Tuesday, March 27, 2018

2018 AHIMA Advocacy Summit – Part 1

by Lauree E. Handlon, MHA, RHIA, CHFP, CCS, COC, FAHIMA 

While our Ohio leadership team and members were experiencing our OHIMA Annual Meeting at the Hilton Easton, I had the privilege to participate in the 2018 AHIMA Advocacy Summit in Washington DC along with Peggy Kilty.  I wanted to share some of my experiences from the first day of the summit.  Peggy will also be sharing her perspectives as well.  While I have participated in the CSOHIMSS and the OHIMA Ohio State Hill Days before, this was my very first experience at the National level. 

AHIMA’s two asks to Congress: 

  • Patient Matching 
    • Omit the 1999 language in fiscal year 2019 appropriations legislation to enable HHS to work with industry to advance a nationwide patient matching strategy

  • Modernize Privacy Laws to Combat Opioid Epidemic
    • Support and co-sponsor bills of ‘Overdose Prevention and Patient Safety Act” (H.R. 3545) and “Protecting Jessica Grubb’s Legacy Act” (S. 1850) to align Part 2 with HIPAA for purposes of healthcare treatment, payment, and operations and strengthen protections around the use of substance use disorder records in criminal proceedings.

So now I have the AHIMA requests I was to take to the Hill.  Was I nervous? Super nervous, but confident.  I knew with Peggy, we could conquer anything.  And really once it all concluded and I could breathe again, my reflections on the series of events and outcomes proved I was silly to be anxious in the first place.  The people involved created an excellent learning and networking experience with speakers from HHS OCR, ONC, and CMS, along with representation from all states.  This experience enabled me to individually grow while also assisting to increase our HIM profession voice and imprint within Congress. 

 Day 1:  Prep Day 

We were introduced to our new AHIMA CEO, Dr. Wylecia Wiggs Harris. While she was being introduced, my attention was grabbed when she was announced to have a degree from our very own Ohio-based Wittenberg University! So this gave me a great avenue to start up a conversation – which actually happened later during our D.C. visit. (BTW - She is an extremely approachable and kind person!) 

Wylecia (and we were instructed she wanted to be talked with using her first name), touched on the importance of voting at the local and state as well as national level. Her message was this is ‘your voice’ and she challenged all of us to speak up.  To increase our voice and make our passions heard, we need to partner with other like-minded individuals related to our profession and ‘show up & show out.’ 

Pam Lane, our Vice President of Public Policy and Government Relations at AHIMA, presented advocacy actions and how we can all help at home.  Check out the AHIMA and Advocacy site where tools have been provided to help us all participate in important initiatives to our profession. 

Once introduced to our asks of Congress and overview of the Summit expectations, Iliana Peters, who spoke on insights from HHS Office for Civil Rights (OCR) touched on cybersecurity, HIPAA audits, and the latest OCR enforcement activities.   She provided a few excellent links:

Maria Durham, Director for the Division of Program and Measurement Support from Center for Clinical Standards & Quality at CMS provided information on latest efforts to improve quality measures and reduce documentation burden including the “Meaningful Measures” Initiative and the “Patients over Paperwork” initiative.



The day was filled with a plethora of fantastic information.   Additional topics to come from Peggy about Day 1: Prep Day and more to come from both of us about Day 2: On the Hill!

About the Author

Lauree Handlon serves as the Director of Data Quality + Reimbursement at Cleverley + Associates, where she has worked since 2002. She primarily analyzes third party payer contractual arrangements for strategic pricing, payment assessments, and regional comparisons.  Ms. Handlon also conducts frequent regulatory research, monitors data integrity by identifying anomalies in the Medicare public claims data and client submitted claims data, and provides Medicare prospective payment system and coding & billing education.

Ms. Handlon received her Masters of Health Administration from the University of Cincinnati in Spring 2017. She received her Masters in Allied Health Management through the School of Health and Rehabilitation Sciences from The Ohio State University in 2008. She received her undergraduate degree in Health Information Management and Systems from The Ohio State University in 2000.  She holds several certifications from AHIMA, HFMA, and AAPC.

Ms. Handlon also has been instructing part-time for the HIMS department in the School of Health and Rehabilitation Sciences at The Ohio State University since 2007 and has served as a Preceptor since 2003. She was awarded Fellowship status from the American Health Information Management Association in 2011.  Ms. Handlon is a Past-President and past 2-term role as Delegate for the Ohio Health Information Management Association. She is also the current Membership Chair for the Central Ohio chapter of HFMA as well as President of The Ohio State University School of Health and Rehabilitation Sciences Alumni Society.

Monday, March 12, 2018

Book Excerpt: What are the Recovery Auditors Anyway?

Formerly known as Recovery Audit Contractors (RAC), the Tax Relief and Health Care Act of 2006 created Recovery Auditors to identify Medicare overpayments and underpayments made on claims of healthcare services provided to Medicare beneficiaries. Overpayments occur when healthcare providers submit claims that do not meet Medicare’s coding or medical necessity policies. Underpayments occur when a healthcare provider submits a claim for a simple procedure, but the medical record reveals that a more complicated procedure was actually performed.

One challenge, however, is that contractors receive compensation for their efforts based on a percent of the claims that they recover and are therefore incentivized to target overpayments, critics say. Based on that critique, in 2012, the American Hospital Association (AHA) filed a lawsuit against CMS claiming that its denial practices violate federal law.

Nonetheless, in fiscal year (FY) 2014, RAs collectively saved Medicare $2.57 billion in a combined 1,117,057 identified and corrected overpayments and underpayments.

RAs need CMS’ approval to pursue record reviews for specific DRGs, and each contractor must publish its focus areas publicly. CDI programs have likewise identified areas of concerns and added these reviews to their to-do lists. For example, CDI program directors should pull MS-DRG lists by frequency and compare their top DRGs to the list of target areas that their regional auditor identified.

Despite RAs’ reported success is recouping and clarifying Medicare claims, the AHA finds that when hospitals appeal their denials, they typically win. AHA’s RACTrac Report indicated that hospitals appeal more than 40% of their denials with a roughly 75% success rate.

According to a 2012 poll, 32% of CDI programs conduct reviews to audit-proof their records from RA targets. Furthermore, although Medicare Quality Improvement Organizations (QIO) maintain statutory authority to monitor the medical necessity of inpatient admissions. RAs expanded their reviews to include medical necessity in FY 2011. To handle those audits and prepare their facilities, CDI specialists increasingly migrate into audit prevention and analysis roles.

Nevertheless, QIOs provide yet another layer of government oversight. By law, the QIO’s mission is to improve the effectiveness, efficiency, economy, and quality of services delivered to Medicare beneficiaries. Its core functions, according to CMS, include the following:
  • Improving quality of care for beneficiaries
  • Protecting the integrity of the Medicare Trust Fund by ensuring that Medicare pays only for services and goods that are reasonable and necessary and that are provided in the most appropriate setting
  • Protecting beneficiaries by addressing individual complaints expeditiously

To complicate matters further, RAs began requesting queries along with their medical record reviews. CDI programs that had no policies in place struggled to determine whether their facility considered queries to be a permanent part of the medical record and therefore recoverable by auditors, or whether queries were business records related to the care and, therefore, possibly not required for submissions.

Editor’s note: This article is an excerpt from the book The Essential Guide to Provider Queries.

Copyright Association of Clinical Documentation Improvement Specialists (ACDIS).  Article reprinted with permission.

Wednesday, March 7, 2018

Maximizing Resources for ICD-10 Coding Audits

by Julia Hammerman, RHIA, CPHQ, and Sam Champagnie 

From internal reviews to external inpatient coding audits, healthcare organizations nationwide are revisiting tried-and-true audit practices with ICD-10 coding quality in mind. MS-DRG validation audits under ICD-10 have also become more strategic to realize a hospital’s revenue cycle success. Coding audit best practices shifted following the implementation of ICD-10. Since all coding stakeholders were comfortable with ICD-9 and needed to maximize budgets, audits were primarily focused on targeted DRGs versus overall coding compliance reviews. With ICD-10, more frequent audits can help identify the root causes of coding errors before they become ingrained as bad habits. More frequent audits can deliver a positive return on investment, based on assessing coder competency, measuring code quality, and showing how missed errors can have negative effects on an organization’s bottom line. Under ICD-10, coding audits have proven cost savings.

The most common areas for ICD-10 coding errors identified through coding audits include:
  • Not coding to the greatest degree of specificity
  • Missing combination diagnosis codes and linked diagnoses
  • Inaccurately assigning codes for complex cardiac surgeries
  • Misinterpretation of coding guidelines
  • Misidentifying appropriate root operations
  • Incorrect assignment for spinal surgeries

Based on these common errors, a combination of random and focused coding audits has become industry best practice.

Editor’s note: Hammerman, director of compliance and education, has more 30 years of leadership experience most recently as the enterprise HIM operations manager for BJC Healthcare. Champagnie, senior director of HIM operations at HIMagine, has 23 years of healthcare business management experience. Opinions expressed are those of the authors and do not represent HCPro or ACDIS. This article originally appeared in HIM Briefings.
Copyright Association of Clinical Documentation Improvement Specialists (ACDIS).  Article reprinted with permission.