EHR Implementation: Understanding and Working with Vendors

Posted by Samantha Serfass on December 11, 2018 in Blog, News

EHR Implementation:

Understanding and Working with Vendors

Planning out an Enterprise EHR implementation is a complex process that goes beyond simply working with an EHR vendor.  Identifying the organization’s strategic initiatives and how the EHR application is going to support those initiatives are key factors in any implementation

EHR vendors have extensive experience creating applications, monitoring data needs, addressing user demands, and dispersing real-time information to multiple care providers.

Configuring software, for example, requires modifications to accommodate state regulations. While EHR vendors are compliant with these regulations, the software will only preform as well as it was configured. One major concern faced during an EHR implementation is the level of expertise provided by the vendor’s implementation team. When working with EHR vendors, it’s important to ensure you have the ability to refuse and/or replace resources. This will help to ensure all allocated resources are providing value to the project.

It’s important to remember to focus planning efforts to focus on the system being ready to support the strategic initiatives. Don’t take for granted the EHR vendor will get it done. Here are two examples from different hospital systems each implementing a different vendor’s solution:

  1. A hospital system with multiple outpatient clinics goes live using the vendors approach to reporting.  After completing the go-live phase, M.U reports are compiled. However, the reports compiled do not display the correct data.  Because there was a lack of specific focus at the start of the project, the team and vendor needed an additional two months to correctly compile the reports.
  2. A 5-hospital system with multiple outpatient clinics discovers after their go-live they are losing significant money. The financial loss occurs because the vendor did not configure the billing rules engine, therefore the charges weren’t tested accurately for processing. This hospital system accepted the vendor’s testing approach and did not fully complete parallel testing, when bills are drop so they can be validated.

Unfortunately, a hospital organization must take part in managing the vendor to verify the system can functionally serve healthcare organization properly at go-live.  Below are four key factors to consider when managing an EHR vendor.

In the age where vendors create report cards on their clients performance, hospital systems need to put the vendor in check when the risks are high and the probability for them to become real, exists (as portrayed so many times in the news). How are things different now than in past EHR experiences?


Todd Klein

VP EHR Services & Digital Solutions

Obstetrical and Newborn Coding Tips for ICD-10-CM and PCS

Posted by Samantha Serfass on November 28, 2018 in Blog, News

Obstetrical and Newborn Coding

Tips for ICD-10-CM and PCS


With the implementation of ICD-10-CM and ICD-10-PCS, some areas of obstetrical and newborn coding have become a little more complicated than we were previously used to.  There were a lot of changes to the diagnosis codes, and new root operations to consider when coding procedures, which continues to cause confusion with coders.


Probably the biggest challenge is appropriately assigning the trimester qualifier versus the in-childbirth qualifier when assigning obstetrical diagnosis codes.  Not all codes have the “in childbirth” qualifier, so it is important for the coder to carefully examine all of the options for the particular diagnosis.  The code for anemia O99.0xx) is a good example of a diagnosis that has multiple qualifiers – first trimester, second trimester, third trimester, in childbirth, and during the puerperium.  If the patient presents for delivery and the physician documents she has anemia, then it is appropriate to use the “in childbirth” qualifier.


Fetal monitoring is performed on many women during the course of labor.  The typical type of monitoring used is external fetal monitoring, where a transducer is worn like a belt.  Most facilities do not require the coder to assign a code for the external fetal monitor.

Induction of labor has been used more and more frequently since the mid-1990’s.  Over the years, more and more types of induction have been used, but the most commonly used procedures are artificial rupture of membranes (AROM),  IV medication (typically Pitocin); cervical gel insertion (prostaglandin), and foley bulb insertion.  In order to code this procedure correctly, first the coder has to understand the difference between labor induction and labor augmentation.


Induction of labor occurs when there is no definitive labor pattern established at the time the medication is given.   Augmentation of labor infers that there is an established labor pattern, but labor may not be progressing well (ineffective contractions).  Sometimes an established labor pattern is given a “boost” by either rupturing the membranes or administering some Pitocin, and should not be assigned an induction code.  Cervical gel insertion requires the placement of a gel-filled capsule containing prostaglandin against the cervix to soften the cervix (often referred to as ripening), thus allowing for dilation.  The last mode of induction is classified in ICD-10-CM as a surgical induction, and consists of a foley catheter bulb being threaded into the cervix.  The saline bulb in the catheter is filled with saline, thus expanding the cervix.


The last area to be discussed are codes from the newborn section, specifically P03.X.  These codes are only to be coded on the newborn chart, not on the mom’s chart.  The P03 section are used to reflect a newborn affected by other complications of labor and delivery.  Basically this means that these codes can only be assigned fi the physician specifically states a complication of the labor and/or delivery directly affected the well being of the baby.  A good example of this is when the baby is delivered with a nuchal cord around it’s neck; unless the physician documents an adverse outcome of the nuchal cord (respiratory distress, aspiration, etc), a code from the P03 section should not be assigned.  Many times the presence of a nuchal cord is documented, but there are no untoward event associated with it.


Obstetrical and newborn coding has always been somewhat challenging but has become even more so in ICD-10-CM and ICD-10-PCS.  Coders must be aware of the documentation requirements, indexing, and knowledge of the procedures being performed in order to apply the correct diagnosis and procedure codes.



Robyn McCoart

Director of Client Services at Excite Health Partners

Breaking It Down: Understanding the Classification of Drug Toxicity

Posted by Samantha Serfass on October 16, 2018 in Blog, News

Breaking It Down:

Understanding the Classification of Drug Toxicity


It is no surprise as to why many coders are having a problem coding poisoning, adverse effects and under-dosing. There are multiple guidelines to apply when considering the code choices in this category thus making the coding more complicated.   Physicians do not always document the terms poisoning, overdose, adverse effect or under-dosing.

This means the coders really need to understand how to apply the guidelines to the documentation in the record. Intent has to be determined in order to apply the correct overdose code and the correct status code for under-dosing.  To add further confusion, the manifestations are coded along with the poisoning code which contradicts the basic coding guidelines on symptoms.  Finally, sequencing guidelines are not consistent and are based on the type of drug toxicity code being assigned.

In order to simplify the process, there are four main elements to think about when making a decision on how to code in this category.

A poisoning is taking too much of a medication or not administrating the medication by the correct route, whether it was prescribed, over the counter or as a result of substance abuse.  This may be either intentional or accidental   Also falling into the poisoning category is taking prescription medication that was not prescribed with a current prescribed drug or mixing current medications with alcohol.  When sequencing, the poisoning codes are sequenced first followed by any manifestations.

  • An individual poisoning code is assigned for all drugs involved.
  •  Acute conditions as a result of drug and alcohol abuse are also included in this category.

Poisoning intent is the intention of why the poisoning occurred and this is built into the poisoning code as the 5th or 6th character.  Categories include accidental, assault, suicide, and undetermined.  If there is no documentation of the intent in the record the default is accidental.  Undetermined should only be used if documentation in the record states the intent of the poisoning cannot be determined.

An adverse effect is an acute symptoms or condition that occurs as a result of taking medication as prescribed and properly administered.  The manifestations are sequenced first followed by the adverse effect drug code.  Intention is not considered for adverse effects since the drug is taken as prescribed.

Under dosing is taking less of a medication than prescribed or not taking the prescribed medication at all.  This may result in an exacerbation of the condition that the drug was prescribed to treat.  The manifestation is sequenced first followed by the Under-dosing drug code.

Under-dosing Intent: Is the intention of why the drug was not taken as prescribed.  This is a status code that is not built into the under-dosing code. Categories are intentional, intentional due to financial hardship, unintentional, and unintentional due to the patient’s age related debility

A manifestation is an acute symptom, condition, or exacerbation of a chronic condition as a result of not taking medications as prescribed, taking medication as prescribed, or as a result of drug abuse. Note that manifestations are coded in all drug toxicity categories.


Case 1

Patient presents with syncope and states he had a couple of beers soon after taking his Metoprolol as prescribed.

  • T44.7X1A Poisoning by beta-adrenoreceptor antagonists, accidental, initial encounter.
  • T51.0X1A Toxic effect of ethanol, accidental, initial encounter
  • R55   Syncope

Rationale: This is a poisoning. Although medication was taken as prescribed, the medication was taken with alcohol resulting in the acute condition of syncope.  The poisoning codes for both the medication and alcohol are sequenced first. The intent was accidental and is built into the poisoning code. The manifestation of syncope is coded last

Case 2

Patient presents with headache and dizziness. He was just started on Metoprolol for his blood pressure and has been taking this as prescribed.

  • G44.40      Drug induced headache, NEC, not intractable
  • R42             R42 Dizziness and giddiness
  • T44.7X5A   Adverse effect of beta-adrenoreceptor antagonist, initial encounter.

Rationale: This is an adverse effect.  The medication was taken exactly as prescribed.   The manifestations are the acute conditions of headache and dizziness. The manifestations are sequenced first, followed by the adverse effect drug code.

Case 3

Patient presents in hypertensive crisis. After questioning, it was found that he was only taking his blood pressure medicine a couple times a week due to the price.

  • I16.9   Hypertensive crisis, unspec
  • T44.7X6A (Underdosing of beta-adrenoreceptor antagonists, initial encounter
  • Z91.120 Patient’s intentional under-dosing of medication regimen due to financial hardship

Rationale:  This is an under-dosing.  The patient was taking less than the prescribed medication. The manifestation is the hypertensive crisis. The intent is intentional due to financial hardship.  In this case, the manifestation of hypertensive crisis is sequenced first, followed by the under-dosing drug code.  The intent is not built into the under-dosing code and is sequenced last as a status code.


Mary J. Wood, RHIT, CCS. AHIMA Approved ICD-10-CM/PCS Trainer

Internal Auditor/Educator

Strategic Planning – Healthcare IT Infrastructure

Posted by Samantha Serfass on October 2, 2018 in Blog, News

Strategic Planning- Healthcare IT Infrastructure 


As the Healthcare Information Technology industry continues to quickly change, it has become important for CIOs and healthcare leaders to understand the financial side of upgrading and investing in new technologies, tools and solutions. They also need to have solid understanding of how best these solutions will help drive organizational business goals and outcomes with minimal risk, primarily around the improvement of patient care and increased revenue.

Business strategic planning and IT strategic planning need to evolve to develop a collaborative and functional strategy to deliver a clear path and direction. Healthcare IT must align with and consider key business goals and initiatives, then develop an all-inclusive strategy to provide flexible solutions that support those goals and initiatives. As healthcare organizations face the challenge of keeping up with and investing in the latest technology and tools, it’s important that all disciplines be included in strategy sessions and provide input in developing planning documentation.

Bringing qualified subject matter experts to the table will gain buy-in, improve performance, increase productivity and ultimately influence the culture. The plan should allow room for rapid growth and transformation occurring in the industry yet remain focused on value-based care. CIOs and key stakeholders need to drive the direction by being actively involved in developing IT planning, documentation and deliverables to support key financial investment decisions.

New Planning Strategies and Approach

We may have the best methodologies, planning processes and procedures in place, but we need to be willing to embrace and develop new approaches of planning that will help transform the healthcare culture. Healthcare CIOs must be willing to change their thinking when it comes to developing organizational business goals and initiatives. The CIOs will need to collaborate with IT departments and other stakeholders to develop thorough and effective planning methods that will support and expedite outcomes. This means adjusting the way we think and interact, eliminating silos, ensuring the roadmap leads us to maximize results by revisiting the plan often, monitoring and measuring progress and preparing us for anticipated growth. By following a more streamlined strategic approach and focusing on agility, teams can easily adapt to any industry disruptors and be prepared to adjust to changing technology solutions. Whether the goal is to improve data workflow and the patients experience, implement and deploy analytics or interoperability, it is important to stay integrated through the entire strategic planning process.

Key Components

Building and retaining the right team to accomplish the goals set forth by leadership is important and should be included as part of the overall strategy. Assessing the inhouse skills, redundancies, succession planning and restructuring are all key planning components. Determining training needs, development and implementation of training programs will promote employee retention. Developing policies to help reach the strategic plans goals, implementing strong risk management and mitigation plans, and establishing timelines with key milestones will help manage the plan. Finally, developing effective communication strategies will encourage healthy relationships, promote innovation, enhance productivity and contribute to growth. All these things bring value in understanding and realizing the strategic components.


Engaging the right stakeholders initiates a strategy to improve organizational outcomes. Good governance will help identify and organize high-level opportunities for outcome improvement, implement an improvement methodology to organize teams, assign accountability and empower individuals. By recruiting the right mix of people as part of the leadership team, including a variety of multidisciplinary stakeholders, this will ensure everyone has a voice. Establishing an effective governance model provides a solid foundation to successfully drive the project, improve efficiency, provide sustainability and less corruption. All of this means lower costs, improved quality and satisfied stakeholders.

Measure Success

It’s important that once you spend the resource hours developing the strategic plan and communicating and the overall goals, you then measure progress and understand the components that drive performance. A strategy management system contains an aligned set of objectives, measures, targets and initiatives that describe the strategy. By developing measures of success and key performance indicators (KPIs) to help measure organizational or departmental performance, you can focus on and adjust relevant information, driving your plan to success.


Nina De Los Santos, PMP

VP Operation Delivery

Coding/Reporting of Chronic Conditions

Posted by Samantha Serfass on September 18, 2018 in Blog, News

Coding/Reporting of Chronic Conditions


With so many patients having multiple chronic conditions and taking a plethora of medications for multiple conditions, we still seem to struggle as coders on what may or may not be considered a chronic condition?  You would think that this might be straight forward, however, we all struggle with determining what to code and what not to code.  First, let’s start by identifying what is considered a chronic condition.  In the dictionary, ‘chronic’ means having an illness persisting for a long time or constantly recurring.  Some synonyms of this are: constant, ceaseless, unabating, unending, persistent, and long-lasting.  Many coders, as we all know, have differing perspectives on this subject.

Something else to consider id if the facility you code for has their own in-house guidelines. Many facilities tend to have their own guidelines for how they want these secondary conditions reported.

Section IV of the guidelines has two components that assist to direct decisions regarding secondary diagnosis code assignment.

  • Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s)
  • Code all documented conditions that coexist at the time of the encounter/visit and require or affect patient care treatment or management. Do not code conditions that were previously treated and no longer exist. However, history codes (categories Z80-Z87) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment.


Here are some things to take into consideration when determining whether to report a diagnosis.


  1. Is this a current condition?  Documentation often makes this more difficult if it is not clear on whether a condition is resolved or if it is a simply in the patients’ history.  If it is resolved, it should not be reported.  Physicians often use “history of” when documenting conditions.  For example:  history of Congestive heart failure would mean that the patient used to have heart failure but has since undergone a heart transplant or other procedure and no longer has it.  However, if the patient is on medication chronically they have chronic congestive heart failure.
  2. Does this condition affect patient care or management?  I also tend to think that if medication/medications are being prescribed and or added, then the physician also would need to know what the patient medical conditions are and what medications the patient is currently taking so as to not cause an additional problem/s due to an adverse effect when making his/her determination.
  3. Is this a chronic condition that the patient receives ongoing treatment?  Per Coding Clinic 3rd Quarter 2007 pages 13 and 14 it states, “If there is documentation in the medical record to indicate that the patient has COPD, it should be coded.  Even if this condition is listed only in the history section with no contradictory information, the condition should be coded.  Chronic conditions such as, but not limited to, hypertension, Parkinson’s disease, COPD, and diabetes mellitus are chronic systemic diseases that ordinarily should be coded even in the absence of documented intervention or further evaluation.”


I was just speaking with a fellow coder the other day and we were debating regarding the condition asthma for example.  She said that she felt if she’s on albuterol inhaler but has not had any issues with her asthma in years that it probably shouldn’t be reported as a chronic condition but on the flip side, my response was that what if you were being seen in urgent care for something like bronchitis and while there you had an asthma attack.  Asthma even though you may not have issues with it is still present and could present itself in the right circumstances and should be considered chronic.

As coders, we review, investigate and paint a picture of the patients’ overall health condition.  It is our responsibility to be clear and concise when doing so and provide the highest level of specificity from the documentation one can provide.  Consistency is key in knowing what to report and what not to report.

Tonya Tucker, CCS, AHIMA approved ICD-10 CM/PCS approved Trainer

Internal Auditor/Educator

Digital Transformation in Healthcare – The Human Experience

Posted by Samantha Serfass on September 4, 2018 in Blog, News


Digital Transformation in Healthcare –

The Human Experience

Technology has changed the world as we know it in what seems like a blink of an eye, giving us endless opportunities and far reaching concepts. Technology has changed our lives for the better, but it has also uncovered unforeseen disruptors in many industries. Digitalization disruption has the potential to reshape markets faster than any force in history. One industry which promises gigantic advances in this rapidly changing landscape is healthcare.

The digital revolution has not only brought changes in the role technology plays in healthcare, it is changing how healthcare data is collected, processed, stored, analyzed and utilized. Health organizations throughout the country and the world are in the early stages of this digital transformation journey. Today, US hospitals are faced with improving the quality of healthcare and access to healthcare, controlling the costs of healthcare as life expectancy increases, providing services to the 76 million baby boomers as well as serving the increasing population.

The US spends more on healthcare per capita per year than any other nation, but it lags in outcomes. By focusing on improving population health, furthering the development of information and cultivating collaborative efforts globally, we will begin to see an improvement in outcomes. An already complicated and intricate industry with a multitude of stakeholders, is now having to rethink the way it delivers service. How can healthcare leadership, clinicians, front-line staff and technologist work together to help the effort within the four walls of our hospitals? Let’s look at four areas of focus that can transform the hospital culture, align perspectives and improve outcomes.

Increasing Patient Engagement

Patients want personalized healthcare. They want to be active participants on their path to improvement with a connection to their physician. It’s important to make interactions and encounters more human, communication among doctors, nurses and patients needs to be clear and consistent. Leveraging technology to extend contact with patients is one area healthcare organizations can improve patient engagement. Easy access to nurses and doctors through patient portals or live chat applications, and automated messaging appropriately timed and tailored to the patient’s treatment can help improve health outcomes.

Empowering Healthcare Teams

It is more important than ever for healthcare organizations to ensure skilled and competent resources are hired at every level. From patient access, ancillary services, patient care, to proper training and education – frequent skill audits can ensure all skill gaps are identified and corrected.  When selecting leaders, select professionals you can trust to do the right thing, allowing them to take ownership and be accountable for results.  Once you’ve conveyed the vision and provided them with the tools they need, give them an active role in developing a short-term business solution plan. This should be designed with improvement, deliverables and milestones in mind. Once they select their team, provide an environment where they can succeed. Nurture the team and monitor progress against those milestones. This will keep the team accountable for results. Expect mistakes and be prepared to reroute and redirect. This will signal trust to other areas within the organization changing and improving the organizational culture.

Optimize Clinical & Operational Effectiveness

As healthcare organizations prepare for digitalization, it’s critical to re-evaluate and optimize clinical and operational workflows.  There are many automated tools and methods accessible to collect workflow information, organize data, monitor usage and optimize activities. Examining bed tracking, transportation and supplies, accessibility to healthcare equipment, as well as procurement processes and procedures will help optimize clinical and operational workflows. Organizations need to implement smarter and faster clinical communication enabling clinicians and staff to spend more time collaborating treatment and taking care of the patient.

Transform the Care Continuum

Clinical care practices within highly complex healthcare systems require leaders to advance their way of thinking. Transitional care models can guide program development to facilitate the adoption of new processes. Direction needs to be driven by a leadership team and steering committee, and initiatives need to be clearly communicated to each department. Implement and track KPIs (Key Performance Indicators) to improve performance. Focus on maintaining high quality care across healthcare settings.  Provide a holistic, personal care approach and align and prioritize care initiatives. High maturity organizations focus beyond their four walls. This allows these organizations to promote self-awareness, flexibility, willingness to learn, creativity, decisiveness and improve effective communication.


Nina De Los Santos, PMP

VP Operation Delivery at Excite Health Partners


TBI: Coding Traumatic Brain Injuries

Posted by Samantha Serfass on August 21, 2018 in Blog, General

TBI: Coding Traumatic Brain Injuries

The correct coding of Traumatic Brain Injury (TBI) can cause confusion… no pun intended. The coder needs to understand not only the definition of a Traumatic Brain Injury, but also must recognize the difference between coding a Personal History of TBI and reporting a residual condition or sequela, that is a result of a TBI.

The Centers for Disease Control and Prevention (CDC) defines TBI as a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head, or penetrating head injury.  Severity may range from mild to severe. Disabilities resulting from a TBI depend upon the severity of the injury, the location of the injury, and the age and general health of the individual.   All TBI’s are serious injuries, as they are brain injuries.  Oftentimes, the brain can be left with areas that are irreversibly damaged. Each year, TBI’s contribute to a substantial number of deaths and cases of permanent disability. There are various types of residual effects that a person can exhibit after the acute phase of the injury has ended.

In ICD-10-CM the term “Late Effect” has been replaced with “Sequela”. A sequela is the residual effect after the acute phase of an illness or injury has ended.  There is no time limit for use of a sequela code. The code for the acute phase of the illness or injury that led to the sequela is never reported with a code for the sequela.

Coding of Sequela requires 2 codes:

The nature of the sequela is sequenced first, with the sequela codes sequenced second.

Additional guidelines for reporting sequela of injuries:

The code that describes the sequela is reported 1st, followed by the code for the specific injury with a 7th character “S”, to identify the condition as a sequela of the injury.  The “S” is added only to the injury code.



Patient experienced a fall down steps, with loss of consciousness, resulting in a traumatic subdural hemorrhage. Physician documents injury occurred 3 years ago.. There are no apparent sequela, late effect, or residual conditions.

Assign code:  Z87.20   Personal History of Traumatic Brain Injury


Same patient, but documentation supports patient has a mild cognitive impairment as a result of the previous TBI.

Assign Codes:  G31.84  Mild Cognitive Impairment, so stated

                           S06.5X9S  Traumatic Subdural Hemorrhage with Loss of Consciousness of Unspecified Duration, Sequela.


Please note:

“Codes from categories Z85 through Z92 are used to indicate a personal history of a previous condition. When the condition mentioned is still present or still under treatment, or if a complication is present, a code from the series Z85 through Z92 is not assigned.”


Format and Conventions and Current Coding Practices for ICD-10-CM and ICD-10-PCS

Z Codes & External Cause of Morbidity Codes/Codes Representing Patient History, Status, or Problems

Healthcare RCM: Everyone’s Responsibility

Posted by Samantha Serfass on August 7, 2018 in Blog

Healthcare RCM: Everyone’s Responsibility

Emerging technologies now drive the transition and evolution of revenue cycle management. This is brought about by the pursuit hospitals and healthcare providers must focus on to not only improve financial system management, but to also identify hidden streams of revenue. Healthcare organizations are looking to implement newer technologies that will streamline processes, speed up insurance authorization, deliver new streams of income and minimize the time it takes to receive payment.


Improving Patient Workflow Automation

The importance of helping hospitals improve their patient workflows through automation and to accurately drop the bills on time is something healthcare technologist know all too well. Every point of patient contact, patient data collection, diagnosis and treatment, eligibility and verification are critical to the bottom line.

Although every healthcare facility may have a unique culture, whether full service or particular specialties, one thing that ties all healthcare systems together is the patients. The challenge for most facilities is the time it takes to capture patient clinical workflows and processes detailed enough to build a comprehensive and robust system. Unfortunately, developing a well-documented workflow takes multiple reiterations and can require hours of work.

Capturing accurate and efficient patient registration, admissions and eligibility, streamlining ER processes, collaborative and seamless transfers to/from healthcare facilities, enhancing efficiency and patient safety through the reduction of medication errors, to minimizing drug dosage and dispensing issues, and ultimately automating medical records management with secure accessibility –all  have major impacts on healthcare revenue management systems. One big challenge many facilities face is the lack of qualified skilled resources.


Coordination & Collaboration of Healthcare System

With increasing improvements throughout the years, many hospitals continually face the challenge of hiring and keeping qualified skilled resources through important projects. Yet, the even greater challenge comes after a productive project leadership team has been established, along with a clear vision and objectives.

Coordinating and communicating with all the respective stakeholders and areas of a hospital system takes preparation and consistency through planning. As we experience the changes in the revenue cycle system process, it no longer only impacts the traditional revenue cycle model. It impacts the entire patient workflow process, all invested departments, and the new advanced technology teams continuously working together to improve the revenue cycle management system.

Investing time to improve and change the quality of our healthcare resources is a must. One important example is frontline healthcare workers. It is critical that frontline healthcare workers understand the importance of improving the quality of patient care through gathering accurate patient information during the first encounter. Many times unskilled admission, registration and eligibility resources are hired to save money. While in the end, hours of work are spent correcting inaccurate patient information during charge capture, claims, coding, or remittance, which ultimately delays the bill drop.

Just like HIT security has becoming everyone’s business and responsibility, revenue cycle management has also become everyone’s responsibility. Whether you’re a clinician or administrator, working in admissions, registration and eligibility, operations, ambulatory, ER or IT, working together to improve the process and obtain accurate patient information is your responsibility.


Complexity of Revenue Cycle Management System

One thing is clear, the last 10-20 years have brought extensive changes in provider productivity and hospital internal revenue drivers. Regulatory changes, ICD-10 and continued mergers of revenue cycle systems have not only become the norm, but appear to be increasing every year. Hospital systems continue to invest time and money in order to gain knowledge and understanding of how new technologies can be implemented to increase their bottom line. Today, healthcare systems are looking for vendors who can provide end-to-end revenue cycle management that can solve the growing financial challenges they face each year.

There are several benefit to improving revenue cycle management such as streamlining patient workflow automation, improving productivity of departments and resources, and creating positive impacts on patient satisfaction.

By improving not only the quality of the patients experience, but educating and investing in the resources, hospital systems can successfully improve revenue cycle management. This allows for continued collaborations towards successfully finding new streams of revenue and increase the bottom line.


Nina De Los Santos, PMP

VP Operation Delivery at Excite Health Partners

Diabetes Mellitus and the Alphabetical Index

Posted by Samantha Serfass on July 25, 2018 in Blog

Diabetes mellitus and the alphabet index

Diabetes Mellitus and the Alphabetical Index

Within the last few years, there have been some changes with documentation and code assignment for various manifestations of diabetes mellitus.  One of the notable changes was to the alphabetical index; coders could no longer assume that documentation of “uncontrolled” was synonymous with hyperglycemia as it had in the past.

Now, when a coder sees documentation of “uncontrolled” diabetes, the alphabetical index directs the coder to further define the manifestation as either hyperglycemia or hypoglycemia.  This is also discussed in AHA Coding Clinic for ICD-10-CM and PCS, 1st Quarter 2017 p 42.  If the documentation is not specific to whether it is hyperglycemia or hypoglycemia, the coder is directed to query the physician for more specificity.

If a coder were to look up “Diabetes, uncontrolled” in the alphabetical index, it would appear in the index as follows:

Many physicians use other terms to define diabetes that is not within optimal control, such as “poorly controlled”, “inadequately controlled” or “out of control” to name a few.  It is very important that the coders review the alphabetical index entries for all of these terms, as the index contains very specific direction to follow for final code assignment.

The alphabetical index for these other terms is as follows:

Assuming that “uncontrolled” is basically the same as the terms above, it would result in an unnecessary query and potentially assigning the incorrect code.

Another term often found in physician documentation is “borderline diabetes.”  If the coder indexes this diagnosis, it guides the coder to assign R73.03.  Please note that this differs from the guidance given in the Official Coding Guidelines for ICD-10-CM for borderline diagnoses.

Under Section 1.B.17, it states that if the provider documents a borderline diagnosis at the time of discharge, it is to be coded as confirmed unless the classification provides a specific entry (e.g. borderline diabetes).

When assigning codes for diabetes, both the encoder and tabular prompts the coder to assign long term use of medications such as insulin (Z79.4), oral antidiabetic drugs (Z79.84) or oral hypoglycemic drugs (Z79.84).  Interestingly, both the 2018 Official Coding Guidelines for ICD-10-CM and AHA Coding Clinic for ICD-10-CM, 4th Quarter 2017 p 82 state: “If the patient is treated with both oral medications and insulin, only the code for long term (current) use of insulin should be assigned.”  However, in the tabular listing, Z79.84 is considered an “Excludes 2” under Z79.4 and vice versa.

Unfortunately, this is incongruent information, as according to the Official Coding Guidelines for ICD-10-CM, “The conventions for the ICD-10-CM are the general rules for use of the classification independent of the guidelines.  These conventions are incorporated within the Alphabetic Index and Tabular List of the ICD-10-CM as instructional notes.  The conventions and instructions of the classification take precedence over guidelines.”

Therefore, because of the Excludes 2 note in the tabular, this takes precedence over the advice given in the Official Coding Guidelines and Coding Clinic.

Coders are always encouraged to refer to the alphabetical index when looking up descriptors for disease processes, as the index is the first step in guiding the coder to the correct ICD-10-CM code assignment.


Robyn McCoart

Director of Client Services at Excite Health Partners

The Opportunity in Failure

Posted by Samantha Serfass on July 10, 2018 in Blog

The Opportunity in Failure


Success is achieved only after many failures. Some days these failures never seem to leave our rear view mirror. The fact is, even the most skilled and qualified program/project manager makes bad decisions through the life of a HIT project.


Winston Churchill once said,

“Success is stumbling from failure to failure with no loss of enthusiasm.”


This holds true in every aspect of life. From the time we’re born to the time we die, our natural instinct and desire is to succeed. While this is common to everyone, one thing that makes us different is the level of enthusiasm we have to succeed.


It’s easy to remember the failed attempts. However, it’s the paths carved by failures that bring value and lead us to big successes.


I’ve personally experienced these failures. I’ve witnessed the impact they’ve had on project teams. Technology teams, hospital operations, clinical staff, and physician teams alike have experienced major technological growth in the last 15 to 20 years, and through this growth came significant amounts of failure.


Never underestimate the impact of one bad decision on a project. Any large HIT project team that pulls off a successful project with minimal issues should be celebrated.


In fact, when I think about how healthcare technology, as a whole, has evolved in the past decade, from significant strides in medical research, advances and breakthroughs, to the advances in technology in healthcare, software & tools, regulatory changes, the innovations in medical devices, the financial perspective, and changes in how healthcare is administered in our communities it’s overwhelming all the opportunities that come along with these amazing advances. Opportunity to imagine, opportunity to learn, opportunities to save lives and help others. Isn’t that what it’s all about?


Hospital systems throughout the country and throughout the world, watch each other through projects for the outcomes, especially the large, big dollar enterprise wide projects. We hear about the good, the bad and the ugly in HIT online news and TV outlets. The latest news these days is all about data and security breaches, digital transformation, and the big healthcare IT acquisitions. While the standing questions being asked by hospital leadership teams working to transform care are:

  • Which hospital systems achieved a seamless outcome and which failed miserably?
  • How can we avoid making the same mistakes and improve our quality of care?
  • What helped, what hindered and how can we have a better outcome?
  • What are the main takeaways and lessons learned?


From selecting the best tools and applications to fit the needs of your facility, selecting the latest technology solutions, searching and identifying the right resources for your project that still fit your budget; every decision is important.


Today, unlike 10 or 15 years ago, there are so many helpful resources available that have relevant and valuable content. Published white papers and books with outstanding case studies help direct our steps along the way and answer the tough questions, and even provide us with those questions we don’t know to ask. New trending topics like digital transformation, robots, and AI tools create the latest buzz. Also, let’s not forget the breaches and threats to our personal healthcare data.



There is no question that 2018 brings with it a wide range of new topics within the HIT space. However, nothing can happen without the collaboration and enthusiasm of people. Below are 4 key areas that are critical success factors for any project, and working in tandem, will make the difference on whether your project succeeds or flops:


  • A Stakeholder Analysis, Leadership Engagement and Stakeholder Buy In – It is critical to a project that a thorough stakeholder analysis be conducted with a clear understanding of who the key players are on a project and what motivates them. Find out what their needs are, what concerns them, collaborate with them, and most of all listen to their requirements. You want to get them engaged and most of all you want them on your team! Getting stakeholders engaged is a critical success factor and one of the most important activities a project manager can spend their time doing.


  • Focused Goals & Measurable Objectives driven by a Clear Project Vision – While your overall vision, driven by the mission of the organization, is what we want to achieve, our goals and objectives need to be aligned with our vision. Our goals should be stated in unmeasurable terms and should be focused statements. Goals are the things that need to be accomplished in order to implement the strategy or overall vision. Our objectives are broken down to specific actions and timelines for achieving each goal, which are further broken down into tasks, durations and timelines. The final but important step here is follow-up and adjustments, ensuring that everything stays aligned with your overall vision.


  • A Communication Plan and Process – We all understand the importance of clear and concise communication on any project, yet communication breakdown can easily occur on any project. There are so many tools and templates available online today that can help us develop a strong communication plan for any size project. Use your goals and objectives as anchors to help pull the communication plan together. Here are 4 important communication goals that will help any project.
    • Get the right message to the people who need it, in a clear and timely manner. Follow ups ensure the message was correctly received and understood.
    • Reiterate your goals and objectives throughout the project to keep the team focused on the overall vision.
    • Assign an owner to the communication plan who will help develop a good communication process.
    • Monitor effective communication often and tweak when necessary.


  • A Lessons Learned Process, Tools & Library – One of the easiest things to do as a project manager is to develop lessons learned during a project, while you are actually experiencing the failure. However, we fail miserably when it comes to actually doing it. Trying to do it after the fact doesn’t count! You must establish a good process, keeping the information freely available to everyone on the team. Yes, it can be tedious and seem like a chore at times, but in the long run it saves time and money. If you’ve actually done it, then you know how valuable it is, especially for anyone preparing to walk down the same path. Again, there are so many tools and templates available online and it’s very easy to create a lessons learned library on Excel or SharePoint.


If you have anything along this topic that you’d like to share, we welcome your comments and suggestions!


Nina De Los Santos, PMP

VP Operation Delivery at Excite Health Partners