Claims Scrubbing: A Case Study

All three of the parties have an interest in ICD-10 codes. They all have to use the updated version of ICD-10 codes, for the fact, it is an medical guideline by the government. The ICD-10 codes are easier to use than writing out the full medical term. They have over ten thousand codes, they can range from weird codes to normal

In searching information regarding the rehospitalization rates and the drop of Medicare reimbursements for those stays, I was surprised to have found there was so much information regarding this and the tools that are out there also to use. My direct supervisor, Amy Suydam RN CPS, was also helpful in bringing up some things not thought of that would assist in the success of our organization in achieving our goal of decreasing rehospitalizations by 10% within the next 6 months. Amy Suydam RN CPS did not feel this was an unreasonable timeframe and decline to be looking towards. This is something we have discussed many times as our organization is non-for profit and this is very important that we follow through with our teachings and get all the information put out there that we can regarding these changes.

CMS preformed a comprehensive review of all diagnosis codes to determine which codes should be classified as CCs when present as a secondary diagnosis. CMS then categorized these diagnosis codes into the different severity levels. CMS also consolidated the CMS DRGs into a new set of base DRGs and then divided each into severity subclasses or MS-DRGs.

There are several potential risks to the company with the introduction of the new triage level 4 & 5 care center. These are patients won’t use the new service and continue to utilize the emergency department for their lower level of care needs. Matching staffing and demand is another risk. The clinic will be a mix of self-scheduling and walk in appointments. Making sure there are enough appointment slots available when patients need them. If this does not happen, patients will have long wait times and will cause them to have a negative experience and not utilize the service for future needs.

The CMS reimbursement rules for never events cause serious revenue loss for the hospitals, hence a shift in the patient care delivery model in inpatient facilities is required. The goal of this rule is to motivate hospitals to accelerate improvement

The continue use of ICD-9 codes after the effective date could result in the denial of reimbursement claims. This task can be assigned to the healthcare organization’s management team to determine a solution avoiding a break down in the system. Rahmathulla states, “In instances of an audit, appropriate documentation will make the query process substantially easier while enabling coders to clarify issues without having to query the provider multiple times for answers” (“Migration To The ICD-10 Coding System S187). It is important to accurately document to reduce the amount of claim denials. With the new specificity requirement of the ICD-10 and documentation supporting a claim, lowers the chances of healthcare fraud. The healthcare management team will oversee the process to prevent the risk of exposure.

A few things are happening soon and for us to be excited about. One is for this Saturday's picnic we will close at 4:30pm as the email stated yesterday. I do hope to see all of you there to enjoy a nice evening by of the family and shorebirds and of course the food!!! We also will be starting to use ICD-10. This is being used all over. From the billing prospective this is a wonderful way of documenting. When we first start this it may take us a few extra minutes with our time patients that have been here before, however; once we do this we will not have to do it again since the codes will then be ICD-10. More information is coming on this.

This memorandum describes Central Health’s Readmission Reduction Program set to commence in May 2017. The Centers for Medicare and Medicaid Services (CMS) has raised concern over the increasing readmission rate and poor quality of care. To address this issue, Congress has created Hospital Readmission Reduction Program (HRRP) statute under the Affordable Care Act, 2010, which was recently updated under 21st Century Cures Act of 2016. Under the constant pressure of a penalty, Central Health has considered to establish its own Hospital Readmission Reduction Program to address specific imperatives, such as care-coordination, treatment adherence program, and streamlined patient discharge process.

Due to ICD-9-CMS’ ability to provide necessary detail for patients’ medical conditions or the procedures and services performed on hospital patients, ICD-10-CM/PCS was implemented.

Id. In order for providers to avoid costly claim denials, a risk management and compliance program should be in place and annual monitoring and auditing of internal controls needs to occur on a regular basis. This text will review the issues that medical providers face with coding and billing regulations, the consequences of improper billing and coding, and resolutions that will aid in the prevention of claims being denied.

UP.01.03.01 requires a time-out before the start of the procedure. The Site Identification and Verification policy describes the time-out process however the policy falls short of fully meeting the intent of this standard. EP 2 describes which team members must participate in the timeout, EP 3 requires a time-out before each procedure when two or more procedures are being performed, and EP 5 requires documentation of the time-out. These 3 elements are missing from the hospital policy/process and therefore revisions to the process/policy are necessary to include these 3 elements. Nightingale’s Safety Report reveals increasing compliance (nearing 100%) with the time-out process, however as mentioned above, EP 5 requires documentation of the process. In addition to the policy revision, I recommend the development of a unique form which will be used to document

Postpartum depression (PPD) affects about eighty-five percent of new mothers and persists as long as a year after childbirth (Texas Medical Association, 2015). In spite of the scope of this problem and the benefits of screening women, it’s not standard procedure (New York State Department Of Health, 2016). This policy brief was written for healthcare providers that treat new mothers at risk for PPD with the goal of improving screening and the number of women receiving appropriate treatment. The recommendations address measures to improve early identification and follow-up care for women found to have PPD.

In an effort to curb these costs, in 2013 the Center for Medicare and Medicaid Services (CMS) enacted the Hospital Readmissions Reduction Program. Under this program, hospitals are penalized for readmissions occurring in the first 30 days. The penalties apply to specific conditions for CMS recipients including acute myocardial infarction, heart failure, coronary artery bypass graft

The Lincoln brand of automobiles includes sedans, crossovers and an SUV. The sedans include the Town Car, MKZ, and MKS. These cars range from $35,000 to $47,000, MSRP. The crossovers include the MKX and MKT and range in MSRP from $40,000 to $45,000. Lincoln’s SUV is the Navigator and starts at an MSRP of almost $58,000.

The healthcare system has seen significant change over the past decade. This is due to improved technology, healthcare reform, and the economic crisis (Hendren, 2010). With the changes that are occurring,