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OIG Fraud Recoveries Dropped $1.2B This Year

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Compliance, Healthcare, OIG, Payment Rates

The Office of the Inspector General Fraud Recoveries Dropped $1.2 Billion This Year

That might not be a bad thing.

 
The federal government brought in 30% less in fraud recovering in 2018 than it did the previous year, thanks to far few large settlements. But the could be a net benefit, according to the Centers for Medicare & Medicaid Services (CMS). The office of Inspector General (OIG) recovered $2.9 billion from fraud investigations during fiscal year 2018, according to the semiannual report to Congress released last week. That's  $1.2 billion decline from last year, when the agency pulled in $4.13 billion (Sweeney, 2018) The year prior, the agency hauled in a historic $5.6 billion. But lower recoveries are not indicative of lighter enforcement, according to OIG spokesperson Don White. Fraud recoveries fluctuate from year to year, based primarily on the volume of large settlements. In 2017, for example, the OIG inked a $155 million settlement with EHR vendor eClinicalWorks and Mylan paid $465 million in an EpiPen settlement. The prior year, Tenet Healthcare forked over more than $500 million (Sweeney, 2018). On another note…a little alarming because CMS does budget in a % of recovery dollars to justify their fraud investigation program. Resources Sweeney, E. (2018). OIG fraud recoveries dropped $1.2B this year. That might not be a bad thing. FierceHealthcare.com. Retrieved from: https://www.fiercehealthcare.com/payer/oig-fraud-recoveries-dropped-almost-1-2-b-year-might-not-be-a-bad-thing
Check out our FREE 30-minute webinar for OASIS-C2 corrections and more. Select Connects with Clinicians Click here to read more.
Select Data is committed to a strong compliance program that includes educating all personnel on mitigating HIPAA breaches. For more information about Select Data and their commitment to quality in Home Health and Hospice, call 1.800. 332.0555.

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CMS Finalizes PDGM: PPS Final Rule Increases HHA’s Payments for 2019

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Clinical Practices, Healthcare, Legislation, Payment Rates, PDGM, Value-Based Purchasing

CMS Finalizes PDGM: PPS Final Rule Increases HHA's Payments for 2019

PPS final rule increases agencies' payments for 2019, finalizes PDGM

 
Wednesday, October 31, 2018, according to Decision Health, CMS has finalized a plan to launch a budget-neutral payment model for home health that utilizes 30-day periods of care and stops using the number of therapy visits to determine payment. That’s according to the 2019 PPS final rule posted Oct. 31 on the Federal Register website. The Patient-Driven Groupings Model (PDGM) will launch “on or after” Jan. 1, 2020, according to the final rule. That language differs from the proposed rule, when CMS indicated PDGM would start on Jan. 1, 2020 (Decision Health, 2018). Additionally, another major change with the final rule is that PDGM will have 432 HHRGs - which is of course double the number of HHRGs outlined in the proposed rule. Home health agencies have spoken and CMS has listened. The change is also likely to the 12 clinical groups that capture the most common primary diagnoses in home health. In the proposed rule, CMS only had sought six clinical groups: musculoskeletal rehabilitation, neuro/stroke rehabilitation, wounds, behavioral health care, complex nursing interventions and medication management, teaching and assessment (MMTA) (Decision Health, 2018). CMS wrote, “We note that although we are categorizing patients into [12] groups according to the principal diagnosis, these groups do not reflect all the care being provided to the home health patient during a 30-day period of care,” CMS states in the final rule. “Home health care remains a multidisciplinary benefit. Additionally, as stated in the CY 2019 HH PPS proposed rule, we will continue to examine trends in reporting and resource utilization to determine if future changes to the clinical groupings are needed after implementation of the PDGM in CY 2020” (Decision Health, 2018).

Payments to Rise in 2019

Decision Health writes, "Adjustments to Medicare’s home health payments under the final rule will increase agencies’ total reimbursement by 2.2%, or $420 million. What this increase means is that the effects of a 2.2% home health payment update percentage are now reflected from a 0.1% increase in payments due to decreasing the fixed-dollar-loss ration mandated by the Bipartisan Budge Act of 2018. Additionally, in order to pay no more than 2.5% total payments as outlier payments, a 0.1% decrease in payments due to the new rural add-on policy by the mandate. In contrast, the 2018 PPS final rue included a 0.4% or $80, payment reduction. The PPS final rule for 2019 now opens the  door for home health agencies to get paid by Medicare Part B to administer home infusion therapy for certain payments who don't qualify for the home health benefit. However, that change would not benefit home health agencies until 2021.

Other Changes Finalized in the Rule

  • No more requirement for a physician estimate - On or after Jan. 1, 2019 the requirement that the certifying physician estimate are required to estimate how much longer skilled services are needed for continued care. Thank you CMS.
  • Value-base purchasing changes (again) - Among the biggest changes to value-based purchasing is CMS’ decision to remove two OASIS-based measures and replace three other, existing OASIS-based measures with two new composite measures designed to evaluate improvement in activities of daily living (ADLs) (Decision Health, 2018).
  • Remote patient monitoring update - It seems CMS is embracing innovation and modernization of health care by allowing the cost of remote patient monitoring to be reported by home health agencies as allowable coast on the Medicare cost report. CMS stated in the final rule, “This is expected to help foster the adoption of emerging technologies by home health agencies and result in more effective care planning, as data are shared among patients, their caregivers and their providers" (Decision Health, 2018).
Read the final PPS rule at: https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-24145.pdf Resources Centers for Medicare & Medicaid Services (2018). Center for Clinical Standards and Quality /Quality, Safety & Oversight Group. Department of Human and Health Services. CMS.gov. Retrieved from: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/QSO-18-13-HHA-.pdf Cornell Law School (2018). 42 CFR 484.60 - Condition of participation: Care planning, coordination of services, and quality of care. Legal Information Institute. Retrieved from: https://www.law.cornell.edu/cfr/text/42/484.60
Check out our FREE 30-minute webinar for OASIS-C2 corrections and more. Select Connects with Clinicians Click here to read more.
Select Data is committed to a strong compliance program that includes educating all personnel on mitigating HIPAA breaches. For more information about Select Data and their commitment to quality in Home Health and Hospice, call 1.800. 332.0555.

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American Heart Month

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Healthcare

American Heart Month

February is American Heart Month

 
Beginnings On December 30, 1963, President Lyndon B Johnson declared by order of proclamation that February would be American Heart Month. The first American Heart Month took place in February 1964. At that time more than half the deaths in the United States were caused by cardiovascular disease. Of the 10 million Americans afflicted, half were afflicted during their most productive years which resulted in a staggering physical and economic loss to the nation. Current State of Heart Disease At 17.3 million deaths, annually, heart disease and stroke remain the leading global cause of death. This number is expected to rise to more than 23.6 million by 2030. The educational efforts, that began 53 years ago, have made a difference. Currently, 27.6 million adults are diagnosed with heart disease which represents 11.5% of the population. Despite the improvements, our work in this industry is not done. Since 2014, Heart Disease remains the leading cause of death in the United States (US). With over 3.7 million patients hospitalized in 2010, Heart Disease remains the 2nd leading cause of hospitalization in the US behind childbirth with 3.9 million deaths. The most expensive procedures performed in 2015, across all ages, were heart related with heart valve procedures representing the highest cost at $51,425 per procedure. What can you do? The first thing to do is become informed. The next step is to take your knowledge and take charge of your health. You are your own best advocate. According to the American Heart Association knowing your cholesterol is vitally important, as too much cholesterol and fats can build up causing the arteries to narrow and diminishing the blood flow. This causes the heart, brain and other organs to lose its blood supply and with it oxygen and cause a heart attack or stroke. Know your numbers:
  • Cholesterol-Talk to your doctor about your numbers and how they impact you.
  • Body Mass Index (BMI) should be less than or equal to 25kg/m2
  • Blood Pressure of less than 120/80 mm/Hg
  • Fasting blood sugar of less than or equal to 100mg/dl
  • Exercise at least 150 minutes a week of moderate intensity exercise, such as brisk walking. 30 minutes a day, 5 days a week are easier numbers to remember.
The importance of Diabetes prevention and management cannot be over stressed. Diabetes is a major risk factor for stroke and heart disease. Uncontrolled Diabetes causes damage to your body’s blood vessels making them more prone to damage from high blood pressure and high cholesterol. What do we do? Select Data will continue to do what we do best and that is to ensure that the most accurate story of the patient is told in the way our researchers, government, and payers understand, through your patients’ codes. Accurate diagnosis coding provides scientists, clinical leaders, thought leaders and yes, the finance leaders with information about our population. It’s through this information they know about the population you serve, how sick your patients are, and what their true needs are. Without accurate data, diagnosis codes, smart decisions can’t be made. These diagnoses along with the data collected via the OASIS and other data collection instruments provide decision makers with valuable information on how to distribute funds, what regulations to change, where to focus research and ultimately the best setting for patient care. Each document reviewed, every code assigned paints a picture of your patient, your agency and your care. Select Data will continue to ensure that it’s correct. It’s what we do. Resources http://www.world-heart-federation.org/cardiovascular-health/cardiovascular-disease-risk-factors/diabetes/ https://www.cdc.gov/nchs/fastats/heart-disease.htm https://c2c476bb6ef038abb8b6-ab5c6310bff1587205981e56ac38a65f.ssl.cf1.rackcdn.com/wp-content/uploads/2016/05/GRFW_Get-Your-Numbers-Cardio-Health-Guide.pdf
Check out our FREE 30-minute webinar for OASIS-C2 corrections and more. Select Connects with Clinicians webinar on December 14, 2016. Click here to read more. Select Data is committed to a strong compliance program that includes educating all personnel on mitigating HIPAA breaches. For more information about Select Data and their commitment to quality in Home Health and Hospice, call 1.800. 332.0555.

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CMS Updates Pricer to Support Value Based Purchasing Model

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Clinical Practices, Compliance, Healthcare, Payment Rates

CMS Updates Pricer to Support Value Based Purchasing Model

New Payment Adjustments to HHA's

 
The 2016 Home Health Prospective Payment System (HH PPS) final rule required the implementation of the Home Health Value Based Purchasing (HHVBP) Model in nine states that represent each geographic area in the United States. All Medicare-certified HHAs that provide services in Arizona, Florida, Iowa, Maryland, Massachusetts, Nebraska, North Carolina, Tennessee and Washington will have their payment adjusted based on the HHA’s total performance score on a set of measures already reported with the Outcome and Assessment Information Set (OASIS) and the Home Health Care Consumer Assessment of Healthcare Providers and Systems (HHCAHPS) for all patients serviced by the HHA. Three new measures are included in which performance points are achieved for reporting data. The HHVBP Model, now finalized, will be tested by CMS and revisions are needed to update the HH Pricer program to accept the necessary adjustment factor and capture the adjusted amount on the claim record. MACs will place the HH VBP adjustment amount on the claim as a value code QV amount. This may be a positive or negative amount. The Pricer has been updated to reflect standardized payment amounts. CR 10167 requires that standardized amounts be calculated by Medicare systems and passed on to claims history databases using the field created for hospital standardized payment amounts. Standardized claims payment amounts are actual payment amounts adjusted to remove sources of variation not directly related to decisions to utilize care. Examples of these variations include hospital wage indexes, geographic cost indexes (GPCIs), incentive payment and penalty adjustments. CR 10167 requires system changes to ensure HH and hospice claims processing are consistent. CR 6550 created edits on hospice claims to ensure that G-codes for service visits are reported with the corresponding revenue code for the service discipline. Editing does not exist for HH claims even though the same G-codes and revenue codes are required. The system has been updated to include these edits. Providers should be aware that the MACs will return to the HHA the following claims:
  • Home health claims (TOB 032x other than 0322) reporting revenue code 042x if the HCPCS code is other than Q5001, Q5002, Q5009, G0151, G0157, or G0159
  • Home health claims (TOB 032x other than 0322) reporting revenue code 043x if the HCPCS code is other than Q5001, Q5002, Q5009, G0152, G0158, or G0160
  • Home health claims (TOB 032x other than 0322) reporting revenue code 044x if the HCPCS code is other than Q5001, Q5002, Q5009, G0153, or G0161
  • Home health claims (TOB 032x other than 0322) reporting revenue code 055x if the HCPCS code is other than Q5001, Q5002, Q5009, G0162, G0299, G0300, G0493, G0494, G0495, G0496
  • Home health claims (TOB 032x other than 0322) reporting revenue code 056x if the HCPCS code is other than Q5001, Q5002, Q5009, or G0155
  • Home health claims (TOB 032x other than 0322) reporting revenue code 057x if the HCPCS code is other than Q5001, Q5002, Q5009, or G0156
References The official instruction, CR 10167, https://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/2017Downloads /R3933CP.pdf
Check out our FREE 30-minute webinar for OASIS-C2 corrections and more. Select Connects with Clinicians Click here to read more.

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New ICD-10 Code Updates: Ask the Right Questions to Get the Right Code

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Clinical Documentation Improvement, Clinical Practices, Coding, Healthcare, ICD-10 CM, OASIS-C2, Uncategorized

New ICD-10 Code Updates: Ask the Right Questions to Get the Right Code

CMS releases updates to the ICD-10-CM coding manual

 
Every October, the CDC and CMS release updates to the ICD-10-CM coding manual. These updates include both codes in the tabular and alphabetical indexes as well as official guideline changes. The following is a summary of some of those changes that Home Health Agencies need to know about.
  • Non-pressure ulcers now have 3 new code subcategories to include those ulcers that are down to the muscle or bone but do not have necrosis and for those ulcers that have tendon/ligaments showing. The clinician should always document the severity of the non-pressure ulcer in terms of skin breakdown, fatty layer, muscle exposed, muscle exposed with necrosis, bone exposed, bone exposed with necrosis, or other appropriate descriptive terms (tendon/ligament, hard eschar, slough obscuring wound bed, etc.).
  • C Diff is now being captured as being recurrent or not stated as being recurrent. Recurrence is defined by complete resolution of C diff symptoms while on appropriate therapy, followed by subsequent return of diarrhea and other symptoms after treatment has been stopped. Recurrence usually occurs within one week after treatment stops but may happen up to 8 weeks later. The physician would need to confirm whether C diff is recurrent or not.
  • Types of myocardial infarctions now play a role in determining the appropriate ICD-10 code. Type 1 is the most common MI which is associated with ischemia and due to primary coronary even. Type 2 MI is due to imbalance in supply and demand of oxygen. Type 3, (which we wouldn’t see in home health), is sudden cardiac death, including cardiac arrest. Type 4 MIs are associated with percutaneous coronary intervention while type 5 MIs are associated with a CABG procedure.
  • Secondary pulmonary hypertension diagnosis code has been further detailed to describe what the condition is that is causing the secondary pulmonary hypertension, including left heart disease, lung disease, etc.
  • Lumbar stenosis should be classified with or without neurogenic claudication. Neurogenic claudication is leg pain with walking. The physician must confirm neurogenic claudication for it to be coded.
  • Bowel obstructions can now be captured as complete or incomplete/partial. Complete bowel obstructions would need surgery to correct while incomplete/partial bowel obstructions can be sent home for it to resolve. The coding specialists need to know whether a bowel obstruction is resolved upon discharge from the hospital. Resolved conditions cannot be coded in home health except for in OASIS items M1011 and M1017 when they reflect the patient’s recent history.
  • New coding guidelines state that if a patient’s visual category is not documented then coding specialists can only code unqualified visual loss. It would be beneficial to query the physician to determine patient’s visual category to be more specific with coding of low vision and blindness. Also, the laterality of the low vision and blindness is necessary in retrieving the most specific code.
Along with these changes come the need for increased specificity for diagnoses. To assign specified codes, coding specialists rely on clinicians and physicians to provide adequate detailed information about each diagnosis being listed on the plan of care. Without this important step, coding specialists are left to code only unspecified diagnoses, which could impact reimbursement, or cause a delay in coding as a query may be necessary. To reduce queries to your clinical leadership and clinicians, here are some tips on being proactive with detailed information:
  • Query the provider for specifics that are not included in the physician documentation prior to completing assessment.
  • Specify sites and laterality of wounds
  • Specify etiology of wounds (surgical, traumatic, diabetic, arterial, venous, etc)
  • Query the provider for late effects of CVA if there are none documented in clinical paperwork
  • List the type of MI the patient experienced
  • Always document patient’s smoking/tobacco use status (current or history of, and what product)
  • Don’t list diagnoses on the plan of care that are not actively being addressed or impacting the plan of care
  • If there are diagnoses listed on the plan of care that will likely impact it, but no direct interventions regarding those conditions are present, document how they will impact the POC
  • Document if patient’s substance disorders are in remission per physician documentation or query to determine this.
  • Document the specific type of heart failure a patient has been diagnosed with
  • Specify which type of diabetes a patient has been diagnosed with, and what, if any, manifestations are present.
For the coding specialists to capture more specific diagnoses based on the clinician’s documentation, clinicians should document in the clinical note that this specific information was provided by the physician. Clinicians can document specificity but unless there is verbiage stating that the condition is physician confirmed, the coding specialists cannot code that specific condition. Select Data enjoys working closely with clinicians to provide the codes being captured in the plan of care. It is truly a team- work experience. If you have any OASIS review or Coding questions please call Select Data at 1.800.332.0555.
Check out our FREE 30-minute webinar for OASIS-C2 corrections and more. Select Connects with Clinicians Click here to read more.

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Top 5 Questions Home Health Providers Ought To Be Asking About HHGM

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Healthcare, HHGM, OASIS-C2

Top 5 Questions Home Health Providers Ought To Be Asking About HHGM

HHGM-Game Changer?

 
HHGM proposal is expected to reduce Medicare payment to providers by up to $4 billion. Unlike the current system, the groupings model doesn’t rely on the number of therapy visits performed to influence payment. It instead will rely heavily on clinical characteristics and other patient information such as diagnosis, functional level, comorbid condition and admission source according to CMS. The changes to the payment system would address the issues MedPAC identified in the home health PPS March 2017 report that noted both the incentives and the payment levels in the current payment system needed to be overhauled. Following the recommendations from the MedPAC report, Congress is attempting through new legislation to provide the Secretary of DHHS the authority to make assumptions about provider behavior, provide notice of those assumptions and implement them through comment rule-making in CY 2019. Top 5 questions Home Health Providers ought to be asking
  1. Is Congress giving the secretary authority to set payment without constraints? According to H,R. 3992 which was introduced in the House of Representatives on October 6, the Secretary would have the authority to set payments for 30 day periods and to revise that model through notice and comment rule-making.
  2. What consequences have occurred with the MedPAC reporting? It was MedPAC who suggested to Congress that providers had been adjusting their services based on reimbursement to increase financial margin. MedPAC has stated that the ACA rebasing provisions aren’t enough and that the appearance is that home health growth is slowing, it is still growing and only appears that way statistically because five states under pre claim review and increased scrutiny have decreased their utilization. MedPAC will continue to assess for trends related to reimbursement and provider response to those patterns.
  3. Is our industry under fire because of expected industry growth? Over the past decade, a lot of attention has been paid to the baby boomers turning the Medicare age of 65. This increase in potential patients is one of the reasons home health is expected to be the fastest growing marketplace in all of healthcare for the next decade. With 82.6% of Home Health patients over the age of 65, Medicare or a Medicare Advantage plan is responsible for a large portion of payments, as such the government has a vested interest in controlling costs. Healthcare costs are controlled by decreasing the volume of people using the service, decreasing reimbursement for the service and decreasing the cost of doing business.
  4. Can HHGM actually give me greater control over my payment? The higher degree of differences in potential payment, the more control over reimbursement received. What on the surface appears to be a model composed of more straightforward categorizations is, in fact, a differentiator. Does this mean the HHGM is without problems, no, but this will most likely be ironed out over the next year.
  5. What should I do in 2019? According to Elevating Home, an agency may expect a decrease in their Medicare reimbursement up to 17% with the new HHGM payment model. The new bill proposes that HHGM be delayed until CY2020 to provide organizations with the opportunity to prepare for the changes coming, but many providers may not know where to start.
Select Data has created SmartCare which has an HHGM predictive analytics model formed by our data science team that analyzes your historical episodes and compares them to the HHGM model to identify potential loss in revenue. SmartCare will be able to provide indicators to support these predictions and will have the capability to offer observations to prevent potential loss using prescriptive analytics. With the information SmartCare can produce, providers have the opportunity to start implementing changes needed to combat the future decline in revenue. Some agencies may be more prepared than others, but with the significant impact HHGM will make, isn’t it worth a conversation? Visit us at Booth 530 at NAHC to find out how to winFREE HHGM analysis.
Check out our FREE 30-minute webinar for OASIS-C2 corrections and more. Select Connects with Clinicians webinar. Click here to read more. Select Data is committed to a strong compliance program that includes educating all personnel on mitigating HIPAA breaches. For more information about Select Data and their commitment to quality in Home Health and Hospice, call 1.800. 332.0555.

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Home Health and Hospice Industry Survey

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Healthcare

Home Health and Hospice Industry Survey

All participants in the survey will be entered into a drawing for a $100 Amazon gift card.

 
To enter to win a $100 Amazon gift card fill out your name and email address below and click the link to take the Home Health and Hospice Industry Survey 

Hurry! Survey ends October 31, 2017 at 11:59 PM PT.
Select Data is committed to a strong compliance program that includes educating all personnel on mitigating HIPAA breaches. For more information about Select Data and their commitment to quality in Home Health and Hospice, call 1.800. 332.0555.

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Coding Is A Fixed Cost-Make It A Return On Investment

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Clinical Documentation Improvement, Healthcare, Value-Based Purchasing

Coding Is A Fixed Cost-Make It A Return On Investment

Leading the way by preparing Home Health Agencies for Value-Based Purchasing

 

We help you focus on patient outcomes

Coding should provide an accurate picture of the patient's clinical condition and help drive the focus of care. Coding to the highest level of specificity is a necessary part of providing quality care. It is not enough to review the entire integrated OASIS assessment for completeness and congruency. We query the agency clinician on incongruencies between the physician orders, clinical record and patient's condition. Our process changes behavior because we engage the clinician when suggesting changes. Have you outsourced coding? Are you happy with it? Select Data provides professional coding services to Home Health and Hospice agencies and are industry experts in the language of CMS. Select Data helps reduce reportable hospital readmissions up to 40%. We assist agencies with the accurate representation of their patient. To find out how Select Data can help you improve coding accuracy check out our OASIS review and coding services. To download the more information on how Select Data reduces reportable hospital readmissions fill out the information below

   
Check out our FREE 30-minute webinar for OASIS-C2 corrections and more. Select Connects with Clinicians click here to read more.
Select Data is committed to a strong compliance program that includes educating all personnel on mitigating HIPAA breaches. For more information about Select Data and their commitment to quality in Home Health and Hospice, call 1.800. 332.0555.

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Patients Are More Than a Number

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Clinical Documentation Improvement, Clinical Practices, Healthcare, Patient Centered Medical Homes, The Affordable Care Act (ACO)

Patients Are More Than A Number. Each Deserves Their Own Portrait

At Select Data we code with an artist's brush, not a rubber stamp.

 

Quality Outcomes Matter

At Select Data we code with an artist's brush, not a rubber stamp. Coding should provide an accurate picture of the patient's clinical condition and help drive the focus of care. Coding to the highest level of specificity is a necessary part of providing quality care. In addition, our professional medical coders & billers have an average of 8+ years of Coding experience. Furthermore, the Select Data Coding and OASIS Review service improved revenue for our clients on average of 6% and a reported 40% reduction rate in hospital readmissions.

Our Process

It is not enough to review the entire integrated OASIS assessment for completeness and conguency. We query the agency clinician on incongruencies between the physician orders, clinical record and patient's condition. Our process changes the behavior because we engage the clinician when suggesting changes. So that you can focus on patient outcomes.

Our Motto

Driving outcomes guided by compassion, values and a sense of stewardship. Check out our Coding and OASIS Assessment review services today!

Helpful Tip


With over 20 years of professional coding service experience in HomeHealth and Hospice Select Data is uniquely qualified to mitigate operational challenges. Because patients are more than a number. Each deserves their own portrait. To find out more contact us today! Email us at Services@SelectData.com Or Call 866-538-CODE (2633).

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