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Background and Objective: Hospital-acquired catheter-associated urinary tract infection (CAUTI) is one of the first 6 conditions Medicare is targeting to reduce payment associated with hospital-acquired conditions under Congressional mandate. This study was to determine the positive predictive value (PPV) and sensitivity in identifying patients in Medicare claims who had urinary catheterization and who had hospital-acquired CAUTIs., Research Design: CAUTIs identified by ICD-9-CM codes in Medicare claims were compared with those revealed by medical record abstraction in random samples of Medicare discharges in 2005 to 2006. Hospital discharge abstracts (2005) from the states of New York and California were used to estimate the potential impact of a present-on-admission (POA) indicator on PPV., Results: ICD-9-CM procedure codes for urinary catheterization appeared in only 1.4% of Medicare claims for patients who had urinary catheters. As a proxy, claims with major surgery had a PPV of 75% and sensitivity of 48%, and claims with any surgical procedure had a PPV of 53% and sensitivity of 79% in identifying urinary catheterization. The PPV and sensitivity for identifying hospital-acquired CAUTIs varied, with the PPV at 30% and sensitivity at 65% in claims with major surgery. About 80% of the secondary diagnosis codes indicating UTIs were flagged as POA, suggesting that the addition of POA indicators in Medicare claims would increase PPV up to 86% and sensitivity up to 79% in identifying hospital-acquired CAUTIs., Conclusions: The validity in identifying urinary catheter use and CAUTIs from Medicare claims is limited, but will be increased substantially upon addition of a POA indicator.

A deficit situation prompted Hôtel-Dieu Grace Hospital in Windsor, Ontario to examine aspects of the funding process. A review of charts suggested that the documentation in the patient record did not accurately reflect the care given. Improving the documentation could potentially improve hospital revenue. This approach has been successfully used in the U.S., but is not reported to have been implemented widely within the Canadian setting. Coached by an American team, three experienced nurses were trained to work with physicians to explore opportunities to improve their documentation, and to work with the Health Records Technicians to optimize the accuracy of their efforts. Results demonstrate that such an initiative could impact behavioural changes in the hospital setting, and that such changes could impact hospital revenue. Realizing that front-line staff could actively participate in financial recovery was very empowering.

Internal chart reviews are useful tools for practices to determine the accuracy of their coding when billing for services, especially to governmental payers. They can also boomerang, however, and be used as evidence against a practice when their results are not fully understood or implemented. This article provides some guidance to help practitioners realize the fuller value of chart reviews in terms of over- and under-coding, adequacy of documentation, and attorney-client privilege.

This analysis was performed to examine whether Medicare claims accurately document underlying rheumatologic diagnoses in total hip replacement (THR) recipients. We obtained data on rheumatologic diagnoses including rheumatoid arthritis (RA), avascular necrosis (AVN), and osteoarthritis (OA) from medical records and from Medicare claims data. To examine the accuracy of claims data we calculated sensitivity and positive predictive value using medical records data as the "gold standard" and assessed bias due to misclassification of claims-based diagnoses. The sensitivities of claims-based diagnoses of RA, AVN, and OA were 0.65, 0.54, and 0.96, respectively; the positive predictive values were all in the 0.86-0.89 range. The sensitivities of RA and AVN varied substantially across hospital volume strata, but in different directions for the two diagnoses. We conclude that inaccuracies in claims coding of diagnoses are frequent, and are potential sources of bias. More studies are needed to examine the magnitude and direction of bias in health outcomes research due to inaccuracy of claims coding for specific diagnoses.

Introduction: The aim was to investigate the consequences of missing or wrong diagnoses and procedure codes in relation to the DRG system., Material and Methods: All patients admitted to the orthopaedic department during the course of one week, 155 patients, were consecutively entered. Former diagnoses were registered from interviews with all the patients, former case notes, and present hospital records. They were then compared to the department case notes, including diagnosis and procedure codes. All codes were then compared in Visual DRG (version 97) for grouping., Results: The coding was correct in 103 of 155 cases (65%). In 52 cases (35%) the coding was incorrect or insufficient, in 18 of the 52 cases (12% overall) it lead to a decrease in the DRG value, which extrapolated on a yearly base, would lead to a loss of DDK 23 million. In total, coding was incorrect or insufficient in one third of the records., Discussion: Irrespective of whether the DRG system is implemented or not, it is important that departments register the correct diagnoses and procedures, not only those relevant to the department. There is a continued need to teach and inform the staff about the correct coding procedures.

A new ambulatory payment classification code was created for observation, with a payment rate of $351. Three diagnoses qualify for reimbursement: congestive heart failure, chest pain, and asthma. Active physician involvement in assessment and writing orders is required. Nurses should document the time when physician orders were started.

The complexities associated with the coding, billing, and reimbursement process seem to increase daily. Keeping abreast of the changes in this environment is, to say the least, a challenge. To succeed in today's billing environment the gastroenterologist should surround his or her practice with staff, resources, and education. Experienced skilled staff, preferably a certified professional coder should be employed. Certified coders bring advanced coding skills to ones practice, which allows increased proficiency with the coding and billing process. Provide the necessary resources for staff. Current coding material is crucial to the financial success of the practice. CPT-4, ICD-9, and Correct Coding Guide are the bare basics of the resource material available to staff. Maintaining a library of resource material (i.e., Medicare bulletins, managed care newsletters, and so forth) aids the staff with the necessary tools to carry out their duties. In addition, specific gastroenterology coding subscriptions are available to assist in staying ahead of the ever-changing billing and coding environment. Continuing education in the billing and coding process for both the physician and staff is essential. Numerous workshops are offered periodically. It is imperative that staff attends all Medicare-sponsored workshops in addition to gastroenterology-specific coding seminars. More and more physicians are now aware of their responsibility in the billing process and have begun to participate in the coding education along with their staff. This is a significant indicator of a physicians' intent to have a compliant and financially successful practice.

Episode creation, the task of classifying medical events and related clinical data to a high-level concept, such as a disease, illness or care, has been primarily an interest of healthcare payers for purposes of cost outcomes analysis. Traditional challenges in episode creation have included: inconsistencies in defining episodes; lack of sufficient information to infer episodes; and differences in methods for diagnosing and resolving episodes. However, with the advent of the electronic medical record, which contains multiple sources of patient-related information, data is now accessible to construct more accurate and refined episodes. This work presents a context-sensitive episode creation methodology that utilizes features extracted from different medical repositories (e.g., claims records, structured medical reports) to associate the data with their respective motivating episodes. The combinatorial approach used to find the optimal clustering of patient-related data into episode groups and the measure used to evaluate candidate episode sets are described.

Unlabelled: BACKGROUND AND QUESTION: In contrast to the per-day-reimbursement specific data like diagnoses, procedures and demographic data of the patient is needed for a per case reimbursement with Diagnosis Related Groups (DRG). Coding errors can have great impact on the height of the reimbursement. A review of the extent and the causes of coding problems does not exist at present., Methodology: A systematic search in Medline using the search words >>coding<< and >>error<< and >>hospital<< was performed. Only articles with quantitative evaluation, written in English or German, were included. Literature cited in the articles was included as well., Results: A total of 33 studies (53 113 cases) were identified. An average of 23 % of cases was showing coding problems. Eighteen percent of the cases were assigned to a wrong DRG. Regarding the date of publication no effect in the extent of the coding accuracy could be detected., Conclusion: An appreciable rate of cases with coding problems should be anticipated when introducing DRG. Training to improve coding accuracy is recommended. Whether coding should be a task of the ward or the management of the hospital could not be decided here, but it should be noted that this assignment of the coding task has major impact on the allocation of competence in the long run.

You've adapted processes to the APC system, but do you really understand the financial impact of APCs on your organization? The author shows you how to analyze your billing data to assess the impact of APCs on your facility's bottom line.

Developing a compliance plan for a small physician practice can be easier than you'd think. The author offers six things HIM professionals can do to ensure a practice's compliance.

After examining their charge description master management processes, HIM professionals, in conjunction with clinical and support departments, redesigned and automated several practice aspects. Turnaround times were reduced and end users are happier. Here's how they did it.

A good audit program can save a provider from sanctions or fines. Whether you work on the hospital or physician side, here are some tips for better auditing practices.

This discussion includes only 20 percent of the modifiers available for physician reporting, but could account for 80 percent of modifiers assigned for physician services. Modifier -91 was the only new modifier introduced in CPT 2000 and it is used to report a repeat clinical diagnostic laboratory test. It is not to be used when confirming initial results or for any other reason other than a clinical need to repeat the test for the same patient on the same day. Success with CPT modifier reporting requires a thorough review of CPT guidelines and some detective work for identifying health plan requirements for modified codes.