One size does NOT fit all when it comes to health insurance. Beneficiaries range from the extremely healthy 65-year-old—the poster child for “65 is the new 45”—to a 65-year old suffering from COPD from a lifetime of smoking, cancer, and a hereditary condition such as Type 1 diabetes. The result is often a huge disparity in the amount paid out for the care of these two patients.  

The insurance market has adapted to these wide disparities with the concept of risk adjustment. Certain payers like Medicare Advantage now offer plans with options for coverage based off demographics and health status of the beneficiary. Risk adjustment applies not just to healthcare reimbursement, but also quality monitors such as 30-day mortality measures, 30-day readmissions, and Medicare spending per beneficiary. Healthcare organizations must be aware of how documentation supports risk adjustment and educate providers of the importance of complete and thorough capture of their patient’s health status to support accurate code assignment representing the potential risk their patients possess.

The American Hospital Association (AHA) is concerned about the documentation and coding reduction, changes to disproportionate share hospital (DSH) payments, and the implementation of many of CMS’s quality programs detailed in the CMS IPPS Proposed Rule for Fiscal Year (FY) 2017, according to a response published by the AHA on June 17, 2016.

Recovery Auditor medical record requests and automated and complex denials all fell slightly in the first quarter of 2016, as did the average number of medical record requests per hospital, which decreased slightly since the fourth quarter of 2015, according to the latest RACTrac report from the American Hospital Association (AHA).

CMS issued a final rule last week to revamp the way it pays for tests under the Clinical Laboratory Fee Schedule (CLFS). Now starting January 1, 2018, CMS will base CLFS payments on the weighted median amount paid by private payers for the same services.  Providers are hopeful that these new weighted median rates based on different process from the existing CLFS updating process.

Physician advisors serve a variety of purposes beyond documentation improvement, including assisting case management, utilization review, quality, and coding departments, among other assignments, according to a recent benchmarking report and survey from ACDIS.

Q: The coders at my facility have stated auto linking congestive heart failure (CHF), hypertension (HTN), and chronic kidney disease (CKD) to the combination code without any documentation of CHF “due to” HTN. There is no documentation of hypertensive heart disease anywhere in the record, and the diagnoses are not linked anywhere in the record. I referenced the Coding Clinic, Fourth Quarter 2008, which states that unless a causal relationship exists between the heart condition and the hypertension—and the physician documents this relationship in the record—each condition requires its own code, and if the documentation does not make that link, an HIM/coding professional must code the two conditions separately.

I understand that ICD-9 Coding Clinics may not apply in ICD-10, but I cannot find any updated guidance. Our coders are going by the Coding Clinic, First Quarter 2016, which still uses the phrase “due to.”

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