Republican Sen. Charles E. Grassley has sent letters to the American Medical Association, the American Cancer Society, and 31 other disease and medical advocacy organizations asking them to provide details about the amount of money that they and their directors receive from drug and device makers. Such funding amounts are often considered proprietary by the organizations and their directors, but critics contend that the industry's sway over such groups leads them to lobby on industry's behalf.
The U.S. Food and Drug Administration has widened its investigation into radiation overdoses that patients have received from a type of brain scan, announcing that it was looking into possible overdoses at Providence St. Joseph Medical Center in California and a hospital in Alabama. Providence St. Joseph is now the third hospital in Los Angeles County under investigation for problems with CT brain perfusion scans. Unlike the other cases, which involved scanners made by General Electric, the scanner at Providence St. Joseph was made by Toshiba.
Blue Cross and Blue Shield of Florida Inc. expects to end coverage at Manatee Memorial Hospital and Lakewood Ranch Medical Center at the start of next year. The hospitals, under the umbrella of the Manatee Hospitals and Health System Inc., informed Blue Cross that they would terminate contracts effective Jan. 1. Negotiations are continuing, Blue Cross said in a release. The health insurer said it has not been able to come to an agreement that is consistent with its goal of providing affordable healthcare choices for its members.
A major push is under way around the country to cut rehospitalizations, in part by arming patients with simple steps to keep their recovery on track, such as getting past harried receptionists for quicker follow-up doctor visits and reducing medication confusion. Less than a year into a Medicare-sponsored "Care Transitions" project in 14 states, participating hospitals already are seeing readmissions start to inch down, says Barry Straube, MD, chief medical officer of the Centers for Medicare & Medicaid Services.
Speaking at a conference on Medicaid in June 2007, Florida's healthcare chief at the time, Andrew Agwunobi, MD, bemoaned the "critical" shortage of doctors willing to accept payment from the state's insurance program for the needy. But two years later, under questioning from lawyers who sued seeking to reform the insurance program, Agwunobi repeatedly insisted he couldn't recall whether there were enough doctors who accept Medicaid reimbursement. Agwunobi's 2009 deposition, played on a video screen opposite the speech he made two years earlier, was included in the opening statements at a federal trial that began in Miami, the Miami Herald reports. Nine children are named as plaintiffs in the class-action lawsuit.
A University of Miami-Jackson Memorial Hospital team is working to improve patient care and cut costs by making sure oft-overused antibiotics are prescribed only when needed. The program serves as a small example of how such evidence-based medicine can provide good care without increasing healthcare costs, which have been going up far faster than the rate of inflation, the Miami Herald reports. The program is building awareness among hospital employees by handing out pocket cards and pushing info on an internal website.
A portable, external hard drive lost by Health Net, which contained customers' personal information, was not encoded and could be read by commercially available software, Connecticut Attorney General Richard Blumenthal said. The hard drive was apparently stolen in May from Health Net's Northeast headquarters, rather than simply misplaced, Blumenthal said. But Health Net officials said it's still not clear whether the information was stolen or misplaced. The drive contained the medical claims and financial information of as many as 1.5 million customers in the Northeast dating to 2002.
With the second wave of H1N1 infections having crested in the United States, leading epidemiologists are predicting that the pandemic could end up ranking as the mildest since modern medicine began documenting influenza outbreaks, the Washington Post reports. Experts warn that the flu is unpredictable, but several recent analyses indicate that the death toll is likely to be far lower than the number of fatalities caused by past pandemics.
Connolly Healthcare has announced the first issues approved for complex RAC review, so providers in several RAC Region C states could begin seeing medical record documentation requests at any time. Connolly is not yet reviewing for medical necessity.
The DRG-validation issues are approved for the following states: Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, and Texas.
According to the Connolly Web site, the 24 approved DRG validation issues are:
MS-DRG 163. Major chest procedures with major complication/comorbidity (MCC)
MS-DRG 164. Major chest procedures with complication/comorbidity (CC)
MS-DRG 165. Major chest procedures without CC/MCC
MS-DRG 166. Other respiratory system OR procedures with MCC
MS-DRG 167. Other respiratory system OR procedures with CC
MS-DRG 168. Other respiratory system OR procedures without CC/MCC
MS-DRG 207. Respiratory system diagnosis with ventilator support 96+ hours
MS-DRG 255. Upper limb and toe amputation for circulatory system disorders with MCC.
MS-DRG 329. Major small and large bowel procedures with MCC
MS-DRG 330. Major small and large bowel procedures with CC
MS-DRG 331. Major small and large bowel procedures without CC/MCC
MS-DRG 372. Major gastrointestinal disorders and peritoneal infections without CC/MCC
MS-DRG 386. Inflammatory bowel disease with CC
MS-DRG 394. Other digestive system diagnoses with CC
MS-DRG 432. Cirrhosis and alcoholic hepatitis with MCC
MS-DRG 813. Coagulation disorders
MS-DRG 871. Septicemia without mechanical ventilation 96+ hours with MCC
MS-DRG 872. Septicemia without mechanical ventilation 96+ hours without MCC
MS-DRG 981. Extensive OR procedure unrelated to principal diagnosis with MCC
MS-DRG 982. Extensive OR procedure unrelated to principal diagnosis with CC
MS-DRG 983. Extensive OR procedure unrelated to principal diagnosis without CC/MCC
MS-DRG 987. Nonextensive OR procedure unrelated to principal diagnosis with MCC
MS-DRG 988. Nonextensive OR procedure unrelated to principal diagnosis with CC
MS-DRG 989. Nonextensive OR procedure unrelated to principal diagnosis without CC/MCC
"I can certainly see why most of the DRGs Connolly is targeting are surgical DRGs," says Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CCDS, director of HIM and coding at HCPro.
A patient may undergo a procedure for a variety of different reasons, so providers would group an admission to a particular DRG based off the combination of the principal diagnosis, any present accompanying additional diagnosis (i.e., CCs or MCCs), and the principal procedure, McCall explains. Therefore, if the provider reports an incorrect code as the principal diagnosis, the assigned DRG may not be correct.
Similarly, principal procedures are by definition definitive in nature (as opposed to diagnostic or exploratory procedures), she says. So if two procedures meet the criteria, then the provider should select the one most closely related to the principal diagnosis, per the October 1990 AHA Coding Clinic.
This concept is also pertinent for the issues involving procedures unrelated to the principal diagnosis DRGs, she says. "These DRGs have high relative weights and should be encountered infrequently. They have long since been a target for payers because of their high weights, as well as the unlikelihood of their occurrence, especially these days with admission criteria and procedures being done more commonly in the outpatient setting."
For example, consider the following weights for 2010 of some of the issues Connolly is targeting:
MS-DRG 981, Extensive OR procedure unrelated to principal diagnosis with MCC: Weight 5.0389
MS-DRG 982, Extensive OR procedure unrelated to principal diagnosis with CC: Weight 2.8954
MS-DRG 983, Extensive OR procedure unrelated to principal diagnosis without CC/MCC: Weight 1.8072
MS-DRG 987, Nonextensive OR procedure unrelated to principal diagnosis with MCC: Weight 3.4020
MS-DRG 988, Nonextensive OR procedure unrelated to principal diagnosis with CC: Weight 1.7836
MS-DRG 989, Nonextensive OR procedure unrelated to principal diagnosis without CC/MCC: Weight 1.0358
Septicemia and ventilation DRGs
"Septicemia is a diagnosis that has been problematic for a long time because coders often misunderstand the ICD-9 Guidelines for Coding and Reporting as it pertains to the sequencing of the assigned codes," says McCall. "This is especially true with sepsis as it relates to septicemia and other underlying infections that can cause sepsis. Many read the guidelines as saying septicemia is always the principal diagnosis when in fact that may not be the case depending on the documentation."
For example, in an admission when the patient has sepsis because of an underlying infection (e.g., pneumonia) the sequencing could change depending on whether the physician's documentation states that the patient also had septicemia, she explains. The instructional note for code 995.91 (sepsis) states that coders should sequence the underlying infection first, which could be pneumonia (code 486) or septicemia (code 038.xx), depending on the circumstances surrounding the admission.
"Ventilation is also tricky," says McCall. "This is another area that has specific guidelines on when it can be reported, and coders have to deal with the time-counting aspect as well. And for the medical DRGs, it makes sense to target those with CCs or MCCs like cirrhosis and alcoholic hepatitis because a common symptom and associated sign is mental confusion, which could be inaccurately coded as an encephalopathy [348.xx are MCCs] or malnutrition (severe protein calorie is a MCC)," McCall says.
Connolly has also provided descriptions of each of the new issues, along with references for providers who are looking to find more information on any of the topics.
Telecommunications giant AT&T has big plans to establish a foothold in the "telehealth" industry, an emerging field that links patients and physicians across the country via video and medical-information technology. AT&T scientist have spent the past year working on prototypes of products aimed at the home healthcare market. For example, "smart slippers" have pressure sensors embedded in their soles to transmit foot movement data over AT&T's network. If something is amiss in an elderly patient's gait, the device will alert a doctor via e-mail or text message, possibly preventing a fall and a costly trip to the emergency room, said AT&T officials.
