Newsletter

RAPS Data Integrity Audit

By Richard Schamp, MD

Chief Executive Officer, Capstone Performance Systems

We have been describing multiple aspects of risk adjustment compliance in our newsletters, along with helpful tips on documentation and coding. CMS requires PACE, Medicare Advantage and similar organizations to submit all relevant diagnosis codes at least once yearly. A “relevant” code is one that impacts Part C or Part D payment. Failure to submit all relevant codes is an important compliance issue. To help our clients with the dual challenges…

10 May

Documenting and Coding Nephropathy and Chronic Kidney Disease

in Articles Clinical Documentation Excellence Newsletter Uncategorized | tagged: coding chronic kidney disease coding CKD coding nephropathy documenting CKD

By Richard Schamp, MD
CEO, Capstone Performance Systems

Definitions
Nephropathy refers to any disease of the kidney. In common clinical parlance, the term is modified by an etiology referring to one of over a dozen types, such as analgesic nephropathy, gouty nephropathy or most commonly, diabetic nephropathy. Chronic Kidney Disease (CKD) is defined by GFR (Glomerular Filtration Rate) less than 60 ml/min per 1.73 m2 and/or kidney damage for three or more months. The presence of albuminuria is most commonly used to…

10 May

Documenting Functional Quadriplegia

in Articles Newsletter Uncategorized | tagged: coding functional quadriplegia documenting functional quadriplegia functional quadriplegia HCC

By George W. Brett, MD

Chief Medical Officer, Capstone Performance Systems

It is unlikely that a clinician would overlook properly documenting a patient with neurologic quadriplegia resulting from a cervical spine injury. However, somewhat less obvious might be functional quadriplegia that results from a patient’s severe weakness. This condition is the inability to move due to disability or frailty caused by another medical condition but not from direct physical injury or damage to the brain or spinal cord (ACP Hospitalist Coding…

10 May

How Past Conditions Affect Current Documentation and Coding

in Articles Clinical Documentation Excellence Newsletter | tagged: Capstone Performance Systems coding history of documenting history of documenting past conditions

By Jan Deyber, CRN-C, and Tiffany Brookshire, BSN, CRN-C

We often see inconsistency in medical records regarding diagnoses as current or historical. Documenting “history of” when referencing a patient’s past medical background is a longstanding practice. Providers may intend a “present perfect” tense – a condition that started in the past and continues in the present. However, in the world of diagnosis coding, “history of” indicates a past (or past perfect) tense; in other words, a condition that no longer…

28 Mar

Changing Documentation in the Medical Record

in Articles Clinical Documentation Excellence Newsletter

by Richard Schamp, MD, Chief Executive Officer

When documenting in the medical record, providers should take care to capture their thoughts and findings as completely as possible. Best practice is to document the patient encounter at the time, or shortly afterwards. Inevitably, situations require some changes in the medical record, of which four types are recognized. (more…)

28 Mar

New ICD-10 Guidelines for the Term “With”

in Articles Newsletter | tagged: Capstone Performance Systems CMS Encounter Data Reporting System (EDRS)

by Katina Yablinsky, CRN-C

In October 2016, there was an update to the ICD-10 coding guidelines that allows a coder more flexibility in assigning certain codes. Previously, the guidelines stipulated that if two conditions are related to each other, the provider needs to document their relationship for them to be coded as such. (more…)

28 Mar

ON TARGET: Senior TLC

in Articles Newsletter

On Target recognizes a client who is showing process improvement from putting Capstone’s processes and advice into action.

Pain points
ICD-10 was the tipping point. CMS’s implementation of the new edition of the coding system was the point of no return for Senior Total Life Care (STLC), a PACE organization serving 175 participants in a rural area less than 20 miles outside of Charlotte, North Carolina. (more…)

24 Mar

Dr. David Wilner Joins Capstone Performance Systems

in Newsletter Press Releases | tagged: Capstone Performance Systems David Wilner MD

David Wilner, MD, FACP, AGSF, has joined Capstone Performance Systems as senior medical consultant. A clinical professor at University of Massachusetts Medical School, Dr. Wilner previously served as medical director and vice president of Summit ElderCare and Fallon Health and as coordinator of geriatric medicine training at St. Vincent’s Hospital in Worcester, Mass. He is a past member of the National Pace Association (NPA) board of directors and former chairman of the NPA’s…

22 Dec

Medical Necessity and Internal Auditing Compliance

in Articles Newsletter

by Richard Schamp, M.D., C.M.D., C.H.C.Q.M., Chief Executive Officer

Several times in 2016, my comments in this column have emphasized elements related to corporate compliance with regulations and rules governing documentation and coding. As 2016 comes to a close, I wish to share two key messages from a recent compliance and auditing conference.

Listening to presentations from several prominent healthcare lawyers, I was reminded of the priority (which we have mentioned repeatedly here) for all healthcare organizations, especially health plans, to have…

22 Dec

Ulcers: Pressure and Non-Pressure (Chronic)

in Articles Newsletter

by Angie Hlad, CRN-C

When documenting ulcers, it is important to clarify if the ulcer is a pressure or non-pressure ulcer. When a provider only documents the stage of the ulcer, such as “stage 2 ulcer, left heel”, it is does not provide enough information for the coder to determine the proper code assignment. Once the provider makes the determination of chronic non-pressure or pressure ulcer, it should be documented as such. The documentation for these two types of ulcers…

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