Archive for May, 2016

May 27, 2016

Memorial Day: A Time to Reflect

As we pack the car for the long weekend trip or get the BBQ ready for a barrage of goodies, it is also an opportunity to stop and reflect upon the origin of this holiday.

In our busy lives it is easy to take for granted all the freedoms and luxuries our nation affords us and the men and women who sacrificed the most to ensure we keep those freedoms.

Memorial Day is not just a day off from work. Memorial Day is a reminder of bravery, a reason to stop and honor those we lost…ones we loved and those we never met. Our fallen service-members have earned our eternal gratitude for their heroic sacrifice. And along with the soldiers, sailors, airmen and marines, we should recognize and celebrate others who worked beside them– photographers, writers, doctors and nurses. There were many in the trenches and all of them should be remembered on this day.

So in the midst of your day off, take time to lift a glass or tip your hat and reflect on the meaning of this special day.

God Bless America

May 26, 2016

The Only Good GEMS Are The Ones We Wear

Remember when physicians were granted a ‘grace period’ of sorts to be able to code unspecified codes? The rest of us have had to deal with lack of documentation, payers that reject unspecified codes, prepayment reviews and medical review policies.

diamond 1
Well, that grace period ends October 1, 2016. And while we may think of the celebrations we’ll have when, all of a sudden, physicians begin specifically documenting what they mean, what we are seeing is unspecified codes when specific documentation is present.

CoDR (pronounced Coder) has found through many audits that the most common error made by coders is choosing unspecified codes, when the documentation is actually there so that the coder could have chosen a more specific code. Now, why is that? My theories:

1. Agencies have chosen to use the GEMs (Generally Equivalent Mappings) developed by Medicare. Medicare developed those GEMs to assist us in learning coding. They were NEVER meant to be a substitute for correct coding. Many EMRs included the GEMs, and EMR clients and salespeople alike touted the convenience of having a map from ICD-9- CM to ICD-10- CM. The problem with those GEMs is they often point to the unspecified code. I always say “they may get you to the right neighborhood, but not to the right house.” CMS has warned us NOT to use GEMs, but to “native code” (which makes me visualize those pictures in the National Geographic magazine I used to sneak a peek at as a kid). Using GEMs or mappers to code leads to inaccuracy and, in time, CMS will note trends and change medical review policies and case mix scoring to the industry’s detriment.

2. Coders are in a hurry. They jump on the first mention of a diagnosis and do not search further for more information. Now why are they jumping on the first mention of the diagnosis? Productivity standards, payment by the assessment, a lack of confidence in the documentation all could be reasons.

Collection of glass gems with green in center

The American Health Information Management Association (AHIMA) has some advice on how to assess a medical practice’s ICD-10 specificity and I think this advice works well for home health agencies and hospices as well, so I’ve added to it.

1. Run reports of top ICD-10 diagnosis codes, paying particular attention to identify unspecified codes. How often are unspecified codes assigned?

2. Conduct analysis of diagnosis codes assigned by clinician and/or coder to identify any patterns or trends in unspecified ICD-10- CM (diagnosis) coding. Drill down into trends in using unspecified codes. Are there patterns?

3. Review clinical documentation:

a. If more specific diagnosis codes can be assigned based on the documentation, provide education to the appropriate staff on proper code assignment. Review the documentation in question. Was there specific information available? Were the appropriate physician queries made?

b. If documentation is not complete for desired level of diagnosis specificity, provide clinical documentation improvement education to clinicians and intake personnel so that the appropriate queries can be made. Is the EMR being used making appropriate recommendations or is there faulty logic involved?

c. Hire a coding company, such as CoDR, to audit your coding to see where your trends are and provide education to correct those trends. CoDR can help you by providing a detailed report of the findings along with rationale.

What else should you do?

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Hire a Credentialed Coding Professional

The importance of a competent and credentialed coding professional to tighten ICD-10 coding practices and establish a compliant coding program cannot be understated. Options are to 1) employ a credentialed coder directly through your agency, 2) train a current employee, or 3) contract with an outsource coding company, such as CoDR.

We can help you with all three! Selman-Holman will be adding an employment opportunity section to the website soon.

Selman-Holman provides the most highly acclaimed home care and hospice training for ICD-10- CM in both on-site and on-line media. Visit and/or for available courses.

Contracting with an outsource company may be the best option for a quality coder. Although, we hope you contact CoDR for your coding needs, any coding company should answer these questions:
1. Are all the coders HCS-D certified? If so, what score did they obtain?
2. Did the coders receive mentoring or training prior to being assigned?
3. Will the same coder(s) be assigned or will coders be assigned randomly?
4. Is there a quality assurance audit process in place to assure the coders maintain the high standard CoDR expects?
5. How do your coders get continuing education and get updated in changes to coding guidance?

Looking Ahead

Home health agencies and hospices face two final coding challenges in the year ahead: a plethora of new ICD-10 codes and a “fluid” ICD-10- CM environment in which the powers-that- be are constantly challenged to make sense of the codes once we started using them. October 2016 brings a flood of new ICD-10 codes as CMS thaws a three-year partial code freeze. There are nearly 2,000 new ICD-10- CM codes, and that does not include changes to the tabular list instructions and guidelines. While no individual agency or hospice will use all of the new codes, agencies should prepare for the changes ahead. We’ve also had major changes to the meaning of ‘excludes 1’, ‘with’ and 7th characters that even seasoned coders are having trouble wrapping their heads around.

Purple diamondA proactive approach to mitigate unspecified documentation, coding, and billing is the best remedy for post-grace period concerns. Now is the time to consider hiring credentialed coding professionals and/or partnering with coding consultants.

Call CoDR for information on our coding audits and/or coding services. 940.383.2130 or 806.831.4914. Do not use the GEMs…contact CoDR for the true “gems” of coding.

May 23, 2016

Recovery Auditors (RA) and Zone Program Integrity Contractors (ZPIC)

Audits are an inevitable facet of the home health industry. Navigating through them can be daunting but recognizing the most common reasons why they occur and the entities who conduct them can offer understanding to the providers.

Top 10 ADR Denials – PGBA

1. Face to Face Encounter Requirements Not Met (5FF2F)
2. Auto Deny – Requested Records Not Submitted (56900)
3. Info Provided Does Not Support the Medical Necessity “M/N” for this Service (5F041)
4. Info Provided Does Not Support the M/N for this Service (5A041)
5. Physician’s Plan of Care and/or Certification Present-signed but not dated (5F012)
6. Unable to Determine M/N of HIPPS Code Billed as Applicable OASIS not Submitted (5FNOA)
7. Physician’s Plan of Care and/or Certification Present – No Signature (5F01)
8. MR HIPPS Code Change Due to Partial Denial of Therapy (M5CHG3)
9.  MR HIPPS Code Change/Doc Contradicts MO Item(s) (5CHG1)
10. No Plan of Care or Certification (5F023)

There have been issues with Palmetto denying because the Face to Face documentation was not present, however the Face to Face was submitted. The same has happened with other important information, such as the Plan of Care and the OASIS for the episode. Ensure that all pages are numbered and a Table of Contents is supplied to ensure that 1) there is less likelihood of the auditor stating it was missing and 2) it will be easier to appeal. The Texas Association for Home Care and other associations have been in
discussion with Palmetto to try to resolve this issue.

The requirement for the physician to date his/her own signature on orders has been in place for a time now. Stamped dates for the signature will not be accepted.

It is the RAs responsibility to review and correct PAST incorrect payments of providers. They are able to go back 3 years from the date the claim was paid and there are two types of reviews:

Automated (no medical records needed)
Complex (medical record required)

ZPICs can conduct interviews, onsite visits, and request medical records. They can also refer cases to law enforcement if they suspect fraud or abuse.

If you need assistance with audits, medical reviews, or appeals, please contact Selman-Holman & Associates, LLC. 940-383-2130 or 940-300-9974

May 16, 2016

ICD-10-CM is “fluid”!

That was the statement made by a well-known national expert on ICD-10-CM as she was explaining another ‘clarification’ regarding ICD-10. According to the Thesaurus, ‘Fluid’ can mean unsolidified. It can also mean ‘effortless.’ And then there is ‘adaptable,’ ‘unstable,’ ‘fluctuating’ and ‘unpredictable.’ I think ICD-10-CM is all of those (except effortless) and more. It also makes you want to drink hard liquor in order to cope (not really…I have other coping strategies).

The newest shifting in the guidelines has to do with the word ‘with.’ Yes, that’s right, the short little convention found right after “And” and right before “See” and “See also.”

Here’s the convention:

The word “with” should be interpreted to mean “associated with” or “due to” when it appears in a code title, the Alphabetical Index, or an instructional note in the Tabular list.

The word “with” in the Alphabetical Index is sequenced immediately following the main term, not in alphabetical order.

Now, here’s the fluid part…When the word “with” appears with indented sub-entries or essential modifiers underneath, that means that the classification assumes a relationship. No physician documentation is required to connect those two conditions! Example:

Diabetes, diabetic


Arthropathy NEC
Autonomic (poly) neuropathy
Charcot’s joints
Chronic kidney disease

And so on…

That little word has big implications. It means that there is an assumed relationship between diabetes and gangrene, diabetes and ulcers, diabetes and neuropathy, to name a few. All of those times we used two codes because we could not get confirmation that the manifestation was caused by diabetes? We could have been using the combination code instead.

The only time we will not code the condition as caused by diabetes is when there is documentation from the physician that indicates there is another cause for that manifestation. For example, if the physician says the ulcer is a stasis ulcer, then that is NOT a diabetic ulcer. And if unclear, always query the physician.

The Coding Clinic thought they had cleared this up with their 1st quarter publication, however they have been inundated with questions. They will be issuing further clarification in the 2nd quarter publication of The Coding Clinic in June. In the meantime, AHIMA provided the clarification in writing.

So there you have it. Check your alphabetical index before assigning a diabetic code that includes the manifestation. There are some that are not there, e.g. osteomyelitis. That one requires physician confirmation.

May 11, 2016

Happy Nurses Week!

Happy Nurses Week to all past, present, or soon to be nurses!

In Honor of Nurses Week, here is an article from the American Nurses Association that outlines a brief history on the progression of Nurses Week in the United States. Also included in this post is a link that highlights 20 facts about nursing. If you have any others that you would like to add, please comment.


Nurse Week