CMS believes that greater Z code capture will enhance quality improvement activities and provide further insights into the existing health inequities that hospitals and their community are facing.

CMs may not be aware of the value of their documentation, particularly for what is means of hospital reimbursement and record integrity.

There has been growing interest in the intersection of utilization review (UR) and clinical documentation integrity (CDI).

Providers shouldn’t be documenting just to get it out of the way; they must recognize that it can enhance or detract from patient care.

When we have the urge to use the word, “need,” we should consider framing the discussion differently. Something important is happening, we need to think about what it means, and what all the options are. We need to provide the patient and their loved ones with the information they require to make the decision that is right for them.

Based on the higher average cost to care for individuals who are homeless, CMS has ruled to consider sheltered and unsheltered homelessness as a complication or comorbidity (CC).

As a healthcare community, rather than labeling our patients based on our own perspective of privilege we should use the situation to ignite a call to action that we may have overlooked a valuable piece in our patient’s healthcare needs.

The idea behind the uncertain diagnosis guideline is that the resources utilized to rule out a condition are similar to the resources used to rule it in.

Putting aside our overt racial issues (such as the recent U.S. Supreme Court ruling regarding affirmative action), I can’t help but continue to call attention to the subject of implicit biases and their impact on our progress. Implicit bias occurs automatically and unintentionally, passively influencing our judgments, decisions, and behaviors.

Today I am going to go over what I picked up from the American Hospital Association’s (AHA’s) Coding Clinic for the second quarter of 2023. It was chock-full of interesting advice.

When the purpose of documentation melded into the support behind reimbursement and quality monitoring, no one really explained this shift to the doctors and other providers.

When rounds are rolled out, I typically see a list of items that “should be covered;” however, I rarely see a discussion with each stakeholder group that dives into the value and worth of rounds to each discipline. The goal of rounds is to get all attendees on the same page, ensure an inline approach for patient communication, and share relevant information with an outcome of reduced intrusions throughout the day. The physician does not want to attend rounds, leave, and then get multiple texts, phone calls, and secure chats from the very same groups that attended the rounds.

From a hospital throughput process, the over-utilization of PT consults creates a large delay, especially for patients under outpatient with observation services (OBS) who are expected to have a quick turnaround, but are now delayed for mobility assessments, regardless if this is a contributing factor to their need for hospital observation services. The result of this consultation is then exacerbated if the therapy assessment recommends post-acute placement, triggering further delays for case management planning and arrangements

This blog is one example of the systemic issues in our communities: there is a failure to intervene with patients, resulting in an unnecessary hospitalization, meaning that their social determinant, most often housing, can be solved in the hospital.

The federal statute 42 CFR § 482.30, in the Conditions of Participation for Utilization Review (CoP), requires that each hospital must have in effect a utilization review (UR) plan and a utilization review committee (URC). The CoP lists specifications regarding committee requirements; however, it is left up to the hospitals to decide how functional these committees will be.

The COVID 19 Public Health Emergency (PHE) is expected to end on May 11, 2023. When this occurs the waiver for the Qualifying Hospital Stay (3-Day Stay) will end as well.

The end of the public health emergency (PHE) brings new challenges regarding the old Three-Day rule.

Delays in transitions to post-acute care are a vexing issue.

What has UR lost being removed from the hospital setting?

The need for benchmarking denials is evident as there are variations in hospital appeal processes.