Job prediction Friday: 5 new job functions for healthcare delivery | Brian Murphy posted on the topic | LinkedIn (2024)

Humans are meant to do hard things. There are few greater rewards than overcoming obstacles and achieving a difficult goal.Richelle Marting JD, MHSA,RHIA,CPC,CEMC,CPMA could have made for a terrific coder or HIM director, but she pushed on with one more exam: The bar. We talk about that in the clip below, and in greater detail on the podcast (see link to full episode below in the comments). Said Marting of the experience:“The bar exam was as awful as you’d expect, it was a multi-day, total of 16-hour exam. So really as much a test of stamina and endurance as anything else.“But if you prepare, you’ve got it.”That last bit is the key. Marting worked hard, studied long hours, and achieved something meaningful that propelled her career into a new and exciting direction.When you combine an RHIA, coding credentials, and a JD, you have a unique skill set that puts you in demand.The most meaningful professional achievements are typically the hardest.***The next Off the Record is queued up for Wednesday and I’ve got a guest on from a profession I’ve never covered on the show or served in any prior role. But it’s one I discovered makes a big impact on hospital quality, patient outcomes, and indirectly (in some limited cases, directly) on organizational revenue.I spent the show learning and suspect you will as well.

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I love history for many reasons.First, the past is a fascinating place. Second, we can learn lessons that apply today (and we should, else we’re doomed to repeat it).Third, people endured events in the past that put everything in the present into perspective.I’ve done and experienced some hard things in my life. I bet you have too. But there’s very few of us (thank the Lord) that waded onto Normandy beach on June 6 1944.Eternal thanks.

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The OIG Toolkit To Help Decrease Improper Payments in Medicare Advantage Through the Identification of High-Risk Diagnosis Codes is a valuable tool in your compliance arsenal. One you should be using if you’re at all involved with risk adjustment.See attached.The toolkit offers Medicare Advantage Organizations (MAO) information to replicate the OIG’s techniques to identify and evaluate high-risk diagnosis codes to ensure proper payments and provide better care for enrollees. In short, it’s the OIG’s auditing blueprint. Use it and you could save your organization hundreds of thousands or millions in fines.What diagnoses are high risk?As of November 2023, the OIG has found that approximately 70% of high-risk diagnosis codes were not supported in the associated medical records. The error rate of some groups of codes is as high as 90%.Conditions and other groups at highest risk of error include the following:·Acute stroke, 96% error·Acute heart attack, 95% error·Embolism, 79% error·Lung cancer, 88% error·Breast cancer, 96% error·Colon cancer, 94% error·Prostate cancer, 89% error·Potentially mis-keyed diagnosis codes, 81% errorThe Toolkit lists the associated ICD-10 codes so that you can drill down into specific problem areas.Why are error rates so high?The OIG reviewed thousands of claims for services that can be used for risk adjustment purposes, including physician, outpatient, and inpatient. It found that MAOs are reporting codes for active conditions or acute exacerbations when a history of is warranted.In most cases, the medical records supported an old condition rather than acute. For example, a prior myocardial infarction diagnosis (which does not map to an HCC) instead of an acute myocardial infarction diagnosis.One high-risk group included individuals who received a lung cancer diagnosis during a service year, but the encounters and the relevant PDE data did not indicate that the individuals received surgical therapy, radiation treatments, or chemotherapy drug treatments administered within a six month period either before or after the diagnosis. A history of lung cancer diagnosis is generally what was supported in the medical records, the OIG said.A few seem to want to skirt the need for active monitoring or support but the OIG isn’t buying it.If it wasn’t documented, it wasn’t done.What should you do with the Toolkit?The OIG hopes that the users of this toolkit will, at a minimum, use the information to detect and correct inaccurate diagnosis codes in their own systems.Read it, disseminate the information with your coding staff, outpatient CDI/pre-visit chart review team, population health, your compliance officers, and of course your providers. Review MEAT criteria and the proper use of history of codes.Make sure your tech stack including point of care technology (i.e., auto-prompts to the physician) isn’t capturing codes without clinical support.

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Establishing facilitywide diagnosis definitions is the gold standard for many organizations. If providers and the CDI/coding team agree on what constitutes postoperative respiratory failure for example, clinical disagreements should be greatly reduced, the need for queries lessened, and coding accuracy improved.Unfortunately payers also (appear) to have the same leeway to define conditions, per AHA Coding Clinic.Coding Clinic Q4 2016, pp. 147-149, states, “a facilityor a payermay require that a physician use a particular clinical definition or set of criteria when establishing a diagnosis, but that is a clinical issue outside the coding system.”The “or a payer” bit from the above Coding Clinic has caused no end to headaches, as described by my guest on Off the Record, Richelle Marting JD, MHSA,RHIA,CPC,CEMC,CPMA, in the clip below.Should organizations take the next step and get definitions written into their payer contracts, in an attempt to get both sides—hospitals and payers—to meet at the table? We discuss that and more in the full program. Listen and subscribe on your podcast player of choice.I welcome any comments on this contentious issue as well.

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Clinical validation audits are on the rise and among the chief causes of claims denials, per my current Off the Record podcast guest Richelle Marting JD, MHSA,RHIA,CPC,CEMC,CPMA.While denials are payer-agnostic, Marting says that Medicare Advantage Organizations have risen to the top of worst offenders. Medicare Advantage plans can set their own individual coverage and payment policies that don’t match traditional Medicare—and their policies are often opaque and more restrictive.Two recent clinical validation tactics being employed with greater frequency include the following:1. Payers ignoring the guidelines for reporting additional diagnoses as detailed in Section III of the Official Guidelines for Coding and Reporting, instead focusing only on diagnostic criteria of a given condition for coverage. Per the guidelines, the definition of “other diagnoses” is interpreted as additional *clinically significant* conditions that affect patient care in terms of requiring:·clinical evaluation; or·therapeutic treatment; or·diagnostic procedures; or·extended length of hospital stay; or·increased nursing care and/or monitoringPayers for example will argue that the patient’s sodium wasn’t low enough to quality as hyponatremia, or the patient’s oxygen saturation wasn’t low enough for acute respiratory failure, i.e., not clinically significant—and therefore can’t be reported as an additional diagnosis. And issue a denial. Even though a physician evaluated the patient, made the diagnosis, and additional nursing time and care was expended in his/her care.2. Payers creating their own diagnostic criteria based on outdated definitions, or in some cases, self-created definitions inaccessible in the clinical literature. Sepsis is a problem but acute respiratory failure even more so coming out of the COVID-19 pandemic, per Marting.Other diagnoses for which payers create their own (restrictive or subjective) definitions include:·Hyponatremia·Severe protein calorie malnutrition·Acute blood loss anemia·Metabolic encephalopathy·Acute kidney injury*Note: The phrase “clinically significant” was added to the Official Guidelines effective Oct. 1, 2023 (see link below). This small change undoubtedly gave payers additional ammunition, as they can now argue any diagnosis lacks sufficient clinical significance.What are you seeing for denials in your organization these days? Leave a comment below.***Wait, you’re not listening to Off the Record? I cover great content like this with amazing guests in new episodes appearing every other week.Search “Off the Record With Brian Murphy” (that’s me) on Apple Podcasts, Spotify, or Amazon Music, and click “Follow.”It’s that easy.And please leave a 5-star review, it helps others find the show.

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Earning your RHIA (Registered Health Information Administrator) is a huge accomplishment, and for some marks the end of a four-year academic journey and an entry intoHIM. For Richelle Marting JD, MHSA,RHIA,CPC,CEMC,CPMA, it was only the beginning. In pursuit of her RHIA, which she eventually earned, my guest on today’s episode took a class on the legal aspects of HIM. That course planted the seed for a career in law—and eventually led her to start her own law firm. All while raising two twin girls. I don’t know how she managed all this, but that’s why I got Richelleon Off the Record.Listen to the full episode below.On this show we discuss:👉 Richelle’s story from RHIA to JD. How difficult was the bar exam?👉 Becoming an entrepreneur and starting her own law firm👉 Most frequent type of healthcare cases: Clinical validation auditsand DRG validation👉 The coding guidelines she sees most frequently ignored or twisted to the payer’s benefit, and other shady tactics👉 What do healthcare organizations make too big a deal out of—and what are they not worried about enough?👉 Qui Tam and the recent spate of cases initiated by organizational whistleblowers, in particular Medicare Advantage organizations👉 Managed care contracting: Legal issues around contract negotiation, how claims get paid, timely filing, and payment policies. How quickly must plans respond to appeals, and should you put a diagnosis definition in a payer contract?👉 What advice would she give to someone who is in HIM and considering a career in law—what does she know now that she wishes she knew then? #OTR #clinicalvalidation #DRGvalidation

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HIM/coding professionals can and do make good CDI specialists. I’ve known several over my career. But, they’re a minority.According to the most recent ACDIS survey data, 74% of CDI professionals are RNs, as opposed to just 7% who possess an RHIA. Another 5% of respondents to the survey are RHITs, though 18% possess a CCS, which can be held by either an RN or a coding professional.While the data is not exact, I would guess somewhere between 10-15% of CDIs are coding professionals, with the rest either nurses or physicians (including foreign medical graduates).Which makes my current Off the Record podcast guest, Kalee Vincent, MBA, RHIA, CDIP, CCDS-O, CCS, even more of an outlier.Kalee is both an RHIA and a CDI educator for WVU Medicine. Her principal role is educating providers on documentation. So being able to tie documentation to the clinical picture and articulate it in either 1:1 or group settings of MDs, a must.In the following video clip she describes the unique skills coding professionals bring to the table, tying it nicely to a clarification of acute kidney failure. Check it out and then listen to the full episode in the comments below.***In the next episode of Off the Record I interview another RHIA—but also a JD, a healthcare attorney who I had on to talk clinical validation audits, Medicare Advantage plan compliance and much more. Her incredibly unique background made for a wonderful conversation. Can’t wait to bring it to you tomorrow.#OTR #CDIeducator

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Point of care technology has a lot of promise, especially in the risk adjustment space. Physicians are busy to the max, and an automated nudge, suggestion, or a best practice advisory/alert can offer a more definitive diagnosis based on clinical indicators in the record. Get it captured quickly and relatively painlessly, without all the hassles of a later question from CDI or coding.But you can see how this could be a problem.It further blurs the line between clinical practice, what constitutes a query, and compliance with coding guidelines.I worried about it often in my ACDIS days. Still do. But we can either sweep it under the rug, or talk about it.We're hosting a free and to-the-point (30 minute) webinar on this subject next week. Jason Jobes will discuss both the promise and the compliance risks of these technologies openly and honestly, as well as reviewing extant industry guidance. I'll be hosting the program. We'd love to have you and listen to your opinions.Sign up here or at the link below: https://lnkd.in/euSbaRXd

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You asked, I answered. Here's an article on the problems of coding from the problem list.The winner of my recent "what should I write about" survey was technical coding/billing (43%), edging out best practices/emerging ideas (39%) by a narrow margin. Personal/professional growth (12%) came in third, followed by important news commentary (5%). I will continue to cover all of these topics but I'm starting with coding. I am not a coder and so welcome your insights/opinions/disagreements.

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