‘Déjà vu’ is a French term describing the feeling that one has lived through the present situation before.
For most health information management (HIM) professionals, many aspects of risk-adjusted coding might give rise to the phenomenon, at least as it pertains to diagnosis-related groups (DRGs)!
The pandemonium regarding documentation coding payment changes brought about by DRGs in the 1980s was instrumental in raising awareness of the critical importance of HIM expertise. For many years, HIM professionals have been seeking improvement in clinical documentation in acute care to support the accuracy of coding and associated reimbursement, and they will continue to work throughout the continuum of care as champions of precise documentation and coding.
The Patient Protection and Affordable Care Act of 2010 (commonly referred to as the PPACA) included provisions intended to contain Medicare costs, grow revenues, improve delivery systems, and increase services. The PPACA was aimed at moving U.S. healthcare from a fee-for-service framework to fee-for-value, and it provided risk adjustment models for reimbursement. Risk adjustment is a statistical process that considers the underlying health status and spending of patients when examining their outcomes or costs. There are several types of risk adjustment models that are used to risk-adjust healthcare data. HIM professionals have been recognized as critical to the success of achieving great results for hierarchical condition categories (HCCs). HIM has also moved into the physician office to educate physicians on creating methods for physician inquiries to obtain specificity in clinical documentation; HIM professionals are continuing to serve as experts in coding requirements for HCCs, particularly for Medicare Advantage.
It has been an important movement for HIM to have been successful in raising awareness of the risk-adjusted factor (RAF) with their medical staffs and the need for implementing HCC coding auditing programs. The RAF is used as a mechanism to differentiate expected resource consumption for the healthy person, who rarely sees a physician, versus the person with multiple co-morbidities who requires complex management.
What’s next? Home health is next! The Centers for Medicare & Medicaid Services (CMS) is moving home health agencies away from a volume-based payment model, to a new value-based payment system called the Patient-Driven Groupings Model (PDGM). To be part of the Home Health Prospective Payment System (HHPPS), the PDGM relies more heavily on clinical characteristics and other patient information to place home health periods of care into meaningful payment categories, and it eliminates the use of therapy service thresholds. PDGM focuses on patient needs and hinges more on patient characteristics in order to pay for home health services. CMS released final language for the PDGM last November, marking the sprawling home health payment overhaul that policy experts see as the biggest industry change in decades. PDGM has roots from the previously proposed Home Health Groupings Model, or HHGM, which CMS has described as focusing on value versus volume of care, better serving all individuals. PDGM ushers in new payment episode timings and removes therapy visits to determine payment.
Just like HCCs, PDGM is another tremendous opportunity for the HIM professional, specifically because of ICD-10 expertise. ICD-10 codes are used to determine the ”clinical group.” There will be a 30-day period assigned to the clinical group based on the principal diagnosis code on the claim – hence the importance of HIM expertise in ICD-10 coding. The average resource use of all 30-day periods varies across clinical groups, and the payment will reflect those differences. If a diagnosis code is used that does not fall into a clinical group (e.g., dental codes or other uncovered/invalid codes), the claim will be returned to the provider for more definitive coding.
The biggest “wow” here is that the PDGM will take effect Jan. 1, 2020. In conjunction with the implementation of the PDGM, there will be a change in the unit of home health payment, going from a 60-day episode to a 30-day period.
In conclusion, PDGM represents a great opportunity for HIM professionals to leverage their ICD-10 knowledge and expertise – and to once again provide their own personal value proposition to their organization. PDGM cannot be successfully implemented without you.
Figure 1
The Patient-Driven Groupings Model (PDGM) uses 30-day periods as a basis for payment. Figure 1 above provides an overview of how 30-day periods are categorized into 432 case-mix groups for the purposes of adjusting payment in the PDGM.
Source: https://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/2019-02-12-PDGM-Presentation.pdf
Resources
MARSI Coding Auditor Program: MARSI is an industry leader in risk adjustment documentation, coding, & auditing. This highly specialized online course is brought to you through a collaboration between AHIMA and MARSI.
Programming Note:
Listen to Bonnie Cassidy report this story live today on Talk Ten Tuesday, 10-10:30 a.m. ET.
The Centers for Medicare & Medicaid Services (CMS) released in its 2025 Outpatient Prospective Payment System (OPPS) Final Rule a new Conditions of Participation (CoPs)
External audit volume more than doubled in 2024 over 2023 while total at-risk dollars increased fivefold to $11.2 million, impacting healthcare provider organizations’ cash flow
Please log in to your account to comment on this article.
Join Beth Wolf, MD, CPC, CCDS, for an in-depth webcast on the FY2025 spinal fusion MS-DRG updates. Discover key changes in DRG classification, understand impacts on documentation and CMI, and learn strategies to ensure compliance.
Join Angela Comfort, DBA, MBA, RHIA, CDIP, CCS, CCS-P, as she presents effective strategies to strengthen collaboration between CDI, coding, and quality departments in acute care hospitals. Angela will also share guidance on implementing cross-departmental meetings, using shared KPIs, and engaging leadership to foster a culture of collaboration. Attendees will gain actionable tools to optimize documentation accuracy, elevate quality metrics, and drive a unified approach to healthcare goals, ultimately enhancing both patient outcomes and organizational performance.
Optimize your outpatient clinical documentation and gain comprehensive knowledge from foundational practices to advanced technologies, ensuring improved patient care and organizational and financial success. This webcast bundle provides a holistic approach to outpatient CDI, empowering you to implement best practices from the ground up and leverage advanced strategies for superior results. You will gain actionable insights to improve documentation quality, patient care, compliance, and financial outcomes.
Enhancing outpatient clinical documentation is crucial for maintaining accuracy, compliance, and proper reimbursement in today’s complex healthcare environment. This webcast, presented by industry expert Angela Comfort, DBA, RHIA, CDIP, CCS, CCS-P, will provide you with actionable strategies to tackle complex challenges in outpatient documentation. You’ll learn how to craft detailed clinical narratives, utilize advanced EHR features, and implement accurate risk adjustment and HCC coding. The session also covers essential regulatory updates to keep your documentation practices compliant. Join us to gain the tools you need to improve documentation quality, support better patient care, and ensure financial integrity.
Dr. Ronald Hirsch provides critical details on the new Medicare Appeal Process for Status Changes for patients whose status changes during their hospital stay. He also delves into other scenarios of hospital patients receiving custodial care or medically unnecessary services where patient notifications may be needed along with the processes necessary to ensure compliance with state and federal guidance.
Healthcare organizations face complex regulatory requirements under the No Surprises Act and Price Transparency rules. These policies mandate extensive fee disclosures across settings, and confusion is widespread—many hospitals remain unaware they must post every contracted rate. Non-compliance could lead to costly penalties, financial loss, and legal risks. Join David M. Glaser Esq. as he shows you how to navigate these regulations effectively.
Protect your facility from unwanted audits! Join Becky Jacobsen, BSN, RN, MBS, CCS-P, CPC, CPEDC, CBCS, CEMC, and take a deep dive into both the CMS and AMA guidelines for reporting post operative pain blocks. You’ll learn how to determine if the nerve block is separately codable with real life examples for better understanding. Becky will also cover how to evaluate whether documentation supports medical necessity, offer recommendations for stronger documentation practices, and provide guidance on educating providers about documentation requirements. She’ll include a discussion of appropriate modifier and diagnosis coding assignment so that you can be confident that your billing of post operative pain blocks is fully supported and compliant.
During this RACmonitor webcast Dr. Ronald Hirsch spotlights the areas of the OIG’s Work Plan and the findings of their most recent audits that impact utilization review, case management, and audit staff. He also provides his common-sense interpretation of the prevailing regulations related to those target issues. You’ll walk away better equipped with strategies to put in place immediately to reduce your risk of paybacks, increased scrutiny, and criminal penalties.
Copyright © 2024 ICD10monitor. Powered by MedLearn Media.
Prepare for the 2025 CMS IPPS Final Rule with ICD10monitor’s IPPSPalooza! Click HERE to learn more
Get 15% OFF on all educational webcasts at ICD10monitor with code JULYFOURTH24 until July 4, 2024—start learning today!
