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OIG Worksheets From Malnutrition Audit Raise Questions About Reasons for Denials, Experts Say
Published on: 11/16/2020
A recent OIG conclusion in July about malnutrition denials was recently looked into further by ACPA member and NPAC 2020 Co-Chair Dr. Beth Wolf and others. Learn what they found in this Health Care Compliance Association (HCCA) Report of Medicare Compliance article from Nina Youngstrom.
SEP-1 and Sepsis-3 are not Incompatible
Published on: 10/26/2020
SEP-1 is the Hospital Inpatient Quality Reporting Program measure titled “Severe Sepsis and Septic Shock: Management Bundle.” But, some have noted this Centers for Medicare & Medicaid Services definition seems to be resulting in denials from Medicare Advantage and other plans, and using their preferred Sepsis-3 definition results in falling out of core measures. ACPA BOD member and CDI Committee Co-Chair, Dr. Erica Remer, discusses this catch-22 in her latest ICD10monitor article:
M.D. Review of Dietician Notes May Help Prevent Malnutrition Denials
Published on: 10/12/2020
Hospitals will continue to see Medicare denials for severe protein-calorie malnutrition when reviewers aren’t convinced the code is accurate or the clinical evidence supports it, experts say. ACPA member and CDI Committee member Dr. Debra Anoff discusses how she's addressed this at UCHealth in this Health Care Compliance Association (HCCA) Report on Medicare Compliance article from Nina Youngstrom.
New Rule: Providers Required to Transmit Electronically All Records to QIOs
Published on: 10/7/2020
In a provision glossed over by most, the 2021 Inpatient Prospective Payment System (IPPS) Final Rule introduced a requirement that all providers transmit all records to Quality Improvement Organizations (QIOs) via electronic means as of Oct. 1, 2020. Learn more from ACPA Advisory Board member Dr. Ronald Hirsch in this RACmonitor article...
It’s No Accident That the OIG is Going After Acute CVA
Published on: 10/5/2020
Documentation of strokes is tricky, so it's no accident the OIG is going after Acute CVA diagnoses as explained by ACPA BOD member and CDI Committee Co-Chair, Dr. Erica Remer in her latest ICD10monitor article.
The Demise of the Medicare Inpatient-Only List – The Myths and Facts
Published on: 8/19/2020
CMS is proposing to eliminate the inpatient-only list over the next three years as outlined in the 2021 Outpatient Prospective Payment System (OPPS) Proposed Rule. Read more from ACPA Advisory Board member Dr. Ronald Hirsch in this RACMonitor.com article...
CMS Plans to End IPO List, Increase Prior Auth; Buck Would Stop with Two-Midnight Rule
Published on: 8/17/2020
CMS is planning to terminate the inpatient-only list, which guarantees Medicare payment for procedures only when they’re performed on inpatients, while expanding prior authorization for outpatient procedures, according to the proposed 2021 outpatient prospective payment system (OPPS). Learn more from ACPA BOD member, Dr. Alvin Gore and ACPA Advisory Board member, Dr. Ronald Hirsch in this Health Care Compliance Association (HCCA) Report on Medicare Compliance article from Nina Youngstrom...
CMS Opens Door to G0463 Billing for Remote Physician Visits
Published on: 8/6/2020
The confusion over what code to use when hospital-employed physicians perform virtual visits with patients has reared its head again in the latest FAQ from Medicare released on July 28th. Learn more from ACPA Advisory Board member Dr. Ronald Hirsch in this RACmonitor.com article...
Although Audits Restart Aug. 3, CMS Will Roll Them Out in Stages; TPE Is On Ice for Now
Published on: 8/3/2020
CMS resumed Medicare audits on August 3, 2020, but it will proceed in stages and Targeted Probe and Educate is still on hold, as explained by ACPA Advisory Board member Dr. Ronald Hirsch in this Report on Medicare Compliance article from Nina Youngstrom...
ICD-10 Codes for Lactic Acidosis
Published on: 7/28/2020
Lactic acidosis shares the ICD-10-CM code, E87.2, Acidosis, with other causes of acidosis, respiratory or metabolic. Mixed acid-base disorders are coded at E87.4. The key question for CDISs and coders is, “when is acidosis considered integral to the causative condition and not separately codable?” Learn the answer in this ICD10monitor article from ACPA BOD member and CDI Committee Co-Chair, Dr. Erica Remer...
Total Joint Replacement Under Scrutiny Again
Published on: 7/22/2020
The attention given to total joint replacement has been a recurring headache for both physicians and hospitals over the last several years, and it appears there is little chance of it abating. Read more from ACPA Advisory Board member Dr. Ronald Hirsch in this RACMonitor.com article...
The OIG is Coming for your Malnutrition MCCs
Published on: 7/21/2020
The OIG released a report titled, “Hospitals Overbilled Medicare $1 Billion by Incorrectly Assigning Severe Malnutrition Diagnosis Codes to Inpatient Hospital Claims.” Yowzers. Read more in this ICD10Monitor.com article from ACPA BOD member and CDI Committee Co-Chair Dr. Erica Remer...
Accurate CDI is Imperative in Coding Severe Malnutrition
Published on: 7/20/2020
One billion dollars is a big number. But, even more astounding is that hospitals were found by the OIG to have incorrectly documented and/or coded severe malnutrition 86.5% of the time! Read more from ACPA NPAC2020 Co-Chair Dr. Beth Wolf in this ICD10monitor article...
Functional Quadriplegia: A Code for a Real Condition
Published on: 7/14/2020
ACPA BOD member and Co-Chair of the CDI Committee, Erica Remer, MD, FACEP, CCDS continues her "A Question a Day Keeps the Query Away" series on ICD10monitor.com, this time featuring functional quadriplegia, ICD-10-CM code R53.2. This condition is defined as being complete immobility due to severe disability or frailty caused by another medical condition, without physical injury or damage to the brain or spinal cord.
Medicare Prior Authorization Program – Ten Things to Know
Published on: 6/30/2020
Medicare's prior authorization requirement for five common outpatient procedures started on July 1st, 2020. Make sure you know these ten aspects of this new process by reading ACPA Advisory Board member, Dr. Ronald Hirsch's article in RACMonitor.com.
Collaboration Platform Links Deaconess Health to Its SNF Network
Published on: 6/28/2020
ACPA member Lori Sieboldt, MD, MBA, CHCQM-PHYADV, medical director of population health at Deaconess Health System in Indiana, discusses in this Healthcare Innovation article how her system deployed a care-collaboration platform that connects physicians with skilled nursing facilities in their post-acute network and cut length-of-stay by as much as nine days.
A Question a Day will Keep the Queries Away: Acute Blood Loss Anemia
Published on: 6/22/2020
When should Acute Blood Loss Anemia be documented? ACPA BOD member and CDI Committee Co-Chair, Dr. Erica Remer delves into the details in this ICD10Monitor.com article.
Prior Authorization for Medicare Two Weeks Away
Published on: 6/17/2020
Required prior authorization from Medicare for five medical procedures begins 7/01/2020. Does your hospital have a process in place to ensure this happens? Read ACPA Advisory Board member, Dr. Ronald Hirsch's RACMonitor.com article to ensure you're clear on what's needed.
As Prior Auth Gets Underway, Hospitals Will Have Several Chances for Claims Approval
Published on: 6/8/2020
Hospitals are required to ask Medicare for prior authorization for five outpatient procedures, but there’s no such thing as flat-out rejection. If the answer is “no,” hospitals can keep asking Medicare to approve payment, assuming there’s documentation of medical necessity somewhere. Learn more from ACPA Advisory Board member, Ronald Hirsch, MD, FACP, CHCQM, CHRI in this Report on Medicare Compliance article by Nina Youngstrom.
Confusion Remains over Medicare Guidance on Treating Patient Homes as Hospital Departments
Published on: 5/19/2020
There is continued confusion over the use of patient homes as off-campus, provider-based clinics for Medicare billing purposes. Read ACPA Advisory Board member Ronald Hirsch, MD, FACP, CHCQM, CHRI's latest article in RACMonitor to find some clarity.
COVID-19 Coding Dilemma: Z20.828 and Z03.818
Published on: 5/5/2020
ICD-10-CM codes under the current guidelines are not robust enough to tell the story correctly. The American Hospital Association (AHA) guidance tried to eliminate some of the confusion about Z03.818, Encounter for observation for suspected exposure to other biological agents ruled out, and Z20.828, Contact with and (suspected) exposure to viral communicable diseases. Learn more from ACPA BOD member and CDI Committee co-chair Dr. Erica Remer in this ICD10Monitor article.
Court Says Inpatients Changed to Observation Have Right to Appeal
Published on: 4/17/2020
A federal court on March 24 ordered CMS to let Medicare patients «challenge decisions by hospitals" to change their status from inpatients to observation, dating back to 2009. Patients who were admitted as inpatients but later got the Medicare Outpatient Observation Notice (MOON) must have «a meaningful opportunity to appeal," according to the decision from the U.S. District Court for the District of Connecticut.[1] However, the new appeal rights won't apply to patients placed in observation at the outset.
Custodial Admissions from the ED: PART II
Published on: 4/8/2020
Custodial admissions continue to be an enormous strain on hospitals. Read about the options to address this issue in this part two RACmonitor article from ACPA Interim President, Juliet B. Ugarte Hopkins, MD, CHCQM.
SdoH: Behavioral Health is a Major Issue in Rural America
Published on: 2/26/2020
Rural communities face enough challenges with access to basic medical care. Accessing behavioral health has become increasingly difficult for every population, yet those in rural areas face obstacles of grand proportions.  Learn more from ACPA member and slated NPAC 2020 speaker, Ellen Fink-Samnick, MSW ACSW LCSW CCM CRP in this RACmonitor article.
New Technology: Price it Right, or Else
Published on: 2/19/2020
New technologies have always posed a financial challenge to hospitals. While they want to provide cutting-edge care to patients, unless a positive margin can be maintained, the costs of those technologies can quickly lead to significant financial losses.  Read how to prevent loss from ACPA Advisory Board member Ronald Hirsch, MD, FACP, CHCQM, CHRI.
Custodial Admissions from the ED: Major Issue Nationally
Published on: 2/19/2020
ACPA VP and  NPAC 2020 co-chair Juliet B. Ugarte Hopkins, MD, CHCQM, reviews a specific quandary playing out in emergency departments all over the country which no one seems to know how to address. Read more in this RACmonitor article.
Underutilization of ICD-10-CM Z Codes for Medicare Beneficiaries
Published on: 2/5/2020
ACPA member and slated NPAC 2020 speaker, Ellen Fink-Samnick, MSW ACSW LCSW CCM CRP discusses how infrequently ICD-10-CM Z codes are being used since they became available as of 2017 in this RACMonitor article.
News Alert: Widespread Recoupments of Incorrect Post-Acute Transfer Claims Have Begun
Published on: 1/30/2020
Is your hospital assigning discharge codes correctly on claims? If not, you could be headed toward recouping payment. Read more in this RACmonitor article featuring ACPA Advisory Board member, Ronald Hirsch, MD, FACP, CHCQM, CHRI.
Hospitals Tackle Unedited Copy/Paste
Published on: 1/27/2020
ACPA BOD member, Dr. Alvin Gore, illustrates his efforts in the 1/27/2020 edition of Report on Medicare Compliance (page 4).
Honoring Hirsch’s Heroes for the Holidays
Published on: 12/19/2019
Congratulations to the 2019 Hirsch's Heroes - including ACPA member Alexander Ogedegbe MD, CHCQM! Read all about their contributions to our field in this RACmonitor article from Ronald Hirsch, MD, FACP, CHCQM, CHRI.
I’m in a New York State of Sepsis
Published on: 12/9/2019
ACPA BOD member and #CDI Committee co-chair Erica Remer, MD, FACEP, CCDS proposes early detection and successful treatment of SIRS + infection to prevent life-threatening organ dysfunction due to dysregulated systemic host response does not equate final diagnosis of #sepsis in this ICD10monitor article.
News Alert: Day of Reckoning Has Arrived for Discharge Planning Conditions of Participation
Published on: 12/2/2019
The new CMS Discharge Planning Conditions of Participation are now live, but that doesn't mean hospitals will find them achievable. According to ACPA Advisory Board member Ronald Hirsch, MD, FACP, CHCQM, CHRI in this RACmonitor article.
The Intersection of Veterans and the SDoH
Published on: 11/13/2019
ACPA member and NPAC 2020-slated speaker, Ellen Fink-Samnick, MSW ACSW LCSW CCM CRP details in RACmonitor how veterans are increasingly identified as impacted by Social Determinants of Health (#SDoH).
Region 4 CMS Input on Medicare Advantage Plans
Published on: 11/12/2019
The South Carolina Hospital Association (SCHA) and members recently met with Region 4 CMS to discuss CMS governance of Medicare Advantage (MA) Plans. This is an issue that has been discussed often in our Physician Advisor (PA) community. Concerns by PAs relate to prolonged observation requirements, delays in payment, volume of denials and incorrect clinical validation audit findings by MA plans. In order to get the issue of MA plan governance elevated, CMS needs...
New CC and MCC Designation Technology Explained by CMS
Published on: 10/26/2019
ACPA BOD member and CDI Committee co-chair Erica Remer, MD, FACEP, CCDS describes in ICD10monitor how CMS explained recently during a conference call focusing on CC and MCC designation methodology, how they asses what CC designation a given diagnosis should have.
Does using SIRS to diagnose sepsis improve mortality?
Published on: 9/30/2019
ACPA BOD member and CDI Committee co-chair Erica Remer, MD, FACEP, CCDS wonders (as do many across the country) if diagnosing and treating sepsis early truly saves lives. Read more in this ICD10monitor article.
Why it’s not About the Documentation
Published on: 9/26/2019
ACPA member Kathy Seward, MD explains in this RACmonitor article how the most valuable communication and education occurs in person and not electronically.
Opinion: Judge Ezra got the Baylor Case Right
Published on: 8/27/2019
ACPA BOD member and CDI Committee co-chair Erica Remer, MD, FACEP, CCDS outlines her thoughts about the recent court decision to dismiss a False Claims Act lawsuit against Dallas-based Baylor, Scott & White Health in this ICD10monitor article.
Observing the Rules for Observation After Outpatient Surgery
Published on: 11/26/2018
ACPA board member Dr. Juliet Ugarte Hopkins provides some much-needed updating to a classic article from ACPA founding member Dr. Steve Meyerson originally printed before the Two-Midnight Rule.
Total Knee Arthroplasty Gets (Even More) Confusing
Published on: 11/14/2018
ACPA board member Dr. Juliet Ugarte Hopkins discusses how "Outpatient" does not mean "same-day.
Understanding the Clinical Diagnosis of Sepsis-3
Published on: 11/5/2018
ACPA President Dr. Edward Hu explains how lack of a SOFA score does not rule out sepsis.
HFMA Offers ACPA Member Discounts on Educational Activities
Published on: 9/8/2018
HFMA Business of Health Care ® Online Program
and
HFMA Revenue Cycle Conference, October 21-23, Denver CO
A Novel Approach to Hospital Efficiency
Published on: 8/15/2018
The status of the post Affordable Care Act landscape, including the fate of the American Health Care Act and the Better Care Reconciliation Act, remains uncertain. Nevertheless, continuation of recent years’ overall healthcare trends seems assured. Guided by public policy, downward pressure on payments and resultant revenues will continue. Alternative payment schemes will be pursued with an emphasis on...
Physician Advisor: Critical Player in Payer Contracting
Published on: 9/27/2017
As the bridge between the frontline troops and the payers, Physician Advisors must be familiar with the terms of their facilities’ contracts and, preferably, involved in negotiation of their terms.
Physician Advisor Return on Investment Tool
Published on: 9/25/2017
Elizabeth Lamkin provides a great ROI tool that can be used to track return on a Physician Advisor Program.
ACPA Response to 2018 IPPS Proposed Rule
Published on: 7/12/2017
In the 2017 Inpatient Prospective Payment System (IPPS) proposed rule (CMS-1655-P) the Centers for Medicare and Medicaid Services (CMS) requested input on ideas that would make regulations less burdensome and more transparent. We appreciate this effort. Our “all inpatient” proposal is aligned with these goals.
Physician Advisor Program Metrics
Published on: 7/2/2017
The success of Physician Advisor (PA) programs in quality improvement, margin protection and regulatory risk reduction has led to the identification of measureable metrics to evaluate and monitor a PA program. This article will provide an overview and examples of how to measure success and how to use metrics to sustain improvements.
Response to RFI for 2017 MAO Transformation Ideas
Published on: 4/24/2017
The American College of Physician Advisors (ACPA) appreciates the opportunity to respond to your RFI soliciting ideas to better achieve transparency, flexibility, program simplification, and innovation in the administration of Medicare Part C.
Strengthening Physician Advisor Engagement in the CDI Process to Decrease Your Unanswered Query Rate
Published on: 4/1/2017
Comprehensive yet pertinent documentation is critical within the medical record. Far beyond coherent communication of data and insight between medical providers caring for a patient, good documentation also allows for accurate representation of patient severity in quality data, and appropriate coding, billing, and reimbursement.
Collaboration with Your Contracting Office Provides the Rules for Status Games
Published on: 4/1/2017
Most of us understand the Medicare Two-Midnight Rule. Whether anticipation of two midnights of medically-necessary care in the hospital at the time of admission, or expectation of a second, medically-necessary midnight the day following admission after a first midnight has passed, we get it. For the most part, it’s become pretty engrained in our psyche.
Five Steps To A Productive 2017
Published on: 2/1/2017
With the start of 2017, I thought I would present something completely unique and un-tried.

Reflections on lessons learned in 2016.
Feather Ruffling and Trail Blazing Required:
Published on: 12/1/2016
Why your search for a physician advisor should not be internal

Now that most health systems are aware of the profound, positive impact a physician advisor can make in the case management, utilization, and clinical documentation improvement (CDI) arenas, hospitals are scrambling to find the perfect candidate. This search inevitably begins with one question: “Hire from within, or recruit an outsider?”
The RAC Tsunami on the Horizon
Published on: 1/30/2013
If you think the RACs are gone, think again. The next wave is about to hit like a tsunami. We believe that the RAC auditors have been taking the easy path to money and flying under providers' radars with automated reviews...
CMS and Contractor Audit Survival Calls for a Strong Offensive Team
Published on: 8/9/2012
As reported on www.RACmonitor.com, by the third quarter of 2011, Recovery Auditors (RAs) were behind in terms of projected recoupments from providers and were relying heavily on automated reviews. With these shortfalls...
Hope in a One-Page Letter: Congress to GAO
Published on: 7/10/2012
This is the second of two articles on this subject appearing in the July 12, 2012 edition of RACMonitorEnews. See Janis Oppelt’s article, “ Congress Directs GAO to Study CMS’s Processes for Multiple Medicare Audits.”
Keeping Track of Your RAC Activity: Let Nothing Fall through the Cracks
Published on: 6/22/2012
In the same way that you wouldn't manage your patient flow without a sound registration system, you shouldn't manage your RAC program without RAC tracking software. Tracking software can help you keep up with medical record requests and appeal...
Need a Silver Bullet? Try Adding a Physician Advisor
Published on: 3/13/2012
Your hospital probably has a chief medical officer (CMO) or vice president of medical affairs (VPMA) who attempts to manage a myriad of relationships in the organization - bridging the gap between the physicians and the dreaded administration, providing...
Crew Resource Management: Improving Patient Safety
Published on: 2/12/2012
In 1970 the aviation industry was experiencing an extremely high accident rate resulting in nearly 2,500 fatalities for every one million flights. Over 80% of those accidents were a result of pilot error. Advancements in technology reduced airline...
HIPAA Compliance Audits: The Newest Risk for Providers?
Published on: 2/1/2012
Providers now have yet another form of oversight to worry about: the HIPAA Compliance Audit Program. In 2011, the Office of Civil Rights (OCR) extracted a few massive settlements and fines for HIPAA violations...
Medicaid RAC Effective January 1, 2011
Published on: 12/1/2011
Trouble comes in threes! First, just as providers were getting Medicare RACs (now RAs) under control, Medicare Administrative Contractors (MACs) got thrown into the mix, which is confusing communication between RAs, MACs and providers. Second, the new Medicare Statement...
More Complex Reviews Expected from the RACs
Published on: 10/4/2011
If you read our last article, “The RAC Tsunami on the Horizon,” you know that The Centers for Medicare & Medicaid Services (CMS) will be pushing the RACs to make up for a projected $307.5 million shortfall from the agency’s financial goal for 2011...