Upcoding seems to be the common link between the Medicare payment reduction related to the “Two Midnight rule” and a new wrinkle in which CMS will double the expected payment reduction, which has been meant to recoup overpayments tied to INCORRECT CODING.
CMS introduced MS-DRG a suggestion from the Medical community and hospitals to account for the fact that “not every patient is the same even if the diagnosis is. The result according to members of congress and in conjunction with “The American Tax Paper relief Act 2012 was to reclaim the overpayments to hospitals (11 billion) because of “Coding errors”.
CMS initiated almost a 1% reduction in hospital payments but now that cut is closer to 1.5%
While CMS may throw some additional funds into the put, it’s goal is to continuing to recoup the overpayments through the reduction methodology.
Modern Health Care magazine and its reporter Virgil Dickson have done an amazing job of uncovering and explaining the mess. But who can explain the sloppy coding that contributed to the problem. Did someone say “start upcoding” or don’t worry about the guidelines. No, our clients have informed us that upcoding isn’t just cheating, but it violates every guideline published about coding. To these clients we have suggested that we continue to monitor Coding, that is, review cases even on a prospective basis to assure quality, reduce errors, learn to communicate with clinicians and review clinical documentation with them as appropriate. Health Systems Management Network, Inc has provided review services for almost 30 years and provided education and role modeling for the coders by helping them to understand that there are huge gaps between physician speak and coding language.
There is more to come as CMS expects hospitals to report any and all overpayments going back six years. Physician practices are expected to self-report as well. It is better to avoid the storm and put a program in place that is independent and competent in correcting cultural and communication issues. After 30 years and working with every clinical discipline, our firm stands ready to help. Please do not hesitate to contact us.
Sources: http://www.modernhealthcare.com/article/20160418/NEWS/160419922 | http://www.modernhealthcare.com/article/20160419/NEWS/160419913