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Published On 1/27/2020
ACPA BOD member, Dr. Alvin Gore, illustrates his efforts in the 1/27/2020 edition of Report on Medicare Compliance (page 4).
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Published On 11/12/2019
The South Carolina Hospital Association (SCHA) and members recently met with Region 4 CMS to discuss CMS governance of Medicare Advantage (MA) Plans. This is an issue that has been discussed often in our Physician Advisor (PA) community. Concerns by PAs relate to prolonged observation requirements, delays in payment, volume of denials and incorrect clinical validation audit findings by MA plans. In order to get the issue of MA plan governance elevated, CMS needs...
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Published On 11/26/2018
ACPA board member Dr. Juliet Ugarte Hopkins provides some much-needed updating to a classic article from ACPA founding member Dr. Steve Meyerson originally printed before the Two-Midnight Rule.
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Published On 11/14/2018
ACPA board member Dr. Juliet Ugarte Hopkins discusses how "Outpatient" does not mean "same-day.
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Published On 11/5/2018
ACPA President Dr. Edward Hu explains how lack of a SOFA score does not rule out sepsis.
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Published On 9/8/2018
HFMA Business of Health Care ® Online Program
and
HFMA Revenue Cycle Conference, October 21-23, Denver CO
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Published On 8/15/2018
The status of the post Affordable Care Act landscape, including the fate of the American Health Care Act and the Better Care Reconciliation Act, remains uncertain. Nevertheless, continuation of recent years’ overall healthcare trends seems assured. Guided by public policy, downward pressure on payments and resultant revenues will continue. Alternative payment schemes will be pursued with an emphasis on...
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Published On 9/27/2017
As the bridge between the frontline troops and the payers, Physician Advisors must be familiar with the terms of their facilities’ contracts and, preferably, involved in negotiation of their terms.
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Published On 9/25/2017
Elizabeth Lamkin provides a great ROI tool that can be used to track return on a Physician Advisor Program.
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Published On 7/12/2017
In the 2017 Inpatient Prospective Payment System (IPPS) proposed rule (CMS-1655-P) the Centers for Medicare and Medicaid Services (CMS) requested input on ideas that would make regulations less burdensome and more transparent. We appreciate this effort. Our “all inpatient” proposal is aligned with these goals.
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Published On 7/2/2017
The success of Physician Advisor (PA) programs in quality improvement, margin protection and regulatory risk reduction has led to the identification of measureable metrics to evaluate and monitor a PA program. This article will provide an overview and examples of how to measure success and how to use metrics to sustain improvements.
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Published On 4/24/2017
The American College of Physician Advisors (ACPA) appreciates the opportunity to respond to your RFI soliciting ideas to better achieve transparency, flexibility, program simplification, and innovation in the administration of Medicare Part C.
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Published On 4/1/2017
Comprehensive yet pertinent documentation is critical within the medical record. Far beyond coherent communication of data and insight between medical providers caring for a patient, good documentation also allows for accurate representation of patient severity in quality data, and appropriate coding, billing, and reimbursement.
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Published On 4/1/2017
Most of us understand the Medicare Two-Midnight Rule. Whether anticipation of two midnights of medically-necessary care in the hospital at the time of admission, or expectation of a second, medically-necessary midnight the day following admission after a first midnight has passed, we get it. For the most part, it’s become pretty engrained in our psyche.
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Published On 2/1/2017
With the start of 2017, I thought I would present something completely unique and un-tried.

Reflections on lessons learned in 2016.
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Published On 12/1/2016
Why your search for a physician advisor should not be internal

Now that most health systems are aware of the profound, positive impact a physician advisor can make in the case management, utilization, and clinical documentation improvement (CDI) arenas, hospitals are scrambling to find the perfect candidate. This search inevitably begins with one question: “Hire from within, or recruit an outsider?”
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Published On 7/13/2022
Dr. Hirsch goes through how the "rare and unusual" exceptions to the 2-Midnight Rule now include scenarios that can be neither rare nor unusual.
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Published On 7/11/2022
In this Report on Medicare Compliance article featuring ACPA Advisory Board member Dr. Ronald Hirsch and ACPA member and former Board of Directors member Dr. R. Phillip Baker, they discuss how this catch-all phrase might capture compliant revenue for patients who may require some outpatient medical care initially but stay in the hospital longer than medically necessary.
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Published On 1/31/2022
In this article, the recent decision from the U.S. Court of Appeals for the Second Circuit on Jan. 25 that the constitutional rights of Medicare beneficiaries are violated when they can't appeal a hospital's decision...
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Published On 1/31/2022
Confusion continues to obfuscate the intent of this new regulation, creating uncertainty for coding, billing and compliance.

There is a hierarchy in coding: the Official Coding and Reporting Guidelines and the American Health Association (AHA) Coding Clinics give recommendations on how to derive the correct code, but the ultimate, definitive source...
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Published On 1/14/2022
When treating Medicare beneficiaries, orthopaedic surgeons must follow Centers for Medicare & Medicaid Services (CMS) policies regarding whether to perform surgical treatments under inpatient or outpatient status. This peer-reviewed paper explores the estimated differences in payment for hospitalizations under inpatient versus outpatient status for common orthopaedic/spinal procedures with a mean duration of stay of <2 days, whose status would be most subject to change from inpatient to outpatient by its removal from the Inpatient Only list.
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Published On 10/5/2021
Observation committee co-chair Dr. Anuja Mohla discusses how to use a proactive approach toward conducting internal short- stay admission reviews to help identify and correct any errors prior to claims submission in "Building an internal electric process for Medicare short- stay admission reviews" by Dr. Anuja Mohla and Patty Resnik, originally printed by the Health Care Compliance Association's Compliance Today.
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Published On 9/9/2021
Outlier cases utilize a disproportionate and increasing share of hospital resources and available beds. The current tendency to exclude such outlier stays in data reporting due to assumed rare occurrence may need to be revisited. Outlier stays require distinct and targeted interventions to appropriately reduce length of stay to both improve patient care and maintain hospital capacity.
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Published On 8/30/2021
Point-of-entry case managers might have eased the sting of almost 260 procedures being removed from the Medicare Inpatient Only list at the start of the year for some hospitals, but it doesn't help many understand CMS's reasoning for reversing their decision in the 2022 Proposed OPPS. ACPA President Dr. Juliet B. Ugarte Hopkins elaborates in this article from the Report on Medicare Compliance from the Health Care Compliance Association.
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Published On 8/10/2021
With comments to CMS due by 9/13/2021, ACPA Board of Directors member and Clinical Documentation Integrity Co-Chair Dr. Erica Remer urges everyone to review the 2022 Physician Fee Schedule Proposed Rule - in particular, the portion about split/shared billing with the professional fee - in this ICD10Monitor.com article...
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Published On 7/26/2021
In a stunning reversal, CMS won't eliminate the inpatient-only list (IPO) and will return 298 procedures it moved off the list in 2021 because of concerns about the safety of Medicare beneficiaries when procedures like limb amputations are performed on outpatients, according to the proposed 2022 OPPS rule announced 7/19/2021. At the same time, CMS proposed to erase its 2021 policy of covering 258 procedures when they're performed at ambulatory surgery centers in 2021. ACPA VP Operations Alvin Gore, ACPA Advisory Board member Dr. Ronald Hirsch, and ACPA Past President Dr. Edward Hu discuss the issues in this article from the Report on Medicare Compliance from the Health Care Compliance Association.
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Backed with clinical knowledge gained from years of practicing as a clinician and an understanding of revenue cycle processes, physician advisors can effectively bridge the communication gap between clinical and revenue cycle staff.
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Published On 4/21/2021
Dr. Hirsch tackles the differences between medical necessity and medical care.
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Published On 4/12/2021
UnitedHealthcare now has a policy (that only applies to some plans) that they are requiring hospitals to get prior authorization for electrophysiology implants after patients are already approved for inpatient admissions. This change creates many issues, both practical and theoretical...
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Published On 3/24/2021
It is crucial to understand the differentiation between a denial for lack of medical necessity and a denial for incorrect status. Last week marked the eighth anniversary of the Centers for Medicare & Medicaid Services (CMS) release of ruling CMS-1455-R. This rule allowed inpatient admissions...
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Published On 2/17/2021
As it turns out, we have all been overthinking the concept of Condition Code 44. Ready for a bit of a history lesson, followed by having your mind blown? Here we go...
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Published On 2/11/2021
A recent discussion on Twitter caught my attention. A physician posted, “Left against medical advice” is not the same as ‘Left to attend sister’s funeral.’ Let’s choose our words better.” This doctor has a point. The choice of words we use to describe patients is not a minor issue. When I trained...
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Published On 1/27/2021
The data may allow you to better understand the intricacies of hospital payments.

When I teach Medicare regulations to physician advisors, case managers, and utilization review professionals, it is always interesting to see the reactions when I explain how Medicare calculates how much to pay for an inpatient admission. Most are aware of the Medicare Severity Diagnosis-Related Group (DRG) system and the DRG triads and dyads...
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Published On 1/20/2021
Documentation should be concise information, justifying the acuity of an inpatient level of care when appropriate.

Statements that physician documentation needs improvement are always being made. These thoughts come from many levels: executives, nurses, utilization review, quality, clinical documentation integrity specialists...
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Published On 1/12/2021
The American College of Physician Advisors’ (ACPA) Board of Directors is saddened to report the passing of Dr. Arthur Broder. Art was one of the few physicians involved in quality assurance and utilization review decades ago. He became involved with The American Board of Quality Assurance and Utilization Review Physicians (ABQAURP) in the 1980's and served as...
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Published On 12/16/2020
The CMS plan to eliminate the Inpatient-Only List does not mean that all procedures are to be performed as outpatient. Learn more from ACPA Advisory Board member and newsletter editor, Dr. Ronald Hirsch in this RACmonitor.com article...
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Published On 12/7/2020
The 2021 OPPS Final Rule is out and there's plenty to review. ACPA's VP of Operations, Dr. Alvin Gore, Advisory Board Chair, Jessica Gustafson, Esq, and newsletter editor, Dr. Ronald Hirsch, are featured in this Health Care Compliance Association (HCCA) Report on Medicare Compliance article from Nina Youngstrom...
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Published On 12/2/2020
The Centers for Medicare & Medicaid Services (CMS) is now accepting waiver requests from hospitals to offer true at-home services. In this program, instead of admitting patients requiring hospital care to the hospital, they will be able to send the patient home and provide them hospital-level care in their home. Read more about this development from ACPA Advisory Board member and ACPA Update Editor, Dr. Ronald Hirsch, in this RACmonitor article...
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Published On 12/1/2020
The Centers for Medicare & Medicaid Services (CMS) has decided the time is right to add a new element to the quarterly Program for Evaluating Payment Patterns Electronic Report (PEPPER) - the percentage of total knee arthroplasties that were done under inpatient status. Learn more from ACPA Advisory Board member, Dr. Ronald Hirsch in this RACMonitor.com article...
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Published On 11/17/2020
ACPA member Dr. Marina Farah details the specific points inpatient providers need to know about denial prevention and healthcare reimbursement in this The Hospitalist article from the Society of Hospital Medicine...
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Published On 11/17/2020
It is with profound sadness that we share with you the passing of Dr. Ronald Rejzer on November 7, 2020. Ron was a leader in the world of Physician Advisors for over a decade, and one of the founding physicians of the American College of Physician Advisors (ACPA), a physician-led, non-profit organization dedicated to the specialty of Physician Advisor.
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Published On 11/16/2020
A recent OIG conclusion in July about malnutrition denials was recently looked into further by ACPA member and NPAC 2020 Co-Chair Dr. Beth Wolf and others. Learn what they found in this Health Care Compliance Association (HCCA) Report of Medicare Compliance article from Nina Youngstrom.
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Published On 10/26/2020
SEP-1 is the Hospital Inpatient Quality Reporting Program measure titled “Severe Sepsis and Septic Shock: Management Bundle.” But, some have noted this Centers for Medicare & Medicaid Services definition seems to be resulting in denials from Medicare Advantage and other plans, and using their preferred Sepsis-3 definition results in falling out of core measures. ACPA BOD member and CDI Committee Co-Chair, Dr. Erica Remer, discusses this catch-22 in her latest ICD10monitor article:
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Published On 10/12/2020
Hospitals will continue to see Medicare denials for severe protein-calorie malnutrition when reviewers aren’t convinced the code is accurate or the clinical evidence supports it, experts say. ACPA member and CDI Committee member Dr. Debra Anoff discusses how she's addressed this at UCHealth in this Health Care Compliance Association (HCCA) Report on Medicare Compliance article from Nina Youngstrom.
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Published On 10/7/2020
In a provision glossed over by most, the 2021 Inpatient Prospective Payment System (IPPS) Final Rule introduced a requirement that all providers transmit all records to Quality Improvement Organizations (QIOs) via electronic means as of Oct. 1, 2020. Learn more from ACPA Advisory Board member Dr. Ronald Hirsch in this RACmonitor article...
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Published On 10/5/2020
Documentation of strokes is tricky, so it's no accident the OIG is going after Acute CVA diagnoses as explained by ACPA BOD member and CDI Committee Co-Chair, Dr. Erica Remer in her latest ICD10monitor article.
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Published On 8/19/2020
CMS is proposing to eliminate the inpatient-only list over the next three years as outlined in the 2021 Outpatient Prospective Payment System (OPPS) Proposed Rule. Read more from ACPA Advisory Board member Dr. Ronald Hirsch in this RACMonitor.com article...
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Published On 8/17/2020
CMS is planning to terminate the inpatient-only list, which guarantees Medicare payment for procedures only when they’re performed on inpatients, while expanding prior authorization for outpatient procedures, according to the proposed 2021 outpatient prospective payment system (OPPS). Learn more from ACPA BOD member, Dr. Alvin Gore and ACPA Advisory Board member, Dr. Ronald Hirsch in this Health Care Compliance Association (HCCA) Report on Medicare Compliance article from Nina Youngstrom...
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Published On 8/6/2020
The confusion over what code to use when hospital-employed physicians perform virtual visits with patients has reared its head again in the latest FAQ from Medicare released on July 28th. Learn more from ACPA Advisory Board member Dr. Ronald Hirsch in this RACmonitor.com article...
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Published On 8/3/2020
CMS resumed Medicare audits on August 3, 2020, but it will proceed in stages and Targeted Probe and Educate is still on hold, as explained by ACPA Advisory Board member Dr. Ronald Hirsch in this Report on Medicare Compliance article from Nina Youngstrom...
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Published On 7/28/2020
Lactic acidosis shares the ICD-10-CM code, E87.2, Acidosis, with other causes of acidosis, respiratory or metabolic. Mixed acid-base disorders are coded at E87.4. The key question for CDISs and coders is, “when is acidosis considered integral to the causative condition and not separately codable?” Learn the answer in this ICD10monitor article from ACPA BOD member and CDI Committee Co-Chair, Dr. Erica Remer...
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Published On 7/22/2020
The attention given to total joint replacement has been a recurring headache for both physicians and hospitals over the last several years, and it appears there is little chance of it abating. Read more from ACPA Advisory Board member Dr. Ronald Hirsch in this RACMonitor.com article...
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Published On 7/21/2020
The OIG released a report titled, “Hospitals Overbilled Medicare $1 Billion by Incorrectly Assigning Severe Malnutrition Diagnosis Codes to Inpatient Hospital Claims.” Yowzers. Read more in this ICD10Monitor.com article from ACPA BOD member and CDI Committee Co-Chair Dr. Erica Remer...
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Published On 7/20/2020
One billion dollars is a big number. But, even more astounding is that hospitals were found by the OIG to have incorrectly documented and/or coded severe malnutrition 86.5% of the time! Read more from ACPA NPAC2020 Co-Chair Dr. Beth Wolf in this ICD10monitor article...
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Published On 7/14/2020
ACPA BOD member and Co-Chair of the CDI Committee, Erica Remer, MD, FACEP, CCDS continues her "A Question a Day Keeps the Query Away" series on ICD10monitor.com, this time featuring functional quadriplegia, ICD-10-CM code R53.2. This condition is defined as being complete immobility due to severe disability or frailty caused by another medical condition, without physical injury or damage to the brain or spinal cord.
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Published On 6/30/2020
Medicare's prior authorization requirement for five common outpatient procedures started on July 1st, 2020. Make sure you know these ten aspects of this new process by reading ACPA Advisory Board member, Dr. Ronald Hirsch's article in RACMonitor.com.
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Published On 6/28/2020
ACPA member Lori Sieboldt, MD, MBA, CHCQM-PHYADV, medical director of population health at Deaconess Health System in Indiana, discusses in this Healthcare Innovation article how her system deployed a care-collaboration platform that connects physicians with skilled nursing facilities in their post-acute network and cut length-of-stay by as much as nine days.
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Published On 6/22/2020
When should Acute Blood Loss Anemia be documented? ACPA BOD member and CDI Committee Co-Chair, Dr. Erica Remer delves into the details in this ICD10Monitor.com article.
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Published On 6/17/2020
Required prior authorization from Medicare for five medical procedures begins 7/01/2020. Does your hospital have a process in place to ensure this happens? Read ACPA Advisory Board member, Dr. Ronald Hirsch's RACMonitor.com article to ensure you're clear on what's needed.
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Published On 6/8/2020
Hospitals are required to ask Medicare for prior authorization for five outpatient procedures, but there’s no such thing as flat-out rejection. If the answer is “no,” hospitals can keep asking Medicare to approve payment, assuming there’s documentation of medical necessity somewhere. Learn more from ACPA Advisory Board member, Ronald Hirsch, MD, FACP, CHCQM, CHRI in this Report on Medicare Compliance article by Nina Youngstrom.
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Published On 5/19/2020
There is continued confusion over the use of patient homes as off-campus, provider-based clinics for Medicare billing purposes. Read ACPA Advisory Board member Ronald Hirsch, MD, FACP, CHCQM, CHRI's latest article in RACMonitor to find some clarity.
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Published On 5/5/2020
ICD-10-CM codes under the current guidelines are not robust enough to tell the story correctly. The American Hospital Association (AHA) guidance tried to eliminate some of the confusion about Z03.818, Encounter for observation for suspected exposure to other biological agents ruled out, and Z20.828, Contact with and (suspected) exposure to viral communicable diseases. Learn more from ACPA BOD member and CDI Committee co-chair Dr. Erica Remer in this ICD10Monitor article.
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Published On 4/17/2020
A federal court on March 24 ordered CMS to let Medicare patients «challenge decisions by hospitals" to change their status from inpatients to observation, dating back to 2009. Patients who were admitted as inpatients but later got the Medicare Outpatient Observation Notice (MOON) must have «a meaningful opportunity to appeal," according to the decision from the U.S. District Court for the District of Connecticut.[1] However, the new appeal rights won't apply to patients placed in observation at the outset.
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Published On 4/8/2020
Custodial admissions continue to be an enormous strain on hospitals. Read about the options to address this issue in this part two RACmonitor article from ACPA Interim President, Juliet B. Ugarte Hopkins, MD, CHCQM.
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Published On 2/26/2020
Rural communities face enough challenges with access to basic medical care. Accessing behavioral health has become increasingly difficult for every population, yet those in rural areas face obstacles of grand proportions.  Learn more from ACPA member and slated NPAC 2020 speaker, Ellen Fink-Samnick, MSW ACSW LCSW CCM CRP in this RACmonitor article.
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Published On 2/19/2020
New technologies have always posed a financial challenge to hospitals. While they want to provide cutting-edge care to patients, unless a positive margin can be maintained, the costs of those technologies can quickly lead to significant financial losses.  Read how to prevent loss from ACPA Advisory Board member Ronald Hirsch, MD, FACP, CHCQM, CHRI.
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Published On 2/19/2020
ACPA VP and  NPAC 2020 co-chair Juliet B. Ugarte Hopkins, MD, CHCQM, reviews a specific quandary playing out in emergency departments all over the country which no one seems to know how to address. Read more in this RACmonitor article.
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Published On 2/5/2020
ACPA member and slated NPAC 2020 speaker, Ellen Fink-Samnick, MSW ACSW LCSW CCM CRP discusses how infrequently ICD-10-CM Z codes are being used since they became available as of 2017 in this RACMonitor article.
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Published On 1/30/2020
Is your hospital assigning discharge codes correctly on claims? If not, you could be headed toward recouping payment. Read more in this RACmonitor article featuring ACPA Advisory Board member, Ronald Hirsch, MD, FACP, CHCQM, CHRI.
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Published On 12/19/2019
Congratulations to the 2019 Hirsch's Heroes - including ACPA member Alexander Ogedegbe MD, CHCQM! Read all about their contributions to our field in this RACmonitor article from Ronald Hirsch, MD, FACP, CHCQM, CHRI.
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Published On 12/9/2019
ACPA BOD member and #CDI Committee co-chair Erica Remer, MD, FACEP, CCDS proposes early detection and successful treatment of SIRS + infection to prevent life-threatening organ dysfunction due to dysregulated systemic host response does not equate final diagnosis of #sepsis in this ICD10monitor article.
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Published On 12/2/2019
The new CMS Discharge Planning Conditions of Participation are now live, but that doesn't mean hospitals will find them achievable. According to ACPA Advisory Board member Ronald Hirsch, MD, FACP, CHCQM, CHRI in this RACmonitor article.
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Published On 11/13/2019
ACPA member and NPAC 2020-slated speaker, Ellen Fink-Samnick, MSW ACSW LCSW CCM CRP details in RACmonitor how veterans are increasingly identified as impacted by Social Determinants of Health (#SDoH).
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Published On 10/26/2019
ACPA BOD member and CDI Committee co-chair Erica Remer, MD, FACEP, CCDS describes in ICD10monitor how CMS explained recently during a conference call focusing on CC and MCC designation methodology, how they asses what CC designation a given diagnosis should have.
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Published On 9/30/2019
ACPA BOD member and CDI Committee co-chair Erica Remer, MD, FACEP, CCDS wonders (as do many across the country) if diagnosing and treating sepsis early truly saves lives. Read more in this ICD10monitor article.
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Published On 9/26/2019
ACPA member Kathy Seward, MD explains in this RACmonitor article how the most valuable communication and education occurs in person and not electronically.
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Published On 8/27/2019
ACPA BOD member and CDI Committee co-chair Erica Remer, MD, FACEP, CCDS outlines her thoughts about the recent court decision to dismiss a False Claims Act lawsuit against Dallas-based Baylor, Scott & White Health in this ICD10monitor article.
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Published On 5/26/2017
The notion that a physician advisor only needs to know how to determine a proper level of care is well past us at this point, because organizations have realized that physician advisors can, and are, impacting healthcare organizations in many other equally important ways. Learn more from ACPA BOD members Drs. Edward Hu, Howard Stein, and Ronald Rejzer in this article originally published by Patient Safety and Quality Healthcare.
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Published On 1/30/2013
If you think the RACs are gone, think again. The next wave is about to hit like a tsunami. We believe that the RAC auditors have been taking the easy path to money and flying under providers' radars with automated reviews...
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Published On 8/9/2012
As reported on www.RACmonitor.com, by the third quarter of 2011, Recovery Auditors (RAs) were behind in terms of projected recoupments from providers and were relying heavily on automated reviews. With these shortfalls...
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Published On 7/10/2012
This is the second of two articles on this subject appearing in the July 12, 2012 edition of RACMonitorEnews. See Janis Oppelt’s article, “ Congress Directs GAO to Study CMS’s Processes for Multiple Medicare Audits.”
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Published On 6/22/2012
In the same way that you wouldn't manage your patient flow without a sound registration system, you shouldn't manage your RAC program without RAC tracking software. Tracking software can help you keep up with medical record requests and appeal...
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Published On 3/13/2012
Your hospital probably has a chief medical officer (CMO) or vice president of medical affairs (VPMA) who attempts to manage a myriad of relationships in the organization - bridging the gap between the physicians and the dreaded administration, providing...
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Published On 2/12/2012
In 1970 the aviation industry was experiencing an extremely high accident rate resulting in nearly 2,500 fatalities for every one million flights. Over 80% of those accidents were a result of pilot error. Advancements in technology reduced airline...
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Published On 2/1/2012
Providers now have yet another form of oversight to worry about: the HIPAA Compliance Audit Program. In 2011, the Office of Civil Rights (OCR) extracted a few massive settlements and fines for HIPAA violations...
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Published On 12/1/2011
Trouble comes in threes! First, just as providers were getting Medicare RACs (now RAs) under control, Medicare Administrative Contractors (MACs) got thrown into the mix, which is confusing communication between RAs, MACs and providers. Second, the new Medicare Statement...
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Published On 10/4/2011
If you read our last article, “The RAC Tsunami on the Horizon,” you know that The Centers for Medicare & Medicaid Services (CMS) will be pushing the RACs to make up for a projected $307.5 million shortfall from the agency’s financial goal for 2011...
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