By Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA A reader asked “Do you need to be a coder to be a coding auditor, and if so, what is the best path to take to achieve the goal of becoming an auditor?” My earlier article focused on whether one needs to be a coder to be a coding auditor. This article will deal with the second part of the reader’s question. What is the best path to take to achieve the goal of becoming a coding auditor? I am a proponent of coders advancing in their career to a
By Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA A reader asked “Do you need to be a coder to be a coding auditor, and if so, what is the best path to take to achieve the goal of becoming an auditor?” I will break my response into two segments. Do you need to be a coder to be a coding auditor? In my opinion, yes, you need to have coded records, of all types, to be a coding auditor. Your experience as a coder should include having a thorough knowledge of the coding guidelines and Coding Clinic advice.
By Rose T. Dunn, MBA, RHIA, CPA, FACHE As health information professionals, we have an obligation to promote the integrity of our organization’s health information. Health information integrity means our clinical staff creates documentation that accurately and completely reflects the conditions addressed at the time of encounter and coding professionals strictly apply the CMS Guidelines and RADV rules when assigning the codes to conditions reported. So how does one know if their manner of coding is going to be acceptable? While there are a number of items to keep in mind when assigning codes, the most beneficial in my opinion
By Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA A reader recently asked how to deal with what appeared to be a contradiction between authoritative coding guidance and payer demands to code conditions from a problem list. In my blog Coding: What Documentation Should I Use?, I quoted the RADV Medical Record Guidance: “Evaluate the problem list for evidence of whether the conditions are chronic or past and if they are consistent with the current encounter documentation (i.e., have they been changed or replaced by a related condition with different specificity). Evaluate conditions listed for chronicity and supported in the
By Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA Recently a reader wrote in response to my article “Getting to the MEAT of Promoting Information Integrity” “… (T)he 3rd quarter 2021 Coding Clinic speaks of not coding from the history list, problem list, or medication list. In the past we coded from the history and problem lists as long as the patient was on home medications noted in the documentation. With this new guidance it looks like this practice needs to stop. I am curious to learn your opinion.” Yes folks, coding from a list is not a recommended approach.
By Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA A reader asked “Do you need to be a coder to be a coding auditor, and if so, what is the best path to take to achieve the goal of becoming an auditor?” In my opinion, yes, you need to have coded records, of all types, to be a coding auditor. Your experience as a coder should include having a thorough knowledge of the coding guidelines and Coding Clinic advice. You need to know where to look for diagnoses, understand clinical indications, and understand surgical procedures. To be competent in the
By Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA Healthcare organizations utilize CAC applications for a variety of purposes, some successfully, others less so. When coding professionals can assign codes more accurately AND in less time than it takes to validate the condition codes suggested by a CAC application, one should not be surprised that many coding professionals believe it is a waste of time to validate the CAC’s suggested codes. Coding professionals working in all venues, including provider and HCC environments, need to recognize that CAC applications are yet another tool for doing their job. Set up right, with
By Rose T. Dunn, MBA, RHIA, CPA, FACHE Are your problem lists a problem? Providers have enough documentation burdens already. For providers, maintaining problem lists takes a backseat to patient care…as it should. However, an accurate and complete problem list can facilitate patient safety and care. Coders and documentation specialists have a critical role to play in support of this powerful tool used to tell a patient’s medical story. You can think of the problem list as a Table of Contents highlighting the major chapters in a patient’s medical history: A compilation of their problems and conditions Active current conditions
By Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA It’s that time of year! No, I’m not talking about holiday preparation. I’m talking about the year-end activities you, as coding professionals, should be doing to ensure your HCC process is truly excellent: prior HCCs are captured in your records, documentation reflects the details that help your coders code to the highest level of specificity, problem lists are being maintained, claims are promptly submitted, and you have a low or zero denial rate. Doing all of these steps will ensure the RAF score for your organization reflects the highest accuracy supported
By Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA The daily healthcare newsletter headlines have had two popular subjects lately—Covid 19 and Medicare Advantage (MA) fraud cases. Let’s look at the MA news: A common theme with the MA fraud cases is the submission of conditions on the claims to CMS that are unsupported by patient medical records or documentation of approved CMS providers. There are no short-cuts to accurate data. Healthcare providers and MA plans need certified coding professionals who are skilled in the requirements of hierarchical condition category coding, the CMS guidelines, and guidelines used by the risk
By Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA In the risk adjustment model used by Medicare Advantage and other insurers, ICD-10-CM diagnosis codes are mapped to the Hierarchical Condition Category (HCC) and the associated coefficients (weights assigned based on residency, payer coverage, etc.) are used to calculate the level of health plan reimbursement for that HCC. Both how these codes are mapped and their coefficients change from year to year. Coders need to know how the diagnosis codes are mapped for the period being reviewed. I have had several individuals reach out to me during 2021 asking where the
By Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA Following on the heels of the federal audit finding Humana overcharged Medicare nearly $200M, we have another large Medicare Advantage Organization (MAO) that did not have adequate or effective safeguards in place to detect claims with faulty diagnoses. Anthem now must pay $3.4 million back to the government. The OIG found a pattern of overpayment due to diagnoses without supporting medical record documentation. In its report, the OIG focused on seven major conditions that are especially at-risk of miscoding, including acute stroke, acute heart attack, embolism, and major depressive disorder. I
by Rose T. Dunn, MBA, RHIA, CPA, FACHE Hitting the headlines recently was the federal audit finding Humana overcharged Medicare nearly $200M. Humana Inc.’s Medicare Advantage health plan for seniors in Florida improperly collected nearly $200 million in 2015 by overstating how sick some patients were. The audit of Humana occurred from February 2017 to August 2020. Auditors found that the plan’s medical records did not support the hierarchical condition category (HCC) conditions claimed. According to an article by Fred Schulte published by NPR, auditors said Medicare overpaid Humana by $249,279 for the 200 patients whose medical charts were closely
by Rose T. Dunn, MBA, RHIA, CPA, FACHE In case we need another reason to stand firm when documentation and/or coding become questionable, we are reminded that not only is it our duty, we may be subject to financial penalty if we do not. Earlier last year, Becker’s identified the failure of Medicare Part C (Medicare Advantage) to perform its duty to validate the coding (and resulting HCCs) it has submitted to CMS, and for which the Medicare Advantage Organization was paid by CMS. (Becker’s Hospital Review “Anthem hit with federal lawsuit alleging Medicare fraud”.) Those of us working in
by Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA The pandemic has affected every sector and population category across the US (and the world). Some business sectors thrived (Amazon, pizza delivery services, plexiglass manufacturers, and mask producers to name a few), but as we know, the healthcare industry took a big hit. When I say the healthcare industry, I’m not just talking about providers. Payers also lost—big time. You might be saying, “Well, Rose, I don’t think that’s true. They took that premium out of my paycheck and I kept my hemorrhoids until the pandemic coast was clear!” But many
by Rose T. Dunn, MBA, RHIA, CPA, CHPS, FACHE, FHFMA In December I posted a blog after reading Merrill Goozner’s GoozNews on CMS’s proposal to adopt a common prior authorization form. I agreed with Merrill when he stated that the proposal was problematic in that it did not apply to Medicaid or to the rapidly growing Medicare Advantage plans. While my earlier blog focused on the exclusion of Medicare Advantage (which is true) I want to clarify the reporting as it relates to Medicaid. A good friend of mine, Margaret Skurka, who, by coincidence is involved in the CMS prior auth
by Rose T. Dunn, MBA, RHIA, CPA, CHPS, FACHE, FHFMA Information in this article has been revised here. An excellent column in the excellent newsletter by Merrill Goozner, GoozNews, has hit the nail on the head. The article describes CMS’s recent proposal to require insurers adopt a common prior authorization form and switch to fully electronic communication with providers’ offices. Further, insurers must respond in a timely manner to prior authorization requests, give a specific reason for every denial, and report on their prior authorization process to include denial rate, success of appeals, and the average time between a request
by Rose T. Dunn, MBA, RHIA, CPA, CHPS, FACHE, FHFMA At the end of last year, this news may not have caught your attention: Federal Auditor Renews Concerns of Medicare Advantage Gaming Axios, December 12, 2019 “A new federal audit presents more evidence that private Medicare Advantage plans are fudging the data about how sick their customers are, as a way to pull in more taxpayer dollars. Medicare Advantage plans received $6.7 billion in federal funding in 2017 based on diagnoses — like cancer or heart disease — that were not reflected in the actual care patients received, according to
by Rose T. Dunn, MBA, RHIA, CPA, FACHE The last few weeks have been busy ones for those of us who work in Hierarchical Condition Categories (HCC) coding. CMS made three major announcements. Let’s look briefly at each. Changes to the Coefficient Calculation For 2022, the coefficient calculation will be based solely on encounter data according to an article in Fierce Healthcare by Paige Minimyer. Before 2022, the coefficient calculation was based on a hybrid model that took both the encounter data and actual CMS costs of Medicare Advantage Organization (MAO) HCCs into consideration. The change has been controversial since
Hear Rose T. Dunn, MBA, RHIA, CPA, FACHE, a nationally recognized HCC expert, provide a free, brief presentation: "Hierarchical Condition Categories: The Roles and Responsibilities of the Internal Auditor." HCC: Auditing in the Risk Adjustment Environment The essential information internal HCC auditors need to ensure their organization receives the reimbursement they are entitled to and that codes and claims are supported by clinical documentation. Learn what to look for and how to communicate your findings. Tips and techniques offered by nationally recognized HCC authority Rose T. Dunn, MBA, RHIA, CPA, FACHE. Learn more here.