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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.

The Centers for Medicare & Medicaid Services (CMS) just released news that they will be working on a 10-year payment and care delivery model called the Transforming Maternal Health Model (TMaH).

I think this report confirms some of the information we have already seen in our hospitals and EDs: that our patients are increasingly more socially and medically complex.

Queries, whether placed by a CDI specialist or an AI solution, need to be compliant and cannot lead providers.

If your facility has not taken steps to ensure that Hierarchical Condition Category (HCC) diagnoses are properly validated, you are just asking to be the next victim in the OIG headlights.

As we step into the new year, the mix of social needs and healthcare will continue to demand our attention.

Today is it is estimated that more than 2 million women of childbearing age live in maternity care deserts, meaning they reside in counties that do not have obstetric care, many of them rural.

Written in March 2013 by the highly respected Dr. Steven Meyerson, “Observing the Rules for Observation after Outpatient Surgery” evolved over time into one of the most-read articles in the history of RACmonitor.

In essence, you are telling the story of the surgery and what happened during recovery in codes. You need the provider to document so you understand the course of events and whether there was a complication or not.

The Biden Administration has released a new playbook addressing three “pillars” of emphasis related to the social determinants of health (SDoH), from the Domestic Policy Council’s Office of Science and Technology Policy.

ABNs are utilized prior to or during the continuation of services that Medicare does not cover when services exceed Medicare frequency coverage guidelines, or when services are deemed not medically necessary.

The Gravity Project and the American Medical Association (AMA) have taken a significant step toward clarifying the coding process for the social determinants of health (SDoH).

A recent study hit the news when the top four AI companies were tested with racial questions regarding healthcare decisions that have been proven false to see if these tools could provide accurate information.

As a case manager, it can be morally distressing to try and place a patient who is medically ready for discharge into a less-than-desirable, post-acute care setting.

It isn’t the operating room location or even the procedure that necessarily determine patient status.