fixed time threshold to be met to qualify for compliant billability. Next, there are certain services (e.g., office-based E/M services, online E/M services, telephone E/M services) that encompass time ranges with established minimum times to be met to qualify for compliant billability time-based CPT codes. There are also constant attendance time-based services (e.g., physical therapy, occupational therapy, psychotherapy) that require greater than half of the intra-service time to be met to qualify for compliant billability.

As compliance professionals, we must take it a step further and raise the issue of whose time can be counted toward each billable service and what level of supervision is required to report those services. This mixed bag of coding and billing rules often leads to physicians/providers/clinical staff conflating different types of time-based coding rules and subsequently billing for time-based services in situations that are improper and ultimately result in overpayments to the organization.

First, let’s start with the example of chronic care management services. Under the current rules, if the provider wants to bill CPT code 99490, they must document a minimum of 20 minutes of total clinical staff time directed by a physician or other QHCP dedicated to that patient, spent in the calendar month. In this scenario, providers can count time spent by clinical staff dedicated to CCM activities if the services are directed by the physician/QHCP and under their general supervision. It would be improper to count any activities unrelated to CCM in the total billable time per calendar month or to double dip CCM time with an overlapping service like transitional care management (TCM). It would also be improper to count time spent by clinical staff not affiliated with the provider or time spent with clinical staff based outside the United States (i.e., offshore care management companies) toward CCM billable time. Suppose the provider wants to bill CPT code 99491. In that case, they must document a minimum of 30 minutes of personal physician/QHCP time dedicated to that patient, spent on CCM activities in the calendar month. In this scenario, providers cannot count or combine clinical staff time dedicated to CCM activities because this CPT code is specifically for physician/QHCP personal time.

Second, let’s dive into the example of office-based E/M services (99202-99215).

Under the current rules, if the provider wants to bill for CPT code 99214 based on time, they must document a minimum of 30 minutes of total encounter time (up to 39 minutes) dedicated to that patient, spent on the encounter date. This total time spent on the encounter date can only be provider time without any

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Define a Comparative Billing Report (CBR).

Understand why a CBR is issued.

Recognize what is current for 2023.

Explore two CBRs issued in 2023.

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combination of clinical staff time. It would be improper to combine the medical assistant or nurse’s time dedicated to the encounter, time spent by the medical scribe, time spent teaching or precepting students/residents/ fellows, or to include any midlevel provider time since office-based services do not allow for split/shared reporting. It would also be improper to count any time toward the E/M level dedicated to a separately billable procedure or service, and time statements must make abundantly clear that E/M time is separate and excludes any procedure/other service time.

Thankfully, in 2024, we will return to fixed time thresholds for office-based E/M services! This will surely alleviate much of the confusion and disparities surrounding prolonged service billing and the mixed bag of payor policies we must navigate under the current system.

Next, let’s focus on constant attendance services using an example of physical therapy (PT) treatment. Many PT services are continuous attendance-based therapies, billed based on time and reported based on 15-minute increments. Under the current rules, if the provider wants to bill for CPT code 97110 x 1, they must document a minimum of 8 minutes (“rule of 8s”) of intra-service time personally spent by the provider and dedicated to that patient at the encounter. We’ll save all the payor policies regarding the rule of 8s for another time!

Throughout this PT session, the provider must maintain visual, verbal, and manual contact with the patient.

This total time spent on the date of the encounter can only include provider time without any combinations of clinical staff time. Unlike the other scenarios described above, the provider does not have to spend the full 15 minutes to fulfill the requirements for billing for the PT service. It would be improper to combine any time outside of the provider’s direct contact with the patient with the time counted toward this billable service.

Conclusion It’s safe to say that even for the most seasoned professionals, it’s easy to get all these time-based coding and billing rules confused, which is why ongoing compliance audits combined with dialogues and education with our physicians/providers/clinical staff are imperative. Don’t

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just assume that your physicians/providers/clinical staff can keep all the hodgepodge of time-based billing and coding rules straight and compliant – we, as compliance professionals, must ascertain that this is done by diving deep into their clinical documentation and clinical workflows.

These regular touchpoints and interactions will aid you in uncovering some of the main sources of conflation.

The moral of the story: Make sure to educate your physicians/providers/clinical staff about the intricacies of time-based billing and coding rules, or the consequences can be catastrophic!

Toni Elhoms, CCS, CPC, CPMA, CRC, AHIMA-Approved ICD-10-CM/PCS Trainer.

Toni Elhoms is an internationally known speaker and recognized subject matter expert on medical practice management, coding, reimbursement, revenue cycle management, compliance, and fee analysis. She is the Founder and CEO of Alpha Coding Experts, LLC (ACE).

She holds multiple credentials with the American Health Information Management Association (AHIMA) and the American Academy of Professional Coders (AAPC). Ms. Elhoms’ expertise extends to both inpatient and outpatient coding, compliance, billing, and reimbursement. She has extensive experience in orthopedic surgery, spine surgery, neurosurgery, cardiology, interventional cardiology, general surgery, oncology, hematology, internal medicine, family practice, geriatrics, pediatrics, pain management, neurology, urology, hospital medicine, critical care, and other practice areas.

Ms. Elhoms serves as ACE’s Senior Consultant and conducts training and educational seminars across the country on a variety of topics including, but not limited to, Medical Coding, Medical Billing, Practice Management, Managed Care, Revenue Cycle Management, Revenue Maximization, Regulatory Compliance, The Social Determinants of Health (SDoH), ICD-10-CM and PCS, Surgical Specialty Coding, etc. https://www.alphacodingexperts.com/

Work Smarter, Not Harder

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Take a Team Approach to Audits with DoctorsManagement 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.

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Coding

Optimizing HCC Coding for Accurate Reimbursement

Hierarchical Condition Category (HCC) codes are an integral aspect of healthcare’s ongoing transition from fee-for-service to a value-based care model of reimbursement—a transition that requires providers to better manage patient costs based on a clear, concise, and comprehensive picture of patients’ health and medical conditions.

U

sed by the Centers for Medicare and Medicaid Services (CMS) and commercial payors to forecast medical costs for patients with more complex healthcare needs, the HCC risk adjustment model measures relative risk due to health status to determine reimbursement levels. The more complex the patient’s medical needs, the higher the provider’s payment.

HCCs are now the preferred method of risk adjustment for the Medicare population which, according to figures from CMS, includes nearly 60 million people on both Part A and Part B, approximately 30.2 million of whom are enrolled in a Medicare Advantage (MA) plan. Thus, doing it correctly is crucial to Medicare providers and payors who wish to be appropriately reimbursed for the

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care provided to patients and beneficiaries.

The Critical Need for Accuracy HCC is a highly complex model under which there are approximately 10,000 diagnosis codes that map to HCC codes and 189 different HCC categories with 87 CMSHCCs, each representing diagnoses with similar clinical complexity and expected annual care costs. Accuracy is crucial, as any error can significantly impact reimbursements and, subsequently, the overall bottom line.

Under HCC, reimbursement is determined by mapping a patient’s diagnoses to these codes to create a Risk Adjustment Factor (RAF) score, which represents the estimated cost of caring for that individual based on

their disease burden and demographic information. The RAF score is then multiplied by a base rate to set the provider’s permember-per-month (PMPM) reimbursement. Typically, healthier patients will have a below average RAF, while sicker patients will be above average.

Each year, CMS publishes a list of diagnosis codes and the corresponding HCC category they adjust to within the model.

Hierarchies are listed among related condition categories, which set values based on the severity of illnesses, with more severe diagnoses carrying the overall risk scores for families of conditions. Failing to properly document HCC codes—or failing to do so at the highest appropriate specificity—results in lower reimbursement rates. For example, HCC 19, diabetes with no complications, might pay an $894.40 premium bonus compared to a bonus of $1,273.60 for diabetes with ESRD, which requires two HCC codes mapping to 18 and 136.

Conversely, properly documenting HCCs at the highest appropriate specificity can boost reimbursements.

For example, if CMS has set a $1,000 PMPM for a patient with an RAF of 2.234 who has diabetes with complications: • •

•

Reimbursement would be just $673 per month if the condition is not coded.

If properly coded as E11.9, type 2 diabetes mellitus without complications, under HCC 19, diabetes without complications, the RAF increases to 2.366, resulting in reimbursement of $1,062 per month.

If properly coded as E11.41, type 2 diabetes mellitus with diabetic mononeuropathy, under HCC 18, diabetes with chronic complications, the RAF increases to 2.513 for a reimbursement of $1,312.5.

HCC coding is important under value-based care models and for population health management. Failing to capture a comprehensive and accurate picture of the health and risks of a patient population can lead not only to reduced reimbursements but also to inaccurate or ineffective decision making regarding interventions and investments. For example, risk scores that inaccurately reflect a population’s rate of diabetes or congestive heart failure could result in a provider organization investing money and resources into something other than a cardiac care or diabetes center, which could ultimately result in poor outcomes

and money lost.

HCC Coding Challenges Its interlocking steps make accurate documentation and coding for HCC as complex as it is critical. Hierarchies ensure an individual is coded for the most severe manifestation among related diseases. Diagnosis codes roll up to diagnostic categories, which are included in condition categories, which then become HCCs. Each mapped diagnosis must be supported with documentation and evidence to ensure timely, accurate, and complete coding and billing.

Maximizing the use of HCC tables to capture diagnosis codes, complication/comorbid conditions (42% of HCCs), and major complication/comorbid conditions (16% of HCCs) is important for accuracy, as is optimizing Medicare Severity Diagnosis Related Groups (MS-DRGs) assignments that confirm the severity of illness and risk of mortality. As such, complete and accurate clinical documentation is the foundation for proper HCC assignment.

The challenge is that the HCC documentation and coding process is fraught with challenges, which typically fall into three categories: 1.

2.

3.

Incomplete medical records, which can lead to undercoding, resulting in lower reimbursements, inaccurate RAF scores, downgrades to lower hierarchical category levels, and bad investment decisions to support the patient population. It is a challenge that can be exacerbated by coders working in a manual environment who may not recognize they are working with incomplete records.

Limited resources, in particular coding specialists with the skills and experience necessary to properly evaluate a patient’s chart and extrapolate the information needed to document the appropriate HCC category.

Complex and rapidly evolving regulations, which can be difficult to stay on top of (particularly in a manual environment), leaving coders to work from outdated HCC code sets and guidebooks.

Additionally, many organizations struggle to engage physicians in the query process, which hinders efforts to improve documentation that relates to risk-adjusted coding. Further, physicians embrace technology at varying rates, so it is often necessary to

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employ multiple communication methods to succeed at risk-adjusted and HCC coding.

Optimizing Reimbursement To optimize HCC coding for accurate reimbursement, healthcare providers should focus on several key areas, starting with adherence to the MEAT criteria (monitor, evaluate, assess/ address, and treat) to support proper documentation. Coders use the MEAT formula to help them correctly identify and assign HCC chronic condition diagnoses, which payors also use to account for the overall health and medical cost expectations of each patient enrolled in a health plan. This is vital, as value-based payment models that require providers to carry greater financial risk are becoming the norm.

Another key focal point is the patient population—both individual patients and the global population. Focus on those areas that have the greatest impact on risk adjustment, as well as high value and volume encounters. Where appropriate, implement outpatient clinical documentation improvement (OP CDI) initiatives to close documentation gaps, shore up weaknesses, and improve evidence capture.

There are also several technology tools that can facilitate needed improvements in HCC coding and documentation, including: •

Computer-assisted coding (CAC) solutions that update automatically.

Computer-assisted professional coding (CAPC) tools that leverage natural language processing (NLP), natural language understanding (NLU), and machine learning (ML) to automatically annotate documentation and autosuggest ICD-10 with HCC mappings for improved diagnosis capture, as well as identify diagnosis without supporting evidence and estranged evidence without a diagnosis.

HCC ROI calculators or RAF aggregation tools that optimize HCC coding and accurately capture all relevant diagnoses.

Dashboards that provide an accurate reflection of a provider’s scores for real-time management.

•

• •

Health plan relationships should also be part of any improvement strategy. In particular, request regular updates on their diagnosis codes, which will allow providers to sync with their

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payors and identify what is missing or no longer allowed.

Additionally, ensure physician engagement—a tricky prospect with risk-adjusted coding—by developing a program that balances the use of auto-generated queries and NLP-based functionality with CDI delivered in meaningful ways. For example, some providers prefer a checklist in the medical record, while others need more direct prospective OP CDI reviews to bring discrepancies to their attention.

Finally, make judicious use of internal audits. Prospective audits can help improve how physicians document care and how coders code health conditions, translating into improved financial performance. Retrospective audits can bridge documentation gaps and identify where additional provider and coder education is needed. For example, if providers are missing documentation of supportive evidence for diabetes and cancers, exclusive education programs can be developed to address the gap.

Conclusion Accurate, compliant HCC coding is critical to the financial well-being of payors and providers, and to the health of their patient populations. The challenges inherent in the HCC process can be overcome with properly designed and implemented strategies that ensure appropriate documentation to support accurate coding at the highest specificity—leading to significantly improved bottom lines and patient outcomes.

Eric McGuire, Senior Vice President, Medical Coding and CDI Service Lines and Corporate Strategy, AGS Health.

Eric McGuire, AGS Health. AGS Health is more than a revenue cycle management company–they are a strategic partner for growth. By blending technologies, services, and expert support, AGS Health partners with leading healthcare organizations across the U.S. to deliver tailored solutions that solve the unique needs and challenges of each provider’s revenue cycle operations. The company leverages the latest advancements in automation, process excellence, security, and problem solving through the use of technology and analytics–all made possible with college-educated, trained RCM experts. https://www.agshealth.com/

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Coding

2024

Medicare Physician Fee Schedule Final Rule: Includes Payment Reductions for Radiology The Centers for Medicare and Medicaid Services (CMS) announced its Medicare Physician Fee Schedule (MPFS) Final Rule for 2024, including provisions for both Medicare reimbursement and the Quality Payment Program (QPP).

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MPFS Payment Provisions

R

eimbursement rates will be calculated by applying the statutory formula as required.

This produces a fee schedule Conversion Factor (CF) of $32.7442, which is 3.37% lower than the $33.8872 CF used for the 2023 fee schedule, and slightly lower than the $32.7476 rate included in the Proposed Rule earlier this year. The CF calculation includes a 1.25% upward adjustment provided by the Consolidated Appropriations Act, 2023 (CAA 23) that was passed late in 2022 to help mitigate the effects of the formulaic calculation for 2023 and 2024. Without the CAA 23, the 2024 reimbursement rate would have been even lower. Note that the CAA 23 also included deferral until 2025 of the PAYGO rule that would lower the fee schedule by another 4%.

code led to a significant projected increase in spending, yielding an approximate 2% reduction to the CF to maintain budget neutrality. While the CMS-estimated -4% overall impact in IR reimbursement is the biggest cut of any specialty, the CMS-estimated impact for family medicine is +3%.

Practices in some areas will feel the effect of changes to the Geographic Practice Cost Index (GPCI). Healthcare Administrative Partners’ review of the Proposed Rule for 2024 described these changes that will negatively impact 109 payment localities across the country, and the Final Rule did not revise what was contained in the Proposed Rule.

CMS estimates the following specific effects for radiology, which are unchanged from the Proposed Rule: Specialty

Non-Facility

Facility

Overall

Radiology

-3%

-3%

-3%

Interventional Radiology

-5%

-3%

-4%

Nuclear Medicine

-2%

-3%

-3%

Radiation Oncology

-2%

-2%

-2%

These CMS estimates could be understated because the 2023 rate used in their calculation did not include the 1.25% CAA increase, and so it does not match the final payment rate for the year.

According to CMS, approximately 90% of the negative fee schedule adjustment is attributable to activation of a new add-on code G2211 for Evaluation and Management (E/M) complexity. A primary policy goal of G2211 is to reimburse certain physicians, such as family medicine physicians, more appropriately for the care they provide to highly complex patients. The utilization assumption for this new

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CMS confirmed its plan to suspend the AUC/CDS program that would deny payment to radiologists when the ordering physician fails to consult a Clinical Decision Support (CDS) system to obtain Appropriate Use Criteria (AUC).

Accordingly, effective January 1, 2024, AUC consultation information including G-codes and modifiers should no longer be included on Medicare claims. CMS has not specified a timeframe within which implementation efforts will recommence.

As described in the Proposed Rule, direct physician supervision of Level 2 diagnostic exams, such as those requiring

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2023 E/M CHANGES

In 2021, the office/other outpatient codes and guidelines went through revisions.

For 2023, the rest of the E/M sections underwent a major overhaul. We cover all sections revised with comprehension checks to ensure attendees will be able to: • Apply the 2023 E/M definitions and guidelines in CPT to the medical record.

• Utilize the revised 2023 Medical Decision Making (MDM) Table in CPT to review E/M services.

• Demonstrate to physicians and other providers proper documentation that supports the level of services reported.

AUDITING SOLUTIONS

CHCS provides many types of audits for CPT and/or diagnosis.

CONSULTING SOLUTIONS

• Physician/provider education on multiple specialties.

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Education can be customized for your practice, department, or group. Services can be performed on-site, or virtually through our eLearning platform.

Health Care Consultant | Educator | Speaker | Author

Betty A. Hovey, BSHAM, CCS-P, CDIP, CPC, COC, CPMA, CPCD, CPB, CPC-I 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.

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contrast administration, will continue to be allowed via real-time audio and video telecommunications through December 31, 2024. Audio-only telecommunication will not be allowed. CMS is considering whether to extend this definition of direct supervision beyond December 31, 2024.

Quality Payment Program (QPP) Some QPP changes in the Proposed Rule that would have been onerous for radiology were not adopted in the Final Rule. The performance threshold was proposed to increase from 75 points to 82 points for the 2024 performance year, but it will remain at 75 points. This is the minimum score that must be earned to avoid a payment penalty in the 2026 payment year. Radiology practices will also benefit from the retention for 2024 of Measure #436, “Radiation Consideration for Adult CT: Utilization of dose lowering techniques,” which was proposed to be eliminated. This Quality Measure is highly utilized by radiologists.

The category weighting will remain the same as it was for 2023; however, the Data Completeness Threshold will be increased to 75% from 70% of total exam volume. The low-volume threshold criteria that benefits small practices of 15 or fewer clinicians will also remain unchanged for 2024 and the range of payment adjustments (for payment year 2026) will continue to be +/- 9%.

Several other Quality Measures that have been useful to radiologists will be removed for 2024, including: •

•

Measure #147, Nuclear Medicine: Correlation with existing imaging studies for all patients undergoing Bone Scintigraphy Measure #324, Cardiac Stress Imaging not meeting appropriate use criteria: Testing in asymptomatic, low risk patients

One new measure will be added to the diagnostic radiology set beginning with performance year 2025: Measure #494: Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in adults.

Although five new Improvement Activities will be added and three removed, none of these will affect radiology. The Cost Category will have episode-based Low

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Back Pain added as a measure for 2024. The Promoting Interoperability performance period has been extended from 90 to 180 days, consistent with the Proposed Rule.

MIPS Value Pathways (MVP) are generally not an option for radiology practices as there are too few of them that are applicable. A minimum of six MVP measures are required for reporting, but there are only four currently available that are relevant to radiology. CMS is including five new MVPs for the 2024 performance year, none of which will be useful for radiology practices.

Complete information on the proposed changes to the QPP is available for download from CMS. Possible Legislative Remedies Healthcare Administrative Partners’ recent article reported on a study published August 31, 2023, in the Journal of the American College of Radiology, which found that, “Between 2005 and 2021, the conversion factor declined 7.9%, and when adjusted for inflation, it declined 33.6%.” Additionally, the study concluded, “From 2005 to 2023, the inflation-adjusted conversion factor declined 43.1%.” A bill introduced in Congress, H.R. 2474, the Strengthening Medicare for Patients and Providers Act that now has 56 co-sponsors, would permanently improve the methodology used in the calculation of the conversion factor for Medicare reimbursement. H.R. 2474 has bipartisan support in the House.

Contact your representative and urge them to support H.R. 2474 by becoming a co-sponsor. For the most impact, be sure to have every member of your group contact their representative, and don’t forget to include the members of your management team, as well.

Buried deep inside a Senate Finance Committee Discussion Draft released November 2, 2023, is Section 407 that would modify the 2024 conversion factor calculation. As mentioned above, the CAA 23 provided an increase of 1.25% to the 2024 CF; the Senate Discussion Draft would make that increase 2.50% instead. If it is introduced and passes, this bill would have the effect of making the CF $33.1485 rather than $33.7442. The decrease from 2023 would then be 2.18% instead of 3.37%.

The American Medical Association has a useful website, “Fix

YOUR FULL SERVICE RADIOLOGY RCM PROVIDER www.hapusa.com info@hapusa.com

Medicare Now,” that provides an easy way for you to send a message to Congress.

Sandy Coffta is VP of Client Services at Healthcare Administrative Partners.

Conclusion

Sandy Coffta joined HAP in 2000. In her current role as Vice President of Client Services, Sandy oversees the team responsible for achieving and maintaining the company’s consistently high retention and referral rates.

While radiology averted some big negatives in the QPP, Medicare payments will nonetheless continue to decline in 2024. Since many commercial payors tie their reimbursement to the Medicare fee schedule, whether immediately or at some future date, the impact will ultimately become more widespread than it might first appear. The full effect on your practice will depend on your modality mix because individual procedure values are also adjusted upward or downward each year. We will continue to analyze the valuation changes using the published RVU tables and keep our readers apprised of the latest information.

Ms. Coffta has over 17 years of experience in client relationship management, including reimbursement analysis, workflow optimization, and compliance education. She specializes in business intelligence and reporting development, she is a subject matter expert in radiology practice billing, and she has deep expertise in resolving payor disputes and contract issues. www.hapusa.com

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Practice Management

Data Use Agreements: Utilization and Distinguishing from Business Associate Agreements Any person in the healthcare industry knows or should learn that if they are considered a covered entity or business associate (including subcontractor), that creates, receives, maintains, and/or transmits protected health information (PHI), then a business associate agreement (BAA) is required. See 45 CFR §160.103, 45 CFR § 164.504. This is not a new phenomenon; in fact, it has been required for over 20 years.

A

nother document, a data use agreement (DUA), has also been around for over 20 years. A typical scenario is a clinical trial or other arrangement, which is neither permitted marketing nor a healthcare operations activity. There are three important items to note: (1) a patient HIPAA authorization is separate from either a DUA or a BAA and must be addressed by the covered entity, especially a provider; (2) the Federal Trade Commission’s enforcement of consumer privacy and security concerns related to health data cannot be ignored and should be considered, along with state laws, in both a DUA and a BAA; and (3) Privacy Rule and Security Rule considerations are complimentary.

This article highlights the DUA and areas of consider-

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ation primarily in relation to clinical trials.

Analysis The text of the Final Privacy Rule, which has been in effect for over 20 years, expressly states, “If a provider is disclosing protected health information to another provider for purposes other than treatment, payment, or health care operations, an authorization may be required under 45 CFR §164.508 (e.g., generally, disclosures for clinical trials would require an authorization).”

DUA, which is set forth in 45 CFR §164.514, is required as follows: (4) Implementation specifications: Data use agreement i.

Agreement required. A covered entity may use or

disclose a limited data set under paragraph (e)(1) of this section only if the covered entity obtains satisfactory assurance, in the form of a data use agreement that meets the requirements of this section, that the limited data set recipient will only use or disclose the protected health information for limited purposes. ii. Contents. A data use agreement between the covered entity and the limited data set recipient must: (A) Establish the permitted uses and disclosures of such information by the limited data set recipient, consistent with paragraph (e)(3) of this section.

(B) The data use agreement may not authorize the limited data set recipient to use or further disclose the information in a manner that would violate the requirements of this subpart, if done by the covered entity; (C) Establish who is permitted to use or receive the limited data set; and (D) Provide that the limited data set recipient will: 1. Not use or further disclose the information other than as permitted by the data use agreement or as otherwise required by law; 2. Use appropriate safeguards to prevent use or disclosure of the information other than as provided for by the data use agreement; 3. Report to the covered entity any use or disclosure of the information not provided for by its data use agreement of which it becomes aware; 4. Ensure that any agents to whom it provides the limited data set agree to the same restrictions and conditions that apply to the limited data set recipient with respect to such information; and 5. Not identify the information or contact the individuals. iii. Compliance.

(A) A covered entity is not in compliance with the standards in paragraph (e) of this section if the covered entity knew of a pattern of activity or practice of the limited data set recipient that constituted a material breach or violation of the data use agreement, unless the covered entity took reasonable steps to cure the breach or end the violation, as applicable, and, if such steps were unsuccessful: 1. Discontinued disclosure of protected health information to the recipient; and 2. Reported the problem to the Secretary.

(B) A covered entity that is a limited data set recipient and violates a data use agreement will be in noncompliance

with the standards, implementation specifications, and requirements of paragraph (e) of this section.

In the clinical trial scenario, where one has a pharmaceutical or medical device company (“A”), physicians and facilities (“B”), and a third-party laboratory (“C”), there are distinct obligations. A common thread – the DUA should be executed between the parties.

As the U.S. Department of Health and Human Services (HHS) clarified in the Final Privacy Rule: Research recruitment is neither a marketing nor a health care operations activity. Under the Rule, a covered entity is permitted to disclose protected health information to the individual who is the subject of the information, regardless of the purpose of the disclosure. See § 164.502(a)(1)(i). Therefore, covered health care providers and patients may continue to discuss the option of enrolling in a clinical trial without patient authorization, and without an IRB or Privacy Board waiver of patient authorization.

However, where a covered entity wants to disclose an individual’s information to a third party for purposes of recruitment in a research study, the covered entity must obtain either authorization from that individual as required at §164.508, or a waiver of authorization as permitted at §164.512(i). See 67 Fed. Reg. 53182, 53230-53231 (Aug. 14, 2002).

This portion of the Privacy Rule falls on A and B at designated clinical trial sites. It is presumed that the client-physicians have obtained the necessary consent from patients. And there should be a Clinical Trial Consent form that A provides, and patients sign. A’s Consent Form satisfies this requirement if it is in writing and provides additional explanation as to how the data will be used and whom it may be disclosed to, including clinical laboratories. Since C, as the third-party laboratory, is in the position of providing laboratory results but not for the purpose of acceptable marketing or healthcare operations activity, the DUA comes into play.

As the Oklahoma State University Center for Health Science succinctly states, “A Data Use Agreement (DUA) is an agreement that governs the sharing of data between research collaborators who are covered entities under the HIPAA privacy rule. A DUA establishes the ways in which the information in a limited data set may be used by the intended recipient, and how it is protected.”

This is consistent with the language in the Privacy Rule:

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In response to commenters who were concerned that this condition would impede certain health care operations activities where the covered entity may not have a relationship with the individual, the Department notes that the new limited data set provisions in § 164.514(e) are intended to provide a mechanism for disclosures of protected health information for quality and other health care operations where the covered entity requesting the information does not have a relationship with the individual.

Under those provisions, the final modifications permit a covered entity to disclose protected health information, with direct identifiers removed, for any health care operations activities of entity requesting the information, subject to a data use agreement. See 67 Fed. Reg. at 53217.

The Privacy Rule also references the Federal Information Processing Standard (FIPS) and de-identified PHI: “The Department encourages inclusion of the additional safeguards mentioned by the commentators as part of the data use agreement.” See 67 Fed. Reg. at 53233. The final modifications state, “Therefore, the Department adds at § 164.514(e) a new standard and implementation specifications for a limited data set for research, public health, or health care operations purposes if the covered entity (1) uses or discloses only a ‘limited data set’ as defined at § 164.514(e)(2), and (2) obtains from the recipient of the limited data set a ‘data use agreement.’” See 67 Fed. Reg. at 53235.

The bottom line, as HHS expressly states, “Finally, the implementation specifications adopted at § 164.514(e) require a data use agreement between the covered entity and the recipient of the limited data set. The need for a data use agreement and the core elements of such an agreement were widely supported in the public comment.” See 67 Fed. Reg. at 53235 (emphasis added).

HIPAA can be viewed in two prongs: (1) Privacy Rule requirements and (2) Security Rule requirements. In order to maintain privacy, security safeguards (i.e., technical, administrative, and physical safeguards) must be in place. Both a BAA and a DUA are mentioned in the August 14, 2002, Final Privacy Rule. Their respective use in clinical trials is not new.

Conclusion Most organizations are most comfortable with the term BAA because it is familiar to them. Here, a DUA is most appropriate and can and should be done between the three parties – A, B, and C. A BAA and a DUA strive to achieve the same protections – having adequate technical, administrative, and physical safeguards in place to protect the PHI and ensuring that privacy and disclosure obligations are met pursuant to the Privacy Rule. It is also important to appreciate the FTC’s authority in this space, too.

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.

Ms. Rose has a unique background, having worked in many different facets of healthcare throughout her career, including: work in acute care hospitals including the operating room and dietary department; consultative work as a top performing representative for the pharmaceutical and medical device industry; work for the Chairman of the Reform and Oversight Committee on Capitol Hill; intern at the Department of Health and Human Services; and compiling policy papers at the Royal College of Nursing in London. She has worked on Wall Street and at one of the Big Four consulting firms. Prior to opening her law firm, she was Director of Business Development and Assistant General Counsel for a healthcare advisory company. She is published and presents on a variety of healthcare topics, including: the False Claims Act, the Foreign Corrupt Practices Act, physician reimbursement, ICD-10, access to care, anti-kickback and Stark laws, U.S. Supreme Court cases impacting the medical device industry, international comparative healthcare laws, and the HIPAA/the HITECH Act. Her practice focuses on a variety of healthcare and securities law issues related to industry compliance and Dodd-Frank.

She can be reached at rvrose@rvrose.com. www.rvrose.com

Ms. Rose has been consecutively named to the National Women's Trial Lawyers Association - Top 25, National Trial Lawyers Top 100, Houstonia Magazine's Top Lawyers in Healthcare Law, and the Texas Bar College.

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Coding

Should I Report the Symptom

or Confirmed Diagnoses for Testing?

Coders frequently ask questions about the guidelines surrounding coding symptoms vs. confirmed diagnoses, especially when tests are ordered during an encounter to rule out a condition, illness, or disease.

F 1.

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requently Asked Questions The following questions were submitted for review along with others that were similar:

A patient comes in with a sore throat and the provider orders a strep test, which has a positive result.

The physician documents that the test was positive and writes a prescription for an antibiotic. Should J02.0 (strep throat) or J02.9 (sore throat) be reported when billing for the test? An ensuing coder discussion revealed some of the coders believed J02.0 should be reported, as the provider documented a positive result, while the other coders felt that J02.9 should be reported, since the reason for ordering the test was the sore throat symptom.

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2.

I have a provider that ordered several lab tests to rule out certain disease conditions, and the only diagnoses listed are rule out or differential diagnoses. Should we report the condition or disease code or look for symptoms documented under the history of present illness to support the tests ordered?

Reference Valid Coding Resources When trying to find answers to coding questions, it is important to know what the approved resources are.

Major code sets have published official guidelines within them. For these specific questions, the correct and official resource is the ICD-10-CM Official Guidelines for Coding and Reporting, found in the front of the ICD-10-CM code book, published online at the Centers

for Disease Control and Prevention (CDC), or accessible through Find-A-Code, without a subscription.

Coding Note: Poor coding information and habits often develop from coding instructions and policies that are passed down by word of mouth without referencing official sources.

ICD-10-CM Guidelines for Reporting Symptoms and Signs As all illnesses, chronic conditions, injuries, and disease processes have associated signs and symptoms, it is important to note that there are many guidelines about when signs and symptoms should or should not be reported. A quick CTRL+F search of the guidelines for “symptoms” reveals approximately 60 results in the guidelines. There are guidelines specific to most chapters; however, Chapter 18 contains detailed guidelines that should be reviewed often.

The following guidelines most accurately reflect the coding circumstances described in the two questions noted in this article, with the reference location and page number for easy reference.

Signs and Symptoms “Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider” (2024 ICD-10-CM Guidelines, I.B.4, p. 13).

Use of Sign/Symptom/Unspecified Codes “Sign/symptom and ‘unspecified’ codes have acceptable, even necessary, uses. While specific diagnosis codes should be reported when they are supported by the available medical record documentation and clinical knowledge of the patient’s health condition, there are instances when signs/symptoms or unspecified codes are the best choices for accurately reflecting the healthcare encounter. Each healthcare encounter should be coded to the level of certainty known for that encounter.

As stated in the introductory section of these official coding guidelines, a joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures.

The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation, accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.

If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report codes for sign(s) and/or symptom(s) in lieu of a definitive diagnosis.

When sufficient clinical information isn’t known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate ‘unspecified’ code (e.g., a diagnosis of pneumonia has been determined, but not the specific type). Unspecified codes should be reported when they are the codes that most accurately reflect what is known about the patient’s condition at the time of that particular encounter.

It would be inappropriate to select a specific code that is not supported by the medical record documentation or conduct medically unnecessary diagnostic testing in order to determine a more specific code” (2024 ICD-10-CM Guidelines, I.B.18, p. 17 [emphasis added]).

Chapter 18: Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (R00-R99) “Chapter 18 includes symptoms, signs, abnormal results of clinical or other investigative procedures, and ill-defined conditions regarding which no diagnosis classifiable elsewhere is recorded.

Signs and symptoms that point to a specific diagnosis have been assigned to a category in other chapters of the classification. a. Use of symptom codes: Codes that describe symptoms and signs are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider. b. Use of a symptom code with a definitive diagnosis code: Codes for signs and symptoms may be reported in addition to a related definitive diagnosis when the sign or symptom is not routinely associated with that diagnosis, such as the various signs and symptoms associated with complex syndromes. The definitive diagnosis code should be sequenced before the symptom code. Signs or symptoms that are

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associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification. c. Combination codes that include symptoms: ICD-10-CM contains a number of combination codes that identify both the definitive diagnosis and common symptoms of that diagnosis. When using one of these combination codes, an additional code should not be assigned for the symptom” (2024 ICD-10-CM Guidelines, I.C.18.a-c, pp. 73-74 [emphasis added]).

Coding Guidelines Provide Answers When reviewing the guidelines with the questions in mind, several guidelines really stand out, and these have been emphasized.

study has been completed, the patient returns to the provider’s office for the results, which confirm the patient has gallstones.

For the encounter in which the test is ordered, the provider will report upper right quadrant abdominal pain only. For the encounter where the provider tells the patient the results of the ultrasound study revealing gallstones, the provider will report gallstones and not report the abdominal pain code.

Coding Checkup When questioning whether symptoms should be reported, ask the following questions: •

• Answers When the provider orders a test or imaging study based on patient symptoms and obtains a result confirming a definitive diagnosis during the same encounter, the definitive diagnosis should be reported, and the symptom of the definitive diagnosis should not be reported.

Confusion often arises when the EHR system requires a diagnosis to be assigned to the test being ordered; in this case, J02.9 (sore throat) would be added to the EHR physician order for the rapid strep test to be performed. However, the guideline states that at the end of the encounter, if the provider has identified a definitive diagnosis that explains the symptom(s), then only the definitive diagnosis should be reported.

There are times when a test or image is ordered that requires the patient to go to a lab or imaging center on a different date to have the test or image taken. When this happens, the provider will either document the symptoms only or a rule out, differential, or possible diagnosis in the medical record. Because a diagnosis has not yet been confirmed because testing has not yet been completed, only the symptoms should be reported.

For example, a patient presents with right upper quadrant abdominal pain and the provider orders an abdominal ultrasound to rule out gallbladder disease. The patient leaves the provider’s office and makes an appointment with radiology to have the imaging study performed. A couple of weeks after the

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•

Is there a definitive diagnosis documented that explains the patient’s symptoms? If yes, then code the definitive diagnosis.

Did the provider order a test with language of rule out, differential diagnosis, or possible diagnosis? If yes, report only symptoms reported by the patient that would support ordering the additional testing.

Are there multiple symptoms documented, some of which are explained by a definitive diagnosis and others that are still pending additional testing? If yes, report the definitive diagnosis and any other symptoms that are not explained by the definitive diagnosis that may require additional testing to determine a subsequent or additional definitive diagnosis.

Including a review of the ICD-10-CM coding guidelines as an annual coding goal is a great habit to create to maintain your coding habits and ensure they are aligned with the most up-todate authoritative resource. This allows you to refresh your knowledge of simple and complex coding guidelines and be a good resource for other coders.

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

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Practice Management

Tomorrow’s Doctors:

Evolving Trends in Healthcare Specialty Training If you’re in healthcare or aspiring to be, specialty training is where the rubber meets the road. It’s the bridge from general medical knowledge to honed expertise in a particular field. You’ve probably caught wind of how specialty training in healthcare is not what it used to be. New tech, evolving patient needs, and a myriad of other factors are reshaping the landscape. As healthcare evolves with technology and societal needs, specialty training is undergoing a metamorphosis, aiming to create professionals who are adept at both traditional and modern healthcare practices.

Why the Shift? Driving Factors Behind the Change Changing Healthcare Landscape The world is changing, and healthcare is no exception. Urbanization, changing lifestyle factors, and evolving diseases create new healthcare needs that specialists must be equipped to address.

Technological Advancements From telehealth platforms to AI-driven diagnostics, technology is revolutionizing how healthcare is delivered, requiring new skill sets from professionals.

Increasingly Complex Patient Needs

T

he Current State of Healthcare Specialty Training

Traditionally, healthcare specialty training has followed a fairly predictable path: After med school, one dives into residencies, followed perhaps by fellowships. During this period, doctors develop expertise in chosen areas—like cardiology, neurology, or surgery— under the guidance of experienced mentors. The cycle is completed with ongoing medical education, which ensures that professionals remain updated on the latest in their field.

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As populations age and chronic illnesses rise, patients’ needs are growing more complex. The old “one-size-fits-all” model no longer works, pushing for innovation in specialty training.

Future Trends in Specialty Training Methods Simulation-Based Training One of the most exciting developments in training is the use of realistic simulations. Forget those creepy dummies; we’re talking high-tech models that respond to treatments just like a human would. These simulations

provide a risk-free way to get hands-on experience, which is crucial for building both skills and confidence.

ethics, and emotional intelligence. These skills are increasingly recognized as critical for patient-centric care and interdisciplinary collaboration.

Interdisciplinary Training Future Trends in Specialty Focus Areas Healthcare is a team sport, and modern training is starting to reflect that. Today’s programs are encouraging interdisciplinary training where doctors, nurses, social workers, and other healthcare providers learn how to collaborate more effectively. So, you’re not just a cardiology expert; you’re an expert in holistic patient care.

Virtual Reality (VR) and Augmented Reality (AR)

Geriatric Care With an aging population, there’s a growing demand for specialists in geriatric care. These aren’t your typical “old-people doctors”; they’re professionals trained in managing complex health conditions that come with age.

Telemedicine

Imagine strapping on a headset and finding yourself in a fully-equipped virtual OR. VR and AR technologies provide immersive training experiences, allowing trainees to practice complicated procedures in a controlled yet realistic environment.

Telehealth is here to stay. As healthcare becomes more digitized, we need a new generation of doctors who are as comfortable in front of a webcam as they are in an examination room.

Remote Learning and Telementoring

As societal awareness about mental health grows, so does the need for specialists in psychiatry and mental healthcare. Finally, mental health is being recognized as equally important to physical well-being, driving an increased focus on these specialties.

Specialized training is no longer limited by geography. Thanks to teleconferencing and advanced software, experts can now mentor young professionals remotely. This is a game-changer for rural or underserved areas that have limited access to specialized expertise.

Focus on Soft Skills Technical proficiency is no longer the end-all-be-all. There’s a growing emphasis on soft skills like communication,

WEBINAR CEU Approved AI: The Good, the Bad, and the Ugly in Healthcare Presenter: Rachel Rose, JD, MBA Description: Both AI and human beings are not going away any time soon. Like most things, AI is not created equal. This webinar delves into the AI landscape, including the good, the bad, and the ugly, and its application to the healthcare industry. The focus is on government initiatives, ethical AI, and considerations that any person that falls under HIPAA or the Federal Trade Commission Act should consider.

Mental Health

Personalized Medicine

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Forget general prescriptions; the future is personalized medicine tailored to individual genetics and health profiles.

Specialties are emerging that focus exclusively on creating personalized

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treatment plans based on unique patient characteristics.

Implications for Healthcare Systems and Professionals

has far-reaching implications, especially for professionals in rural or less affluent areas who deserve access to the same quality of training.

Adaptability

Ethical Considerations

First off, let’s talk about adaptability. If healthcare systems are rigid and resistant to change, they risk becoming obsolete. It’s crucial for these systems to be adaptable in implementing new training protocols. Whether it’s introducing AR-based surgical training or cloud-based patient management systems, adaptability isn’t just a nice-to-have; it’s a must.

With great power comes great responsibility, and new technologies bring about new ethical dilemmas. These need to be integrated into training. For example, when we talk about personalized medicine based on genetic profiling, we must also discuss the ethical implications of genetic data storage and use. These are questions that the next generation of healthcare specialists will need to grapple with.

Continuous Learning Conclusion Remember when you thought learning ended with graduation?

Cute, right? The reality is: The professionals of the future will need to be committed to lifelong learning. Given how swiftly healthcare technology is evolving, what’s considered groundbreaking today may be outdated in just a few years. Learning isn’t a stage; it’s a continuous journey.

Quality of Care All these changes aren’t just for show; they aim to improve the overall quality of healthcare. For instance, with simulation-based training, doctors can rehearse complex procedures multiple times before performing them on real patients, thereby increasing chances of success. Better-trained professionals inevitably mean better care for patients.

Challenges and Considerations Keeping Pace with Technology One of the major challenges in this evolving landscape is keeping the curriculum updated with fast-evolving technology. It’s not just about throwing in a module on how to use an EHR system; it’s about deeply integrating tech skills into the core of medical training. Falling behind is not an option; the curriculum needs to be as agile as the tech it’s teaching.

Accessibility and Equity We’ve got all these cool new toys like VR sets for surgical training, but how do we make them accessible to all healthcare professionals? Training tools shouldn’t be a privilege confined to big, well-funded urban institutions. This is an equity issue that

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Let’s be clear about one thing: The world of healthcare specialty training is experiencing a seismic shift, driven by technology, societal needs, and increasingly complex patient profiles. From the methods of training to the areas of focus to the need for continuous learning, adaptability, or ethical acumen, tomorrow’s doctors face a whole new set of expectations. The integration of technological advancements in training is both exciting and challenging, requiring healthcare systems to be more adaptable than ever.

If you are a medical educator, a healthcare administrator, or an aspiring specialist, it’s time to lean into these changes. Embrace new methods, consider the ethical implications of new tech, and above all, be prepared for a lifetime of learning. These aren’t just trends; they’re the building blocks of a new era in healthcare.

Don’t just adapt; thrive. Let’s be the catalysts for a healthcare system that’s not just cutting-edge but also equitable and ethical.

So, now, more than ever, is a thrilling time to be stepping into the field, ready to meet the challenges of tomorrow’s healthcare landscape. Are you in?

Randi Tapio, MBA, CMRS, CPCS, CHM, CHBP is the Owner/CEO of MedCycle Solutions, creating revenue cycle solutions for healthcare practices that improve efficiencies, maximizing reimbursements, helping their clients get paid faster. As an experienced revenue consultant with over 20 years experience, she has a long history of cultivating strong working relationships with providers, ancillary staff, and healthcare executives. www.medcyclesolutions.com

Coding

Missing HCC Codes Leave Money on the Table

Improper clinical documentation of one patient can mean a difference of more than $10,000 in yearly estimated healthcare costs. How much money are you potentially leaving on the table?

CM diagnosis coding. There are 9,500 ICD-10-CM codes that map to 86 total HCC codes within 19 different HCC categories. The diagnosis gets an HCC score, and the patient receives a RAF score made up of HCC scores.

Insurance companies expect patients with few serious health conditions to have average medical costs for a given time. A risk score of 1.000 is an average patient, and Medicare would expect to spend $10,000 on that patient. For patients with a RAF score of 1.100, Medicare would expect to spend $11,000 ($10,000 x 1.100). They expect patients with chronic conditions to have a higher RAF score and higher healthcare utilization and associated costs.

HCC Coding and RAF Score Process:

M

edicare/Medicaid and other insurance companies use Hierarchical Condition Categories (HCC) coding, a risk-adjustment (RA) model, to assign patients a Risk Adjustment Factor (RAF) score. They use this score to predict future healthcare costs and reimbursements associated with each patient on an annual basis.

• • • •

Providers treat patients on RA model Providers document code diagnoses correctly HCC and RAF scores are determined by accurate code assignment based on provider documentation Reimbursement levels are set based on HCC and RAF scores

HCC Impact on Providers As a provider, you tell your patient’s health story through medical coding and documentation. When done correctly, this not only provides the patient with better overall care, but also improves your practice’s profitability.

Know Your RAF Score HCC assigns risks scores to each patient using ICD-10-

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Documentation is an ongoing process. The risk adjustment calendar restarts each year in January, and insurance companies consider all patients healthy until providers once again add an active diagnosis into the documentation. Chronic conditions and comorbidities affect RAF scores and, therefore, reimbursement levels.

That’s why it’s important to collaborate with any other

providers or specialists a patient sees. Failing to document chronic conditions affect everyone’s reimbursement.

Payment Differences Based on HCC Coding Poor coding quality creates inaccuracies and the potential loss of revenue for providers, not to mention misallocated resources and missed opportunities for patient care. An article on HCC coding and risk adjustment from AAFP’s Family Practice Management Journal states, “Failing to adequately capture a patient’s risk through documentation and coding may lead to an inaccurately low level of attributed risk and eventually to reduced reimbursement. On the other hand, accurate and thorough documentation and coding will give your practice its best chance of earning shared savings and in turn help you become more successful in managing your patient population.”

Are your RAF scores much lower or higher than the national average of 1.00? This could indicate either missing HCCs or possible overcoding. More specific coding results in a

more accurate picture of your patients and the complexity of their conditions and treatment. Do your own audit and investigate documentation gaps, inaccurate code selections, and find missed coding opportunities (or get in touch with companies like AQuity Solutions that can help you). Do not leave money on the table.

AQuity Solutions In a span of about two years, AQuity found clients an additional 770,000+ ICD-10-CM codes and was able to assign more than 244,000 HCC codes. This brought the average HCC score from 0.7 to 1.3.

Our clients receive specific provider findings and recommendations for coder and/or physician education to better improve the process going forward. Find your missing codes, improve your patient care, and stop leaving money on the table with AQuity Solutions Medical Coding Solutions. Learn more at https://aquitysolutions.com/solutions or call 866542-7253.

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Compliance

Monthly Spotlight on Fraud, Waste, and Abuse

The following cases highlight fraud, waste, and abuse (FWA) and serve as a reminder to uphold high ethical standards when providing patient care and services. genetic tests (CGX). Employees of the company called beneficiaries and pressured them to agree to accept orthotic braces and/or CGX, regardless of medical necessity.

He and his company paid kickbacks to telemedicine companies to obtain doctor’s orders for the orthotic braces and CGX tests. He then steered the doctor’s orders to orthotic brace suppliers and testing laboratories located in the U.S., with which he and his company had additional kickback arrangements. The orthotic brace suppliers and laboratories submitted claims for reimbursement to Medicare, and thereafter sent a portion of the proceeds to him and his company as payment for the doctor’s orders generated through the conspiracy.

O

wner of Indian Marketing Company Admits Role in $11.5 Million Healthcare Fraud and Kickback Scheme

Early November saw a case involving the owner of a marketing company located in India who admitted his role in conspiracies to commit healthcare fraud and to pay and receive illegal kickbacks.

The man pleaded guilty in a New Jersey federal court to information charging him with conspiracy to violate the federal Anti-Kickback Statute and conspiracy to commit healthcare fraud. According to documents filed in this case and statements made in court, from February 2017 to May 2022, he participated in a kickback and bribery scheme with orthotic brace supply companies, telemedicine companies, and testing laboratories, resulting in the submission of false and fraudulent claims to Medicare.

He controlled a marketing company in India through which he and his co-conspirators identified Medicare beneficiaries to target for orthotic braces and cancer

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In total, he and his co-conspirators caused a loss to Medicare of more than $11.5 million.

The conspiracy to commit healthcare fraud count is punishable by a maximum of ten years in prison and the conspiracy to pay illegal kickbacks is punishable by a maximum of five years in prison. Both counts are also punishable by a $250,000 fine, or twice the gross gain or loss from the offense, whichever is greatest. Sentencing is scheduled for March 2024.

Read the specifics of this case at www.justice.gov.

Georgia Doctor Pays $225,000 to Resolve Allegations for Improper Billing Here, the doctor and her practice group have agreed to pay $225,000 to resolve allegations that they violated the False Claims Act by, among other things, billing the government for office visits that were not medically necessary, were not provided as claimed, and were not

supported by patient medical records.

This settlement resolves allegations that from January 2, 2018, to February 12, 2021, the doctor knowingly submitted false claims to federal healthcare programs for office visits that were not as complex or lengthy as the doctor purported. This is a practice commonly known as “upcoding.” The government also alleged that she submitted claims of certain office visits to federal healthcare programs as though she had personally provided the service, even though she was traveling out of the country at the time these services were allegedly performed.

The settlement also resolves allegations in a lawsuit filed by two former employees, under the qui tam, or whistleblower, provisions of the False Claims Act. The False Claims Act authorizes private parties to sue for false claims on behalf of the United States and share in the recovery.

The claims resolved by the settlement are allegations only, and there has been no determination of liability.

Read more about this case at www.justice.gov.

Second Owner of California Sleep Clinic Pleads Guilty to Submitting Over $1.5 Million in Fraudulent Claims to Medicare and Medi-Cal for Sleep Studies Early November also saw a brother who co-owned and co-operated a California entity, which operated sleep clinics in multiple counties in California. Sleep clinics perform diagnostic sleep studies to identify disorders like sleep apnea and narcolepsy.

According to court documents, between August 2016 and July 2020, he allegedly caused the entity to submit thousands of claims to Medicare and Medi-Cal for sleep studies that were not actually performed on patients. The claims also stated falsely that the patients had been referred for the sleep studies by physicians with whom he had previously worked. This was done because Medicare and Medi-Cal will not pay for a sleep study unless the patient was referred by a physician.

He faces a maximum statutory penalty of ten years in prison for the healthcare fraud conviction and an additional, mandatory two years in prison for the identity theft conviction. The actual sentence, however, will be determined at the discretion of the court after consideration of any applicable statutory factors and the Federal Sentencing Guidelines, which take into account a number of variables.

In September 2023, his brother pleaded guilty to similar health-

care fraud and aggravated identity theft charges related to other sleep clinics in another California location.

Read further information about this case at www.justice.gov.

Attorney General Announces Guilty Verdict of Physician Who Subjected Patients to Unnecessary and Invasive Tests Late November saw a case involving a doctor and his company who were found guilty on charges related to running a kickback scheme that defrauded Medicaid and subjected patients to invasive procedures they did not need.

In August 2022, the Office of the Attorney General (OAG) indicted the doctor, and in late November 2023, he was found guilty of grand larceny in the third degree, healthcare fraud in the third degree, four of eight counts of falsifying business records in the first degree, and two counts of violating the statute prohibiting the payment of kickbacks, all felony charges.

Details include that from January 2006 to August 2017, the doctor ran a kickback scheme in which he gave gift cards and cash to two physicians in exchange for the physicians’ referral of patients. In addition, from January 2014 to August 2017, he directed his employees to add additional, unordered radiological procedures to orders submitted by referring physicians to increase the amount of money received from Medicaid.

He defrauded Medicaid and subjected patients to medically unnecessary and often invasive radiological testing without the direction, consent, or approval of the referring physicians responsible for the underlying care of those patients. The additional tests included MRIs of the brain, cervical spine, and lumbar spine, all “with contrast,” which required subjecting patients to unnecessary and invasive injections. He then directed his staff to submit claims for payment to Medicaid for those medically unnecessary tests.

Read additional details of this case at www.justice.gov.

Sonal Patel, BA, CPMA, CPC, CMC, ICDCM, is founder, CEO, and Principal Strategist at SP Collaborative, LLC. SP Collaborative, LLC was founded by Sonal Patel, BA, CPMA, CPC, CMC, ICDCM. Sonal utilizes her unique background and education in the humanities, fine art, and art history to complement her partnerships with her clients in healthcare.

SP Collaborative believes in the voices of all its partners and strives to maintain mutually beneficial relationships. www.spcollaborative.net

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