Excite Health Partners

Chief Medical Information Officer

Chief Medical Information Officer
Illinois

Since 2010, Excite Health Partners has been a growing leader in the Healthcare consulting and staffing industry. We are committed to the development of the HIT industry, which is why we ensure our employees are educated, prepared and confident. We understand our employees are the backbone of our company, so we work to find the best fit position for each of our unique professionals.

Qualifications
At Excite, we want you to succeed. We want to help you reach your goals and find a satisfying and challenging work environment. For the Chief Medical Information Officer, you should meet the following criteria:
• Must have at least 5 plus years’ Epic experience
• Previous experience with Epic build focused in provider governance, change control and data analytics
• Strong communication skills and experience working with C-level suite executives
• Must have previous experience leading a team of providers through an Epic install
• Medical degree from a US Medical Healthcare Institution
• Must be able to commit to an 18-month contract
• Completed Epic Builder Physician Training, a plus

Joining the Team
Excite understands that employees are the cornerstone to our success. We are proud to offer the following benefits:
• Competitive compensation
• Health, Vision, Dental plan
• Life and long-term disability
• 401k plan with designated company match
• Weekly pay

BREAKING IT DOWN: EGD WITH ENDOSCOPIC ULTRASOUND

Breaking It Down: EGD with Endoscopic Ultrasound

Esophagogastroduodenoscopies with endoscopic ultrasound examination can appear rather confusing, especially when additional procedures such as fine needle aspirations or injections of adjacent structures are also performed in tandem with the original procedure.

The first thing to remember is that all of the Upper EUS codes are subsets of the parent code, 43235 Esophagogastroduodenoscopy.  If you look at the code book, all of the codes under 43235 start with “with”.  Keeping this in mind, you will realize it is always assumed that an entire EGD has been performed (esophagus, stomach, 2^nd portion of duodenum) prior to the insertion of the echoendoscope.  Also note that there is a separate code for esophagoscopy with EUS, meaning the stomach and/or duodenum is not entered with the scope.

For the purpose of the EGD’s with EUS, the GI system is broken down into three basic regions:

1. Esophagus
2. Stomach
3. Duodenum (or surgically altered stomach where the jejunum is examined distal to the anastomosis)

The next thing to distinguish is the subtle verbiage differences in the code descriptions, namely AND versus OR, which helps identify the best code for the operative scenario.  For these procedures, the word “and” (esophagus, stomach, AND either duodenum or surgically altered stomach…) means that all three regions have to be evaluated using ultrasound.  When “OR” is used, the intent is to reflect that two out of the three regions are evaluated.  Typically, 43237 is used when the EUS probe is inserted through the esophagus and into the stomach, but does not reach the duodenum. 

Of note, it is also assumed that adjacent structures are always visualized during an ultrasound, even though the only codes that specifically state “and adjacent structures” are 43237 and 43238.  Adjacent structures is defined as not only the walls of the GI tract, but other structures such as the liver, biliary tract, pancreas, lymph nodes.

When determining the correct code assignment, remember that the code descriptions for endoscopic ultrasound refer specifically to the ultrasound probe, and the depth to which it is inserted.  A complete esophagogastroduodenoscopy has to be performed prior to the EUS in order to correctly choose a code from this section as evidenced by the code format contained in the CPT book.

CODES WITH THEIR DEFINITIONS:

For additional uses for EUS, check out Excellent Endoscopy.

Robyn McCoart, RHIT

Managing Auditor, Excite health Partners

SPLIT/SHARED SERVICES: THE IMPORTANCE OF PROPER DOCUMENTATION

SPLIT/SHARED SERVICES: THE IMPORTANCE OF PROPER DOCUMENTATION

When an E/M service is performed in the hospital inpatient (POS 21), hospital outpatient (POS 19, 22), or emergency department (POS 23) and is shared between a physician and non-physician practitioner (NPP) from the same group practice, the service may be billed as a split/shared E/M service.

The CMS definition of split/shared visits can be found in the CMS Internet Only Manual (IOM): Medicare Claims Processing Manual Publication 100-04, Chapter 12, Section 30.6.1 Split/Shared E/M Visit: 

“A split/shared E/M visit is defined by Medicare Part B payment policy as a medically necessary encounter with a patient where the physician and a qualified NPP each personally perform a substantive portion of an E/M visit face-to-face with the same patient on the same date of service.  A substantive portion of an E/M visit involves all or some portion of the history, exam, or medical decision-making key components of an E/M service.  The physician and the qualified NPP must be in the same group practice or be employed by the same employer.”

The following documentation requirements must be met in order to report the service as split/shared:

• Both the physician and the NPP must provide a face to face encounter with the patient.
• Each clinician must document a note in the medical record. Typically, the NPP note is more extensive, but that is not a requirement.
• Physician must document at least one element of the history, exam, and/or medical decision- making component of the E/M service.  It is not sufficient for the physician to simply document “seen and agree” or simply countersign the non-physician practitioner (NPP) documentation. 
• Physician must legibly sign the documentation.
• Physician and the NPP must be actively involved in the Medicare Program and both have a valid provider number for reporting purposes.

The level of E/M service selected to report is based on both the physician and NPP documentation. 

If any of the above elements are lacking, then the service will be reported using the NPP’s NPI.  This will result in a reduction in payment for the E/M service as NPPs receive 85% of the fee schedule rate, whereas reporting using a physician’s NPI number will receive 100% of the fee schedule rate.

The following services may not be reported as split/shared services:

• Critical care services-this is a Medicare rule.  Do not combine time for critical care services done by a physician and NPP, even when working in the same group, same specialty.
• Procedures are performed by one person.  Report under the NPI number of the clinician who performed the service.

Remember that physician supervision alone is insufficient for split/shared services, proper documentation is the key!

Janice Spaulding, CCS CPC

Auditor, Coding Educator Excite Health Partners

IN THE KNOW: CODING THE PETERSEN SPACE

In The Know: Coding the Petersen Space

Did you know that an internal hernia can occur in a Petersen space? But what is a Petersen space?

Petersen space is the defect space that can sometimes occur in the mesentery between the alimentary loop of a gastrojejunostomy and the lower part of transverse colon mesentery after a gastric surgery.¹

One of the complications that can arise following any type of gastrojejunostomy is a Petersen space hernia.

A Petersen space hernia can develop “when the intestinal loops protrude through the defect between the small bowel limbs, the transverse mesocolon and the retroperitoneum.” ²

The hernia can occur anywhere from days to years after a gastric bypass.

Because it is an internal hernia, it is usually not visible thru the abdominal wall (i.e. protrusion like ventral hernias or umbilical hernias) and symptoms include severe abdominal pain and sometimes obstruction.¹

Because of the increasing prevalence of gastric bypass, the occurrence of a hernia in Peterson’s space is more common than it used to be.  Prior to this, it was typically only seen in the small amount of cases where a bypass was performed after gastric resection for things like severe ulcers and stomach cancer.

How do you code repair of a Petersen Space hernia?

In the coding scenario for a laparoscopic repair of an internal Petersen space hernia presented in AHA Coding Clinic for ICD-10-CM/PCS, First Quarter 2018, the correct ICD-10-CM PCS code would be “0DQV4ZZ Repair of mesentery, percutaneous endoscopic approach.” ³

If an open repair of the mesentery is performed for a Petersen Space hernia the appropriate PCS code would be 0DQV0ZZ Repair of mesentery, open approach.

Be sure and read the whole Operative Report description of the procedure for accurate code assignment.

Lorrie Strait, RHIT, CCS

Manager HIM Services

References:

1. https://www.ncbi.nlm.nih.gov › pmc › articles › PMC319962

2. https://www.sciencedirect.com/science/article/pii/S2210261211000447

3. AHA Coding Clinic for ICD-10-CM/PCS, First Quarter 2018

Desktop Support Engineer

Desktop Support Engineer
Evansville, IN

Since 2010, Excite Health Partners has been a growing leader in the Healthcare consulting and staffing industry. We are committed to the development of the HIT industry, which is why we ensure our employees are educated, prepared and confident. We understand our employees are the backbone of our company, so we work to find the best fit position for each of our unique professionals.

Qualifications
At Excite, we want you to succeed. We want to help you reach your goals and find a satisfying and challenging work environment. For the Desktop Support Engineer position, you should meet the following criteria:

• At least 3 years desktop or network support experience
• Technical background experience
• Basic Technical Certified (A+ or Network +etc.)
• Previous experience with installation/support for hardware, operating systems & computer software
• Troubleshoot network & server issues
• Offer Tier 2 support for entire Network
• EMR/ Healthcare experience, preferred
• Strong verbal, organizational and written skills
• Bachelor’s degree or related field experience

Joining the Team
Excite understands that employees are the cornerstone to our success. We are proud to offer the following benefits:
• Competitive compensation
• Health, Vision, Dental plan
• Life and long-term disability
• 401k plan with designated company match
• Weekly pay

Epic Integration Leader

Epic Integration Leader

Detroit, MI

Since 2010, Excite Health Partners has been a growing leader in the Healthcare consulting and staffing industry. We are committed to the development of the HIT industry, which is why we ensure our employees are educated, prepared and confident. We understand our employees are the backbone of our company, so we work to find the best fit position for each of our unique professionals.

Qualifications

At Excite, we want you to succeed. We want to help you reach your goals and find a satisfying and challenging work environment. For the Epic Integration Leader position, you should meet the following criteria:

• At least 3 years Epic Integrations experience (at multi-hospital system)
• Experience implementing new Epic modules
• Experience managing and overseeing interface configurations based on specific workflows
• Experience coordinating and supervising logistics
• Strong critical thinking and leadership skills

Joining the Team

Excite understands that employees are the cornerstone to our success. We are proud to offer the following benefits:

• Competitive compensation
• Health, Vision, Dental plan
• Life and long-term disability
• 401k plan with designated company match
• Weekly pay

Cerner CoPath Analyst

Cerner CoPath Analyst

Pittsburgh, PA

Since 2010, Excite Health Partners has been a growing leader in the Healthcare consulting and staffing industry. We are committed to the development of the HIT industry, which is why we ensure our employees are educated, prepared and confident. We understand our employees are the backbone of our company, so we work to find the best fit position for each of our unique professionals.

Qualifications

At Excite, we want you to succeed. We want to help you reach your goals and find a satisfying and challenging work environment. For the Cerner CoPath Analyst position, you should meet the following criteria:

Joining the Team

Excite understands that employees are the cornerstone to our success. We are proud to offer the following benefits:

• Competitive compensation
• Health, Vision, Dental plan
• Life and long-term disability
• 401k plan with designated company match
• Weekly pay

Breaking Down Denials: CC/MCC Denials

BREAKING DOWN DENIALS: CC/MCC DENIALS 

When someone in the healthcare industry hears the word “denial”, many things can come to mind.  There are many different types and kinds of denials; what could be said about denials could fill a book. To narrow the conversation, let’s touch on one specific type of denial that has become more prevalent for hospitals in recent years. 

A documented and coded diagnosis acting as a CC or MCC for the DRG is denied by the payer with the claim that the clinical picture does not support that it is a true and valid diagnosis.  By removing the diagnosis code, the DRG is reduced, resulting in a reduced payment to the hospital.

This type of denial has been called various things which can create confusion when assigning the appropriate person to address it.

A few examples are:

• “clinical denials” which could also mean denial of admission to an inpatient bed stating the patient’s clinical picture does not warrant inpatient care
• “DRG denials” which could also mean the entire admission was denied, not just a denied diagnosis changing the DRG
• “Coding denials” which tends to sound like this is a coder issue when in fact it is not a coding issue at all

Payers have learned how to target the types of inpatient discharges that lend well to this type of challenge.  Common targets include DRGs with a single CC or MCC where the CC or MCC is acute renal failure/injury, acute respiratory failure, encephalopathy, malnutrition, or sepsis.

If this is not a coding specific issue, then where does the problem lie?  The Center for Medicare and Medicaid Services (CMS) has not stated any one criterion as the official clinical criteria for all to follow.  As a result, many payers including the RACs have created their own criteria or adapted existing criteria in the industry such as AKIN (Acute Kidney Injury Network), RIFLE (Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease), or KDIGO (The Kidney Disease: Improving Global Outcomes).  Providers most often do not know what individual payer criteria is being used.  Physicians have not been educated on when additional documentation is needed to support certain conditions that they diagnose and document. 

The coding teams are stuck in the middle.   Facilities can trend what different payers are targeting and the basis of their denials.  Armed with this information, coders still cannot diagnose the patient.  Even with outlined criteria to follow, conditions documented in the record and not ruled out cannot be ignored by the coder.  The coder cannot make the determination that a documented diagnosis is not valid and choose not to code it. 

What’s a hospital to do?  Hospitals should create a team to review these types of denials and fight back whenever possible.  Some hospitals have taken the extra steps to create internal clinical guidelines to give direction and promote consistency; however, payers may still deny diagnoses based on their own criteria.  Offer as much education on the issue as possible to physicians, CDI staff, and coders.

Who should review and argue the cases? The best person to review these denials and write up an appeal letter would be the very person that documented the diagnosis in question, the physician.  However, it is a rare hospital that has a medical staff member with the time and willingness to do so.  So, the task should fall to someone with strong writing skills with a clinical background that can create a strong argument in support of a documented diagnosis by outlining the patient’s clinical picture in detail.

From a different angle: Coding was initially created for the primary purpose of statistics and research.  Coded data can play a key role in value-based care and other programs based on patient care outcomes and quality of care indicators.  While Official Coding Guidelines offer clear direction on when to assign a secondary diagnosis code, the guidelines could be a part of the problem.  The guidelines state additional conditions are coded when they affect patient care by requiring clinical evaluation, therapeutic treatment, diagnostic procedures, they extended the length of stay, or necessitate increased nursing care and/or monitoring.  But what the guidelines neglect to include are conditions that create a patient health risk for the future.

One example includes patients with morbid obesity that decline nutritional counseling or any other type of intervention.  Because the condition is not being addressed, some payers are denying it as a secondary code/s.  As patients develop obesity related conditions in the future, there will be limited data for research of obesity related health problems because the condition of obesity is not being coded now.  This also could create a problem with quality of care analysis when patients’ conditions are uncontrolled due to unaddressed obesity such as diabetes, respiratory conditions, joint problems, and cardiac disease.

 Every denial should be reviewed and where possible and appropriate, challenged.  Payers may tend to target facilities that do not argue or fight back.  Do not accept a payer’s denial at face value.  Review the case.  If there is enough clinical support in the record to argue, do so.  The continued challenge is what constitutes “enough clinical support”?  Not even CMS answers that for us.

Lisa Marks

VP of HIM Services

FLU SEASON’S HERE: CODING RESPIRATORY INFLUENZA

FLU SEASON’S HERE – Coding Respiratory Influenza

Every year, influenza season is considered to stretch from October through May.  The peak occurs between December through February, causing a lot of hospital encounters— whether as inpatients, emergency department visits, or physician office visits.

Within the medical world, there are different types of influenza viruses.  In order to reflect the type of influenza appropriately, the coding professional must carefully examine the documentation provided by the physician in order to assign the correct influenza code.  Within this article, we will discuss the different types of influenza and the documentation/coding nuances for each.

Sometimes the type of influenza will not be identified, but the physician will still document “influenza” and treat it as such.  Within the alphabetical index, this would be considered an unidentified influenza virus (J11.x).  Other times, the physician will order a nasal swab and it will come back positive for Influenza A or Influenza B.  In these cases, the influenza would be indexed as Influenza, identified influenza virus, NEC (J10.x).

Novel A Influenza virus is considered to be an influenza arising from animal origin, and is actually somewhat rare.  Some of the key words the physician must document in order to assign a code for Novel A are: “novel”, “avian”, “swine”, “H1N1”, “H5N1”.  The inclusive list of sub terms can be found within the alphabetical index and are also listed in the tabular index under J09. X.  These codes can only be assigned on confirmed cases of Novel Influenza because these are nationally reported infectious diseases.  If the physician uses equivocal terms such as “possible” or “probable” a code from the J09 section should not be assigned and the physician should be queried for clarification.

There are times when the coder will see documentation of “influenza like illness”.  In the alphabetical index, there is a specific entry for this, which directs the coder back to the main term of influenza.  Because there is a specific alphabetical index entry, this diagnosis is appropriate for assignment on both inpatient and outpatient cases.

Under all specified influenza types, there is a subset of manifestations defined by the word “with”.  Referring back to the Official Coding Guidelines for ICD-10-CM and PCS, the diagnoses listed under the term “with” are assumed to be linked and can be coded as such (i.e., influenza with pneumonia).

It’s important to remember chart documentation is critical when assigning the appropriate code for influenza.  The coder should carefully review the alphabetical index entries and assign the most appropriate code.  Remember that Novel A Influenza and Influenza A are not the same.  Influenza A is most common, whereas Novel A Influenza is rather rare.

Robyn McCoart

Director of Client Services, Excite Health Partners

Senior Project Manager- Shaker Heights, OH

Senior Project Manager – Shaker Heights, OH

Since 2010, Excite Health Partners has been a growing leader in the Healthcare consulting and staffing industry. We are committed to the development of the HIT industry, which is why we ensure our employees are educated, prepared and confident. We understand our employees are the backbone of our company, so we work to find the best fit position for each of our unique professionals.

Qualifications

At Excite, we want you to succeed. We want to help you reach your goals and find a satisfying and challenging work environment. For the Senior Project Manager position, you should meet the following criteria:

• At least 7 years of project management experienced, required
• Project Management Professional (PMP), preferred
• Build and implement Lean process workflows – project & portfolio management
• Identify and resolve issues and conflicts within various project teams
• Assist department talent management: talent selection, conduct performance reviews, maintain team dynamics
• Strong communication, organizational and leadership skills
• Bachelor’s degree or related field experience

Joining the Team

Excite understands that employees are the cornerstone to our success. We are proud to offer the following benefits:

• Competitive compensation
• Health, Vision, Dental plan
• Life and long-term disability
• 401k plan with designated company match
• Weekly pay