Glenn Krauss’ Post

Guidelines for Coding Casual Relationships Between Diabetes, Hypertension, and Chronic Kidney Disease in Medical Coding Medical coding plays a crucial role in ensuring accurate billing, proper diagnosis, and clear communication between healthcare providers and insurers. For patients with multiple chronic conditions, such as diabetes mellitus, hypertension, and chronic kidney disease (CKD), coding can be complex. These conditions often interact and affect one another, requiring coders to be familiar with how to appropriately represent their relationship in coding systems like ICD-10-CM. In this blog, we’ll explore the guidelines for coding casual relationships between diabetes, hypertension, and chronic kidney disease, focusing on how to correctly assign codes to reflect these interconnected conditions. https://lnkd.in/gtb9JwZi

Medical Coding and Billing Guidelines for Complications: A Comprehensive Guide Complications arising from medical treatments, procedures, or conditions can significantly affect patient care and treatment outcomes. In medical coding and billing, it is essential to accurately document and code these complications to ensure appropriate reimbursement and maintain compliance with healthcare regulations. This article provides a detailed guide to coding and billing medical complications, addressing key aspects such as terminology, relevant coding systems, and best practices. https://lnkd.in/gXxJDDi4

A key driver of rising healthcare costs is the rise in utilization of services - Clinic visits, inpatient admissions, Radiology and Lab referrals and pharmaceutical prescriptions. Making sure these services are being used appropriately whilst maintaining high quality patient safety takes careful consideration. Here is a Case Study of a utilization project we have undertaken as part of Johns Hopkins Aramco Healthcare’s five-year Clinical Services Transformation Plan to optimize referrals from Primary Care to Specialty Clinics. We started by identifying 26 common conditions that contributed to a large proportion of referrals from Primary Care, working with our clinicians to create standardized criteria for referral, and then hard-wiring them into our electronic medical record system Epic. By auditing compliance and working with referrers to improve their understanding and address any knowledge gaps, we are optimizing the availability of our Specialists to see new patients and bring down the median waiting time for new patients. Once we have perfected these 26 pathways, we will apply the same principles to additional common conditions referred to Spexialry Clinics. By doing this, we safely improve access to care for our patients whilst controlling escalating healthcare costs. Other opportunities for utilization management include: - Putting in place standardized criteria for discharging patients from Specialty Clinic back to Primary Care. - Creating protocols for Radiology and Lab investigations - Agreeing and complying with length of stay targets for individual elective surgery procedures. - Increasing the proportion of surgical procedures undertaken as a Daycase. - Providing clear guidance on the most appropriate and effective pharmaceuticals at the point of prescribing. By doing these things well, we are able to provide the highest quality care to the greatest number of patients whilst continuing to make care accessible and affordable. Interested to hear about any other initiatives you have introduced that help manage utilization of clinical services in a safe way. Thank you. #JHAH #UtilizationManagement #PopulationHealth #ClinicalServicesPlan #Vision2030 #CHI

Communication – using ISBAR for clinical handover Sharing incorrect or omitting information can have harmful or life-threatening consequences for patients and residents in our care. Therefore, clinical handover and communication of critical information can be a high-risk process in healthcare. Using ISBAR for clinical handover (e.g. change of shift, prior to ward/external transfer) Identify: introduce and identify the patient using the three patient identifiers (name, DOB and UR number) – these identifiers can be checked with the patient/resident if they are cognitively intact, or using their wristband if the patient is cognitively impaired or has limited verbal communication. Situation: what is the patient or resident’s current diagnosis and medical history? What are the latest pathology and radiology results? Are there any alerts for this person identified as a result of your assessments e.g. falls risk, wandering behaviours, advanced care directives, allergies or adverse drug reactions, infectious risks? Provide any relevant documentation to the receiving nurse for them to visualise, such as a documented Advanced Care Directive. Background: what has been happening with the patient/resident during your shift? Are there any abnormal findings or observations to report, and what have been your actions as a result of these findings (e.g. MET call initiated, doctor review, altered MET criteria)? What procedures or activities have occurred? Assessment: provide details of the plan of care – any procedures, treatment thus far, outstanding tasks or interventions, discharge planning. Response: has the person you are handing over to understood? Is there anything that requires clarification or follow up (e.g. what time was their procedure scheduled for? Could you follow up on the order from pharmacy?). Allow the staff member who is receiving handover to review the charts before moving on to the next patient. Using ISBAR it is recommended to ensure that all nurses have a good understanding and a clear plan for the patient’s progress ISBAR should be used every time they have handover information about their patient ISBAR can protect the nurses from any investigation or any other issues with their patients.

Imagine building a thriving medical practice is like building a fire. Each element plays a crucial role, contributing to its growth, strength, and sustainability. Here's how: The Fire Starter: The Practitioner Every great fire begins with a spark, and in a medical practice, that spark is you. Your expertise, leadership, and vision ignite the process. Without this foundational element, the fire or practice cannot begin. The Pine Needles: Level 1-2 Visits Like pine needles catch the initial flame, level 1-2 visits bring in patients and create opportunities to establish trust and rapport. While small, they are vital to getting the fire started. The Sticks: Level 3-5 Visits As the fire grows, sticks keep it going. Higher level visits deepen patient care and allow for more comprehensive assessments. Keeping the small flame steady. The Charcoal: Lab Work, Injections, and Vaccines Charcoal burns hotter and longer, representing in-office procedures like lab work, injections, and vaccinations. These services not only enhance patient outcomes but also contribute to your practice's financial stability. The fire is starting to grow. The Logs: Diagnostic Testing, RTM, and RPM Finally, logs provide the long-lasting heat and structure that sustain the fire over time. These represent diagnostic testing, Remote Therapeutic Monitoring (RTM), and Remote Patient Monitoring (RPM) services that elevate your practice, improve patient outcomes, create durable revenue streams and stimulate growth. A successful practice, like a fire, requires balance. You need all these elements working together. Focus too much on one (like pine needles), and the flame may burn out. Ignore others (like logs), and the fire won't grow strong enough to thrive. Let's work together on igniting your businesses success!

According to most sources that track and trend medical claims denials, about 15% of claim denials are coding-related. This includes denials for invalid HCPCS, CPT, modifiers, and ICD-10. According to the AMA, for CPT alone there are 270 new codes, 112 deletions, and 38 revisions for 2025, mostly related to laboratory analyses and emerging medical services and technology. If these codesets are not updated in a timely manner in health plan core claims adjudication systems, your Medicare Advantage encounter data, commercial EDGE server medical claims data, and/or Medicaid encounter data will not be submittable and plans may lose out on significant risk adjustment revenue from untimely or incomplete data submission by the risk adjustment deadlines. In my strategic advisory practice for Centauri Health Solutions, Inc, I find that failure to complete these codeset updates in a timely manner is one of the biggest root causes of why claims costs are so high relative to a lower-than-forecasted plan average risk score. If this is your plan's situation, the Five Whys is a useful starting point to uncover the root cause(s) of the failure to perform timely data updates. Get in touch if you'd like to know more about this kind of analysis and how to address the root causes of untimely codeset updates. The effective date for 2025 CPT is nigh...are you ready?

Medical decisions can be overwhelming, especially when patients are faced with complex diagnoses or surgical procedures. With so many options available, it’s easy for patients and their families to feel confused and unsure of the best course of action. This is where patient advocacy plays a crucial role. What Does A Patient Advocate Do? Patient advocates help the individuals to fully understand their diagnosis, treatment options, and potential outcomes. They help patients weigh the benefits and risks of each option, considering not just medical facts but also the patient’s values and beliefs. For example, when faced with a daunting diagnosis, patients often struggle with choosing between treatments or surgeries. A patient advocate can break down the medical jargon, explaining the pros and cons of each treatment option in simple, clear language. This makes the decision-making process far less stressful for both the patient and their family. Informed Decision-Making By working closely with a patient advocate, patients are empowered to make informed decisions about their health. They gain confidence in their choices, knowing they have a medical expert who fully understands the situation and who is advocating for their best interests. Patient advocates are particularly valuable when patients have ethical or personal concerns about treatments. The advocates respect the individual’s values and beliefs, helping them navigate their options in a way that aligns with their personal preferences. In today’s complex healthcare environment, the role of patient advocacy is more important than ever. They provide patients with clarity, ensuring that medical decisions are made with confidence and care.

Physicians shift to passion over protocols We talk as if their role is set in stone: diagnose, treat, manage But what if the most important shift isn’t about redefining medicine—it’s a shift to rediscovering passion? Physicians didn’t go to med school for PAs or reconcile medication lists They went to solve mysteries, to heal, to help change lives Old school thoughts of medicine were a linear path: Training leads to practice Practice leads to mastery Mastery leads to fulfillment But that’s industrial-age healthcare thinking. Assembly-line medicine. This isn’t just about efficiency. It’s about purpose. Physicians following protocols:  “How many patients can you see?” Physicians shifted in passion:  “How many lives can you truly impact?” The old metrics don’t work anymore: Volume over value? Ask the burned-out doc racing through 30 patients a day Compliance-driven care? Ask the patient with perfect labs but no quality of life. Professional prestige? Ask the physicians who left the field to rediscover meaning Passion-aligned physicians know something the protocol-driven physicians overlooked: Diagnosis is art Treatment is science Managing medications? That’s where a pharmacist belongs. Educating patients? That’s where a pharmacist belongs. Here’s the shift: You’re not the system’s cog; you’re its architect Your time isn’t a commodity; it’s a gift to patients Your job isn’t paperwork; it’s passion work The question isn’t “What’s on your to-do list today?” It’s “What lights your fire?” Do more of that. There's a pharmacist for the rest. When was the last time you checked your passion’s vital signs? PS. Ready to shift to passion over protocols by starting clinical pharmacy services, DM me PHARMACY to get started.