Blog and Helpful Articles

What We’re Reading – How to get your behavioral health codes right

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (DSM-5, in medical parlance) is a handbook, if you will, to assist in making diagnostic judgments in cases of mental disorders.  The manual classifies conditions and provides diagnostic criteria in addition to medical codes from the International Classification of Diseases (ICD-9).   The DSM-5 released in 2013 includes both ICD-9-CM codes which are currently in use, and also features the relevant ICD-10-CM codes to prepare clinicians for the code-set transition later this year.

Although the behavioral health sector will not experience the vast increase in codes as, say, the field of orthopedics, mental health professionals still need to be familiar with the coding intricacies of these diagnoses and the changes posed by ICD-10. Not only is the actual code different in ICD-10 but the guidelines for coding certain diagnoses may have also changed. For example, ICD-10 includes combined codes for alcohol use and its related conditions such as hallucinations or withdrawal. Understanding the changes and proper education of clinicians and staff will minimize revenue disruptions.


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What We’re Reading – Improve Clinical Documentation for ICD-10

Your administrative staff has probably hounded you for years to improve your documentation.  With the ICD-10 transition around the corner on October 1, 2014, clinician documentation will be more important than ever.  The code sets from have expanded from 14, 400 codes in ICD-9 to 70,000 codes in ICD-10.  The main reasons for such the huge increase are the specificity that will exist, in addition to specifying laterality and causality – just to name a few.

For example, for the diagnosis of diabetes mellitus, the number of codes grew from 69 ICD-9 codes to 239 ICD-10 codes.  For fractures, the number of codes went from 747 ICD-9 codes to 17,099 in ICD-10.

Get a jump on the transition by improving your documentation, and by reading this useful article. Your bottom line is only as good as your documentation.

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How is the ICD-10-CM Code Set Different from ICD-9-CM?

ICD-9 codes have between three and five characters, and with the exception of “V” and “E” codes, are exclusively numeric.  The fourth or fifth character is utilized for greater specificity and combinations of diagnoses are coded separately.  One example is diabetes with polyneuropathy which codes as 250.6x and 357.2.  It would be incorrect to code 250.0x for a diabetic patient with neurological manifestations.  In ICD-10-CM, this diagnosis would be coded as E08.42   Diabetes mellitus due to underlying condition with diabetic polyneuropathy because the new code set introduces combination codes.  When a condition has associated symptoms and/or manifestations, ICD-10 has created one code to encompass several diagnoses.

That ICD-10 code certainly looks different from what we’ve become accustomed to, right?  That’s because ICD-10 makes substantial changes to the appearance of codes.  Although some of the general coding characteristics and categories (called chapters) remain the same, ICD-10 adds some interesting twists:

  • ICD-10 codes have between three and seven characters.
  • ICD-10 codes always begin with an alphabetic character followed by two numeric ones. All alpha characters, except the letter “u,” are included.  (Some codes that contain the letter “I” or “O” followed by a one or zero can appear a little strange, but after some practice, they will seem less so.)
  • The fifth and sixth characters are used for greater specificity, each one increasing the precision of the diagnosis.  Examples are Z67.20  Type B blood, Rh positive and Z67.21  Type B blood, Rh negative.  Some others include: O30.012 Twin pregnancy, monochorionic/monoamniotic, second trimester and L89.022  Pressure ulcer of left elbow, stage 2.
  • The seventh character is called an ‘extension’ and is used to identify the type of encounter or to expand on the nature of the condition (e.g., sequelae, complications, etc.)
  • ICD-10 requires the specification of laterality, which impacts the code selected.  The majority of ICD-10 codes are for the identification of a condition affecting the right, left or bilateral sides.  Examples are: H61.21  Impacted cerumen, right ear and H61.22  Impacted cerumen, left ear, as well as H61.23  Impacted cerumen, bilateral.
  • “X” marks the spot!  ICD-10 uses the placeholder character ‘x’ to occupy one or more spaces in codes where other characters don’t yet exist.  An example is M22.2x2  Patellofemoral disorders, left knee.  Note that laterality is also specified.

General Equivalence Mapping (GEMs) is a system of ‘translation’ that helps to convert an ICD-9 code into ICD-10.  However, GEMs are not considered crosswalks, and it’s dangerous to think they operate like, for example, an English-Spanish dictionary.  Keep in mind that ICD-10 has roughly four times more codes than ICD-9, many of which represent new conditions, more specific aspects of conditions, and combinations of diagnoses/symptoms.  It is best to understand and learn ICD-10’s format and practice using the code set than to rely on shortcuts that will definitely impact your organization’s productivity and profitability.

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What We’re Reading – OSHA Proposes Publishing Worker Injury Data

In 2012, nearly three million people were injured at work, according to The Bureau of Labor Statistics.  A proposed law, announced on November 7th , would require businesses with more than 20 employees to annually file their OSHA 300 form online and report illness and injury records for the calendar year.  OSHA currently requires businesses to complete the OSHA 300 form and post it in their workplace for 90 days so that employees can be informed of the number of workplaces injuries and illnesses.

Under the proposed law, businesses with more than 250 employees would be required to submit these records on a quarterly basis. The objective of this new law is to make the workplace safer with the collection and utilization of this timely submitted data.  To read more about this rule and to see if it will affect your business this article is a great opportunity.   Businesses with fewer than 20 employees will not be required to report the data.

This article provides additional detail.

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Outsourcing: The Key to Mission Control

During a recent dinner presentation, a hospital CEO from another state commented about her NFP’s strong profit orientation and how its sustainment necessitated a critical review of all processes.  The leadership team’s decision was to outsource several functions that are traditionally performed in-house, specifically laundry, environmental and maintenance services.  The CEO commented that she struggled with the decision because outsourcing runs counter to the traditional mentality of a community hospital.  “We had to remember that we’re not a linen company,” she explained. “That’s not one of our core competencies.  We’re a hospital. Providing excellent patient care is our mission.”

The strategic decision to outsource – or insource – is never easy.  It involves the systematic dissection of all the sequential processes and activities involved in the delivery of a product or service – analyzing the organization’s value chain – to identify how and where the organization brings value to its market.  The subsequent analysis should yield areas where costs can be lowered and/or value increased in the quest for a competitive advantage. Often the illusion of control balances perceived cost-effectiveness.  How much of your company’s resources (dollars, time, management) are devoted to activities that support the primary processes that meet your overall mission?  How much value does your organization (and its constituents) receive from that investment of resources?

Deciding whether to outsource doesn’t so much require thinking outside the box, but of blowing up the box and perhaps creating a triangle or a circle.  The exercise turns traditional business on its head in the search for better: better processes, better activities, better value, better efficiency, better quality and better margin.  Some issues to consider include:

  • Often the centralization and economies achieved by outsourcing firms – such as linen, billing or IT companies – allow them to provide your organization with superior, specialized services at a lower cost.  Just factoring personnel costs – the price tag to recruit, hire, train, supervise and compensate the provision of services – can be a huge persuader toward outsourcing.
  • In order to stay competitive with each other and with the organization’s in-sourcing tendencies, these specialized companies need a commitment to continuous education in their field. They have/should have access to the latest technology and stay current on the latest trends in their field, benefits that your organization receives at no additional cost.
  • Finally, contracts with external companies should contain provisions for accountability.  Here, an organization can build performance guidelines into its vendor relationship with less potential for variability than that which occurs in an employment relationship.

Given pressure to continue decreasing overall costs while achieving higher and higher quality standards, scrutinizing your internal value chain might warrant new consideration as you debate whether every single activity adds to your mission or distracts you from it.

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How to Open a Business in the Long-Term Healthcare Industry

Today’s entrepreneurial culture and trends in the long-term care industry have converged into a perfect storm.   The home health field is rife with opportunity for building a profitable business that provides needed, quality and compassionate care.  In response to the questions we receive about how to start a successful agency, we’ve developed webinars that cover the basic requirements for starting your business in this field.

Home health agency (HHA):  HHAs can provide skilled or non-skilled care.  Skilled services encompass care from a licensed professional, such as a nurse or therapist and, if they meet certain requirements, can bill Medicare.  Non-skilled care is limited to helping clients perform activities of daily living (ADLs).  Some agencies provide both skilled and non-skilled services while others limit themselves to the latter.    We have two upcoming webinars that explain the requirements for establishing each type of home health agency.

Nurse registry (NR):   Nurse registries are a “hybrid” type of organization; they can provide both nursing and non-skilled services, but they may not be Medicare-certified.  The requirements to open a NR are less than those to open an HHA, and our upcoming webinar will familiarize you with the steps to launch this type of business.

Homemaker/Companion Service (HCS):  HCS have the least requirements of the three types of Florida businesses and are limited to providing only “hands-off” services.  HCS can offer homemaking services, such as laundry, light housekeeping, meal preparation and errands, in addition to supportive care and assisting clients in maintaining their social connections.  Companions can help clients participate in social outings, pursue hobbies or just keep them company.  If you’d like information about opening an HCS, please call our office.


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What We’re Reading – How to Manage an OSHA Inspection

Does your company have a process for if and when any government agency shows up for an inspection?  If you don’t, we suggest you add this to your priority list for the end of this year because many regulatory agencies are increasing their compliance efforts.  What are your staff members expected to do?  Who will they contact?  Will your organization present a calm, confident air to the inspector, or is there apt to be mass hysteria throughout the office?  Preparation is the key.

If you do have an established process, make sure to retrain staff periodically on their responsibilities and review the plan – perhaps even role-play different scenarios – with all applicable staff members.  Make sure that more than one manager is educated on your organization’s processes so there is always someone knowledgeable on the premises.  There are three aspects to your preparation:

  1. Plan in advance.  As mentioned above, advance planning and communication can go a long way to a less stressful inspection.
  2. Manage the inspection. For this step you need to ask yourself, “Why is OSHA here?”  The compliance officer needs to communicate to you: an applicable standard; a hazard; employee exposure; and that you, as the employer, knew of the violation or hazard, or should have known of it with the exercise of “reasonable diligence.”
  3. Be informed. Don’t just accept citations or a penalty reduction.  If you have legitimate disputes for a citation or penalty, don’t miss the informal conference to defend your case.   For more in-depth reading on any of these issues, check out this helpful article.

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What We’re Reading – Medicare E/M claims for new patients

Beginning on October 1, 2013, CMS will use a new claim edit to determine if more than one initial visit code was billed for a Medicare beneficiary within a three year period.   This edit will also identify claims where established visits were billed in advance of the new patient visit. 

Don’t be alarmed if you begin to receive claims denials and/or recoupment letters because of these edits!  There are a few easy solutions to rectify any problems.  If you receive a denial for an initial visit and, upon review, conclude that it should have been billed as an established visit:

  • Use the Interactive Voice Response (IVR) to have the claim reopened;
  • Submit a new claim; or
  • Request in writing to have the claim reopened.

If you have already received recoupment letters regarding these issues, or have any questions about the new edit, please refer back to FCSO’s article.

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What We’re Reading – Improve Medical Practice Staff Communication Skills: 5 Best Practices

A patient’s first contact with your office is by phone, whether scheduling an appointment and/or requesting information.  If your staff doesn’t have the proper communication skills to create rapport with that patient, established or new, you could be in jeopardy of losing that business and any future referrals they could have provided to you.  When we think about it, the front staff is the first line of communication for your practice and their demeanor is a reflection on you as the provider.  This article supplies you with five ideas to help with choosing, directing, and overseeing your employees.

  • Effective staff selections – Utilize the interview process correctly.  Resist the impulse or pressure to hire “a warm body” and recruit employees who are the best fit for your practice.
  • Proper use of scripting – develop standardized scripts – at a minimum – for simple but common situations, such as greeting patients, collecting insurance information, etc.  That way everyone will be on the same page and reflect the standards you want for your practice.  You obviously can’t create a script for every circumstance, but for the more difficult scenarios, think about using continuous training with staff and even role playing as a form of education.
  • Focus on delivering total communication – pay close attention to the three main components of communication: what you say, how you say it and finally, your non-verbal communications.  Facial expressions and/or body language can speak volumes and perhaps contradict what your words are saying.
  • Analyze telephone communication skills – think about playing “mystery caller” from time to time – or ask a friend to call – and assess how your staff interacts with patients.  This will give you an idea of training needs or other coaching that may be necessary.
  • Take the right approach to training – for a successful practice, you need to provide your employees with the essential skills they need in order to construct lasting relationships with your patients.

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The Importance of Customer Service in the Healthcare Industry

The need for healthcare organizations to be profitable drives the industry to enhance the participation of physicians and other caregivers, to stay abreast of technology and cutting edge changes to stay competitive and to innovate in cutting operational costs.

Where does patient satisfaction and the necessity of providing “world class service” fall into this?  Does the healthcare industry truly feel that patients have a choice in where they seek care? As the Affordable Care Act implementation gets underway with its associated expansion in patient choice, customer service and satisfaction will continue to be a priority for all providers. The Agency for Healthcare Research & Quality reminds that, “CAHPS surveys ask patients to report on their experiences with a range of health care services at multiple levels of the delivery system.”  These surveys ask about the patient’s experience with ambulatory care providers, such as health plans and physicians’ offices, and others ask about experiences with care delivered in facilities such as hospitals and nursing homes. The disincentives for lower than optimal satisfaction scores will continue to escalate, so regardless of the payor, every provider needs a solid customer service program in order to survive.

James Merlino, MD, Chief Experience Officer at Cleveland Clinic, says it well, “Patients are made to feel that, because healthcare is a necessity rather than a luxury, they aren’t entitled to a superior patient experience. And this is probably the biggest mistake our industry makes.” The question becomes where to start and the answer is: in Human Resources. The HR team’s plans and policies must ensure that new hires understand that this is the core of the business.  A few musts to achieving this are: 

• Hiring the right people.
• Informing employees from the start what you expect from them and reinforce it routinely.
• Consistent training.
• Monitoring your employees’ performance.
• Holding staff accountable.
• Rewarding superior performance.
• Monitoring patient feedback and setting benchmarks. 

One last suggestion is to involve the entire organization in the results of patient feedback and reward excellent performance for attaining predetermined goals. Imagine a scenario where every employee in your facility is invested in this goal, and that any patient walking through your facility is greeted with a smile and kind word by every single employee with whom he or she comes into contact.  That’s world class service. 

Every business’s success rests on its customers and in the ability to develop them into repeat customers who “spread the word.” The core of this mandate must be rooted in our talent pool and supported by management in order to succeed.

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