by Katherine (Katy) Rushlau

If you’re a loyal follower of ACDIS, you’ve most likely visited the ACDIS Blog once or twice. There, we post daily tips, news, and updates on clinical documentation improvement. Whether you’ve been a fan of it for years, or have never heard of it, our blog is about to get even better—with a little help from you! We’re switching up our daily cadence to make our posts more centered on our members. What does this mean? Well, for starters, our new weekly “Featured Member” series will highlight one of our awesome members, CCDS holders, or followers, and the incredible things they are doing to further the CDI industry. If you or a colleague would like to be one of our featured members, email me at krushlau@hcpro.com.

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The federal government could delay implementation of the physician payment reforms under the Medicare Access and CHIP Reauthorization Act (MACRA), according to statements made by CMS Acting Administrator Andy Slavitt during a July 13 hearing. CMS wants to provide physicians opportunities to gain experience with the program prior to complete implementation, Slavitt told members of the Senate Finance Committee. To do that, CMS is considering alternative start dates for the proposed MACRA rule—which is currently set to begin on January 1, 2017—and the possibility of shorter reporting periods.

Prime Healthcare Services hospitals in California allegedly pressured emergency department (ED) physicians to admit Medicare patients without the medical necessity for an inpatient admission, according to the False Claims Act complaint filed by the Department of Justice on June 23. The lawsuit accuses Prime, its 14 hospitals, and CEO, Prem Reddy, MD, of submitting claims to Medicare for medically unnecessary admissions where the patient could have been treated in observation, as an outpatient, or discharged. According to the complaint, Reddy coached physicians to embellish medical records to help them supports appeals in the event of claim denials.

Q: What is the rationale behind not being allowed to code the HIV disease B20 when the provider has documented "probable HIV disease" on the discharge summary?

A: Uncertain diagnosis, per The Official Coding and Reporting Guidelines, are those classified in the documentation by the provider as “probable, likely, suspected” or similar terminology. It is required that these conditions be documented at the “time of discharge” as “probable, likely, or suspect,” meaning they are not ruled out during the hospital stay.