This measure is expected to extend health coverage to approximately 100,000 previously uninsured DACA recipients, addressing a pressing need within the community.

In late April the Center for Medicare & Medicaid Innovation Center (CMMI) released the evaluation of their Year 8 Independence at Home (IAH) demonstration.

My philosophy always has been to encourage providers to deliver excellent medical care, foster excellent documentation, have CDI specialists (CDISs) pick up the slack when needed, and ensure that coders accurately and compliantly code – and your reimbursement and quality metrics will fall where they belong in every model.

Providers shouldn’t be able to engage in fraud and abuse, and payors should have to pay for services legitimately rendered without throwing up roadblocks.

Pediatric experts have expressed their agreement: there is no such thing as sepsis without organ dysfunction.

Sepsis without organ dysfunction is…pneumonia or urinary tract infection or cellulitis. It doesn’t belong in the sepsis DRG, and I am going to predict that the OIG is going to agree with me.

Consistent with the annual updates to account for changes in resource consumption, treatment patterns, and the clinical characteristics of patients, CMS is recognizing inadequate housing and housing instability as indicators of increased resource utilization in the acute inpatient hospital setting.

The Centers for Medicare & Medicaid Services (CMS) recently unveiled its proposed changes for the Inpatient Prospective Payment System (IPPS) for the 2025 fiscal year (FY).

Indeed, despite the comprehensive efforts of a multidisciplinary care team, including the involvement of case management personnel to orchestrate a “safe” discharge plan, the threat of potential litigation or adverse patient outcomes looms heavily within hospital settings.

Kepro rebranding in Fall 2024

Overall, these investments align with the Administration’s goals of improving healthcare access, addressing mental health challenges, and ensuring equitable care for all Americans.

Metrics like observation rate, denials rate, and case mix index (CMI), although interconnected, are frequently established with independent goals, further complicating the pursuit of comprehensive success.

These commitments collectively contribute to demonstrate comprehensive efforts and offer tangible solutions to tackle hunger, improve nutrition, and reduce health disparities.

Make sure clinical documentation integrity specialists are vigilant when reviewing records of patients with pneumonia, and query when indicated.

When a CDIS composes a query, they should be providing the provider with the clinical indicators they need to make a thoughtful, informed decision.

Almost two months into the 2024 Outpatient Prospective Payment System (OPPS), I thought I would provide some clarity regarding the new social determinants of health (SDoH) and supportive service codes that have been released – specifically, the SDoH assessment, community health integration, and principal illness integration.

A condition may be diagnosable, but not relevant if it does not impact the current encounter. A diagnosis is not codable if it is not documented in an appropriate format.

It has been brought to my attention that some payers are citing the American Hospital Association (AHA) Coding Clinic, pages 147-149 of the 2016 fourth-quarter edition, to justify using their own criteria as the basis for denials.

Since Jan. 1, 2023, practically speaking, all evaluation and management (E&M) service coding is based on medical decision-making or time. And some providers are not documenting time appropriately.

On February 8, CMS released a memorandum outlining new guidelines and permission to text patient information and patient orders to health care team members.