Rayellen Kishbach's blog

Claims Adjudication and Payer Rules under ICD-10

Rayellen Kishbach's picture

Because we process thousands of LCDs updates weekly for our Coding Suite, we often get some insights that we can share. With the implementation of ICD-10, a significant drop off in the number of local coverage determinations (LCDs) and coverage articles published by the Medicare Administrative Contractors (MACs) has occurred. (See table in the white paper link below). While this may be partly due to MAC consolidation, it has left providers with less guidance than before about the proper coding and billing of covered services.

How health care economics teams communicate with payers (and other healthcare entities)

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In January 2017, the FDA released draft guidance specifying the nature of communications between manufacturers and payers: The first draft guidance, entitled “Drug and Device Manufacturer Communications with Payers, Formulary Committees, and Similar Entities--Questions and Answers,” provides answers to common questions regarding communications of health care economic information (HCEI) about their approved prescription drugs to payers.

Keeping up with MS-DRG Revisions

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CMS has issued two errata and correction notices for how MS-DRG logic functions in FY2017. These changes may impact payment. This article highlights a few examples.

It is important to note that CMS published v34 r2 in time for implementation on 10/1/2016, but the v34 r3 was released after claims for FY2017 had begun, so improper payments may have occurred.

Understanding non-covered codes – help for denials management and pre-payment review edits

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Wouldn't it be great if there was just ONE LIST of procedure codes published somewhere by Medicare to identify non-covered services? Unfortunately, there isn’t one, but a quick review of the information that is provided by Medicare can get you there.

Supporting Compliance in the New World of Remote and Outsourced Coding & Billing.

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According to a recent HIM Benchmark Report, HIM department managers equally ranked Coder Productivity, Quality, and Managing Financial Metrics as their biggest challenges, while that same report noted that close to 60% of HIM professionals outsource a portion of their coding needs. Even without direct outsourcing, we notice an increase in the opportunity to do coding and billing work remotely.

Understanding MS-DRG Grouping under ICD-10

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Now that ICD-10 is in full swing, we are seeing a lot of activity with providers, payers, consultants and regulators who need to understand how Acute Inpatient and Long Term Care Hospital claims "behave" when the claim is coded in ICD-10. This includes both prospective and retrospective review of claims scenarios to understand MS-DRG grouping. This article offers a basic primer on MS-DRG grouping logic, and research techniques for using related MediRegs Coding Suite tools.

How we can help you "Ramp Up" your ICD-10 Operations

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On July 31, 2014, CMS announced that the U.S. Department of Health and Human Services (HHS) issued a rule finalizing Oct. 1, 2015 as the new compliance date for health care providers, health plans, and health care clearinghouses to transition to ICD-10. According to CMS:

"This deadline allows providers, insurance companies and others in the health care industry time to ramp up their operations to ensure their systems and business processes are ready to go on Oct. 1, 2015."

How do Medical Review professionals keep up?

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The ever-increasing pace of healthcare benefit and coverage policy change makes it harder than ever for medical review professionals to make quick, completely informed policy and reimbursement decisions. Without the right information and tools, your organization’s exposure to risk increases. This risk is multiplied when you have to monitor and comply with updates across multiple states.

Understand Local and National Coverage with MAC Coverage Articles

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We know understanding Medicare coverage is a challenge, and we've just made this challenge easier by upgrading all of our health care products to include Medicare Administrative Contractor (MAC) Local Coverage Articles. These articles can provide a deeper explanation of the MAC Local Coverage Determination (LCD) logic, or explain special topics like non-covered services, self-administered drug lists, coding rules for National Coverage Determinations (NCDs) and more.

Demystify Inpatient Reimbursement with Simple Tools

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Understanding the Inpatient Prospective Payment System can be quite a challenge (see below for key references!), but MediRegs subscribers can know right now with our MS-DRG electronic codebook, MS-DRG Grouper, and MS-DRG Calculator. We’ve recently released a significantly improved provider-specific MS-DRG calculator, powered by New Health Analytics. This calculator demonstrates MS-DRG payments under the Inpatient Prospective Payment System and includes the following enhancements:

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