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Welcome to the weekend, and thanks for checking in.

We’re bringing you the news from this past week as well as providing you with a look at the week ahead.

Looking back, here are two big story we have been monitoring this week… 

Developing: The Catch 22 of Reporting Dicey Diagnoses

EDITOR’S NOTE: This summary is from a special bulletin written by Allen Frady, RN, BSN, CCS, CCDS, AHIMA Approved ICD-10-CM/PCS, for RACmonitor on Aug. 16.

What is a facility to do when a physician documents a diagnosis that may be unsupported by the clinical circumstances reflected in the medical record?

There is a section in the guidelines that reads: “the assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.” 

This represents a catch-22. If the diagnosis is not clinically validated, then both Recovery Auditors (RAs) as well as commercial insurance auditors are going to deny the claim. On the other hand, if the coder or the facility decides not to report the diagnosis, then they are in violation of the coding guidelines, which is also a major problem.

Either you violate the coding guidelines or you set yourself up for denials and face financial penalties, which can include being placed on the CMS “naughty list” and dealing with the bad publicity of being on record as having received a large set of denials.

In many cases, the facility’s hands are completely tied. There is no way a health information management (HIM) director or revenue head can go in to work at the start of the day and have any clued what the appropriate policy actually is any more.

However, at the end of the day, the physician is going to document what the physician is going to document, and the auditors are going to deny what the auditors are going to deny. The facility? Caught in the middle. 

And therein lies the contradiction. On the one hand, the conditions of participation for Medicare prevent the reporting of diagnoses that are not clinically validated – but then the coding guidelines turn around and require providers to ignore clinical indicators and report such diagnoses.

Probably the worst kept secret in the healthcare industry is that insurance companies and auditors will just deny more than they should and hope that facilities do not have the resources to maneuver through an appropriate appeal.

At some point in recent years, a lack of clinical knowledge on the part of someone empowered with payment veto power has translated into grounds for rejection. According to this philosophy, I should just be able to declare the Higgs boson an error. I don’t understand it; therefore, I can just declare it incorrect right?

It seems that ignorance isn’t bliss; but it is, however, grounds for saving money. 

CMS Announces PACE: Better Care for Older Adults

EDITOR’S NOTE: Andy Slavitt, Acting Administrator, Centers for Medicare & Medicaid Services (CMS), authored this blog post on the CMS website. The story is relevant to RACmonitor and Monitor Monday since home health is under scrutiny by the Recovery Auditors (RA).

Since becoming acting administrator, I have spoken frequently about to the importance of moving to the next chapter in implementing the Affordable Care Act. This new chapter goes beyond providing people with quality, affordable coverage – but making sure that we are delivering patient-centered care to all consumers at critical stages of their lives. 

What does that look like? It looks like more individualized care – care that allows people to heal, recover, and age in their homes and communities; care that is coordinated so we avoid people falling through the cracks; and care that includes family members and the realities of all the things that impact our health like culture, nutrition, and other social factors. For the growing number of aging and frail Americans, many living with Alzheimer’s, it looks like PACE. 

The Programs of All-inclusive Care for the Elderly (PACE) is a Medicare and Medicaid program that helps people meet their health care needs in the community in which they live instead of a nursing home or other care facility. The focus is on the participant. A team of health care professionals works to make sure that care is coordinated in the home, the community, and at a PACE center.

Today, CMS proposed the first major update to the PACE program in a decade. This proposal will help the program reflect the latest advances in caring for frail elders and changes in the use of technology. 

The goal of this proposal is to strengthen beneficiary protections and provide PACE organizations with more administrative and operational flexibilities so they can do what they do best – caring for our nation’s most vulnerable individuals. While PACE serves a relatively small number of people today, our proposal is intended to encourage states to further expand these programs.

Our proposals aim to offer the kind of common sense supports to allow older adults to get the best care possible. For example, individual care team members would be able to serve more than one role in addressing the wide spectrum of a participant’s needs, rather than just the one role they are permitted to occupy today. This would help better coordinate services, while providing important flexibility to care providers.

We also propose more modern and simplified administrative and operational rules to enhance PACE organizations’ ability to do a number of things more easily, including a more automated application process to speed up and customize services to participants. 

Over the last six years, since the onset of the Affordable Care Act, we have been taking significant steps to care for more people, care for them better, and make health care more affordable. But for us to be successful, we need to work hand-in-hand with patients and their families, physicians and clinicians, and other actors to support new approaches to care. Team-based models that put the individual in the center, like PACE, will be a vital part of the fabric of our system.

We must work hard to support these approaches so our country can continue to provide our people with the care they need in the years ahead.


Chuck Buck

Chuck Buck is the publisher of RACmonitor and is the program host and executive producer of Monitor Monday.

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