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C FMG MA 2016 C MS FO C US & 2017 IC D- 10 UPDAT ES PRE SE NT E D BY: T RI SH ST ONE , RHI A, CPMA, CHSP, CPC, AHI MA APPROVE D I CD-10-CM/ PCS T RAI NE R AGENDA Compliance 1. Security Risk Analysis: A Foundation for HIPAA

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SLIDE 1

PRE SE NT E D BY: T RI SH ST ONE , RHI A, CPMA, CHSP, CPC, AHI MA APPROVE D I CD-10-CM/ PCS T RAI NE R

C FMG MA 2016 C MS FO C US & 2017 IC D- 10 UPDAT ES

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SLIDE 2

2

AGENDA

Compliance

  • 1. Security Risk Analysis: A Foundation for HIPAA Compliance
  • 2. Billing Audits: Showing your Intent
  • 3. Effective Documentation: E/M Coding

ICD‐10 Updates 2017

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SLIDE 3

COMPL IANCE PR OGR AM

Can yo u affo rd to lo se Me dic are and Me dic aid inc o me ?

Sinc e 2010, a c o mplia nc e pro g ra m ha s b e e n

r e quir e d fo r Me dic a re a nd Me dic a id pro vide rs.

8/ 23/ 2016 3

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SLIDE 4

WHAT IS A COMPL IANCE PR OGR AM?

  • Ope ra tio n Ma nua l
  • HI

PAA po lic e s a nd pro c e dure s Ma nua l

  • Co ding c o mplia nc e pla n
  • T

he de ta ile d po lic ie s a nd pro c e dure s tha t insure the c o ding a nd b illing pro c e sse s c o mply with a ll rule s a nd g uide line s.

8/ 23/ 2016 4

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SLIDE 5

COMPL I ANCE : # 1

Se c ur ity R isk Analysis:

A F

  • unda tio n fo r

HI PAA Co mplia nc e

8/ 23/ 2016 5

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SLIDE 6

HIPAA

  • Se ts rule s fo r pro te c tio n o f e PHI
  • HI

PAA a pplie s to a b e wilde ring va rie ty o f

  • rg a niza tio ns, fro m o ne - do c to r pra c tic e s to va st

me dic a l syste ms, to e ve ry kind o f spe c ia lty, a nd to Busine ss Asso c ia te s

9/ 17/ 2015 6

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SLIDE 7

A F OUNDAT ION F OR COMPL IANCE

E ve r y or ganization should c omple te thr e e pr

  • c e sse s to

lay a foundation for HIPAA c omplianc e :

1. Co nduc t a Se c urity Risk Ana lysis 2. I mple me nt upda te d HI PAA do c ume nta tio n, inc luding po lic e s a nd pro c e dure s, BA Ag re e me nts, a nd the No tic e o f Priva c y Pra c tic e s 3. Co mple te a nd Do c ume nt HI PAA Co mplia nc e T ra ining

9/ 17/ 2015 7

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SLIDE 8

T HE PR IVACY R UL E

1. Pro te c ts e ve ry fo rm o f PHI , whe the r e le c tro nic , writte n, ve rb a l,

  • r o the rwise

2. Go ve rns use a nd disc lo sure o f PHI 3. Gua ra nte e s pa tie nts the rig ht to a c c e ss the ir o wn PHI 4. Pa tie nts ha ve the rig ht to ma na g e the disc lo sure o f the ir PHI

8

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SLIDE 9

T HE PR IVACY R UL E – COR E PR INCIPL E

Minimum Ne c e ssa ry

  • 1. Busine ss Asso c ia te s c a n a c c e ss PHI
  • nly if it is

ne c e ssa ry to the ir se rvic e s

  • 2. Only the minimum ne c e ssa ry info rma tio n fo r a

le g itima te purpo se sho uld b e sha re d

9

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SLIDE 10

T HE SE CUR IT Y R ISK ANAL YSIS

  • T

he Se c urity Risk Ana lysis is the first a nd mo st impo rta nt re q uire me nt o f the Se c urity Rule

  • Co nsists o f thre e pa rts
  • Risk Asse ssme nt, a de ta ile d list o f a sse ssme nt q ue stio ns

b a se d o n ONC/ OCR/ NI ST g uide line s

  • I

T I nfra struc ture Asse ssme nt

  • Pro duc e s de ta ile d re me dia tio n re po rt to c lo se

c o mplia nc e g a ps

9/ 17/ 2015 10

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SLIDE 11

WE L COME T O T HE CIA

  • T

he Se c urity Rule c o nc e rns the Co nfide ntia lity, I nte g rity, a nd Ava ila b ility (CI A) o f e PHI

  • T

he Se c urity Rule re q uire s te c hno lo g y me a sure s suc h a s fire wa lls, b ut the prima ry g o a l is to c re a te a “c ulture o f c o mplia nc e ”

  • A c ulture o f c o mplia nc e is re a lize d thro ug h pro pe r

po lic ie s a nd pro c e dure s, tra ining o n tho se po lic ie s a nd pro c e dure s, a nd sa nc tio ns fo r fa iling to fo llo w the rule s

9/ 17/ 2015 11

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SLIDE 12

R E QUIR E D OR ADDR E SSABL E ?

  • Spe c ific a tio ns a re e ithe r Re q uire d o r Addre ssa b le
  • Addre ssa b le do e s NOTme a n o ptio na l
  • Addre ssa b le spe c ific a tio ns a llo w mo re fle xib ility, b ut
  • rg a niza tio ns must do c ume nt why the spe c ific a tio n do e s

no t a pply o r de mo nstra te a n a lte rna tive me tho d o f sa tisfying it

9/ 17/ 2015 12

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SLIDE 13

BR E ACHE S

  • I

nve stig a tio ns c o me in re spo nse to b re a c h re po rts, pa tie nt c o mpla ints, a nd whistle b lo we rs

  • A b re a c h typic a lly le a ds to a n inve stig a tio n tha t

e xpo se s ma ny o the r vio la tio ns, inc re a sing fine s

  • T

he “Wa ll o f Sha me ” ha s mo re tha n 1,300 b re a c he s

  • f 500+ re c o rds

9/ 17/ 2015 13

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SLIDE 14

WHAT IS A BR E ACH?

  • Me re ly lo sing c o ntro l o f PHI

is a b re a c h, e ve n if the re is no e vide nc e tha t the da ta wa s e ve r a c c e sse d

❖ L

  • ss o r the ft o f ha rdwa re sto ring PHI

is a b re a c h

  • Una utho rize d a c c e ss is a b re a c h

❖ A pro vide r who sno o ps in a he a lth re c o rd b ut is no t

invo lve d in c a re

  • Una utho rize d disc lo sure

❖ F

a xing PHI to the wro ng pa tie nt

9/ 17/ 2015 14

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SLIDE 15

NOT IF ICAT ION R E QUIR E ME NT S – 500+

  • Pa tie nts must b e info rme d o f a b re a c h within 60 da ys o f

disc o ve ry

  • Pa tie nts sho uld b e info rme d b y le tte r whe ne ve r po ssib le
  • Busine ss Asso c ia te s must info rm Co ve re d E

ntitie s o f a ny b re a c h, a nd the Co ve re d E ntity must info rm pa tie nts

  • F
  • r b re a c he s o f 500 r

e c or ds or mor e, HHS must b e

info rme d within 60 da ys, a nd the b re a c h will b e liste d o n the “Wa ll o f Sha me ”

9/ 17/ 2015 15

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SLIDE 16

NOT IF ICAT ION R E QUIR E ME NT S – <500

  • F
  • r b re a c he s o f fe we r than 500 re c o rds, the
  • rg a niza tio n must info rm HHS a nnua lly, within 60 da ys
  • f the e nd o f the ye a r
  • Ste ps to a ddre ss

1. I nc ide nt Re po rt 2. I nc ide nt inve stig a tio n 3. I nc ide nt T ra c king lo g

9/ 17/ 2015 16

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SLIDE 17

AUDIT PR OT OCOL E XAMPL E

Sanc tion Polic y Audit Pr

  • toc ol:
  • 1. I

nq uire a b o ut fo rma l pro c e ss

  • 2. Ob ta in a nd re vie w the fo rma l do c ume nta tio n
  • 3. E

va lua te c o nte nt

  • 4. Ob ta in e vide nc e
  • 5. De te rmine

9/ 17/ 2015 17

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SLIDE 18

HIPAA TRAINING

8/ 23/ 2016 18

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SLIDE 19

2016 SRA TOOL WORKSHEET

8/ 23/ 2016 19

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SLIDE 20

SRA MI T I GAT I ON RE PORT

8/ 23/ 2016 20

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SLIDE 21

COMPL I ANCE : # 2

Billing Audits: Sho wing yo ur I nte nt

21

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SLIDE 22

CMS ANNOUNCE S

  • CMS F

ina l Rule Sta te s:

  • Me dic a re Pro vide rs L

ia b le F

  • r Six Ye a rs Of Ove rpa yme nts.
  • I

nc re a sing the numb e r o f RAC a udits in 2016.

  • E

xpa nd RAC a udit pro g ra m to Me dic a re Adva nta g e

8/ 23/ 2016 22

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SLIDE 23

WHY PE R F OR M AN AUDIT ?

  • Ide ntific ation/ Suspic ion of Pr

ac tic e De fic ie nc ie s

  • Pote ntial Me ans to ide ntify Misse d/ Additional R

e ve nue

  • R

e duc e Payme nt De nials

  • Complianc e

8/ 23/ 2016 23

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SLIDE 24

WHAT IS A CHAR T AUDIT ?

An unb ia se d re vie w o f a ra ndo m se le c tio n o f e nc o unte rs pe r c linic ia n 1. I de ntify Disc re pa nc ie s

Unde rc o ding , o ve r-c o ding , misc o ding , no n-c o mplia nc e

2. Re c o mme nd E

nha nc e me nts

Co ding , b illing , do c ume nta tio n pro c e sse s a nd re ve nue c yc le

3. Mitig a te Disc iplina ry Ac tio ns a nd F

ine s

T hird pa rty c a rrie rs, fe de ra l, sta te , a nd o the r re g ula to ry a g e nc ie s

8/ 23/ 2016 24

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SLIDE 25

AVE R AGE PE R CE NT OF E R R OR S

8/ 23/ 2016 25

  • CMS e stima te s tha t 30% to 40% o f me dic a l b ills c o nta in

e rro rs

  • T

he Ac c e ss Pro je c t, a Bo sto n-b a se d he a lth-c a re a dvo c a c y g ro up, sa ys it ma y b e a s hig h a s 80%

  • Audits we ’ ve c o nduc te d o ve r the pa st ye a r ha ve e rro r

re sults ra ng ing b e twe e n 20% - 85%

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SLIDE 26

IT COME S DOWN T O YOUR INT E NT !

T he F

alse Claims Ac t (F

CA) impo se s c ivil lia b ility o n any pe r

son who kno wing ly sub mits, o r

c a use s to b e sub mitte d, a fa lse o r fra udule nt c la im to the Go ve rnme nt. T he “knowing” sta nda rd inc lude s a c tio ns re la te d to the truth o f the c la im:

  • De lib e ra te I

g no ra nc e

  • Re c kle ss Disre g a rd

Civil pe naltie s fo r vio la ting the F

CA ma y inc lude :

  • F

ine s o f $5,500 - $11,000 pe r inc ide nt

  • AND Up to 3 time s the a mo unt o f da ma g e s susta ine d b y the Go ve rnme nt a s a re sult o f the

fa lse c la ims.

(E x: 57 e nc ounte r s r e sulting in an ove r payme nt of $4,560. $4,560 x 3 = $13,680. Possible fine s: $313,500 - $627,000)

T he re a lso is a c r

iminal F

CA (18 U.S.C. Se c tio n 287).

  • Cr

iminal pe naltie s fo r sub mitting fa lse c la ims ma y inc lude fine s, impriso nme nt, o r b o th.

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SLIDE 27

DE T E R MINE T HE CODE

8/ 23/ 2016 27

Ne w Patie nt (3/ 3)

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SLIDE 28

DE T E R MINE T HE CODE

8/ 23/ 2016 28

E stablishe d Patie nt (2/ 3)

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SLIDE 29

E NCOUNT E R / CHAR T AUDIT DE L IVE R ABL E S:

  • Co mple te d a udit she e ts a nd summa ry re po rts fo r

e a c h pro vide r

  • Org a niza tio na l a udit summa ry re po rt
  • F

ina l me e ting fo r pre se nta tio n a nd re vie w o f a udits/ summa ry re po rts pe r pro vide r a nd o rg a niza tio n

8/ 23/ 2016 29

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SLIDE 30

INT E NT T O COMPL Y

8/ 23/ 2016 30

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SLIDE 31

COMPL I ANCE : # 3

E ffe c tive Doc ume ntation: E / M Coding

8/ 23/ 2016 31

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SLIDE 32

E F F E CT IVE DOCUME NT AT ION

E / M, CPT , a nd I CD-10-CM Co de s: Assure me dic a lly ne c e ssa ry se rvic e s we re pro vide d “I f it isn’ t do c ume nte d, it didn’ t ha ppe n!!”

32

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SLIDE 33

DOCUME NT AT ION SPE CIF ICIT Y

I de ntify mo st c o mmo n Dx b y physic ia n De te rmine if do c ume nta tio n suppo rts the le ve l o f de ta il fo r the c o de s se le c te d

8/ 23/ 2016 33

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SLIDE 34

E VAL UAT ING YOUR DOCUME NT AT ION

Asse ss the q ua lity o f me dic a l re c o rd do c ume nta tio n Asse ss the impa c t o n:

  • 1. Co ding & Billing

a . Pro duc tivity b . Ac c ura c y

  • 2. $$$ I

mpa c t o n Re ve nue Cyc le

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SLIDE 35

E VAL UAT ING YOUR DOCUME NT AT ION

  • I

s the Chie f Co mpla int do c ume nte d?

  • Do e s do c ume nta tio n suppo rt the E

/ M L e ve l c la ime d?

  • I

s the dia g no sis do c ume nte d to the hig he st spe c ific ity?

  • I

s the a sse ssme nt o f the pa tie nt’ s c o nditio n a ppa re nt in the me dic a l re c o rd?

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SLIDE 36

DE NIAL S

8/ 23/ 2016 36

  • 1. Pa tie nt re g istra tio n e rro rs
  • 2. L

a c k o f re fe rra l/ a utho riza tio n

  • 3. I

nc o rre c t dia g no sis c o de s

  • 4. Me dic a l Ne c e ssity
  • 5. Duplic a te b illing
  • 6. T

ime ly filing

  • 7. Cha ng e s to pa ye rs’ o rg a niza tio ns

Common R e asons for Claim De nials:

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SLIDE 37

APPE AL S

Na tio na lly, o nly 35% o f pro vide rs a ppe a l the ir de nie d c la ims.

8/ 23/ 2016 37

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SLIDE 38

PR OCE SSE S

38

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SLIDE 39

E DUCAT ION PR OGR AM

  • F
  • c use s o n Re me dia tio n Pla n
  • Suppo rts the Co mplia nc e Pro g ra m
  • Pro vide s Me dic a l sta ff e duc a tio n o n the c o rre c t me tho ds

Do c ume nta tio n

Co ding

Pro c e sse s

  • Optimize s re sults a nd le a ds to b e tte r da ta q ua lity

8/ 23/ 2016 39

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SLIDE 40

I CD-10

2017 ICD-10 Update s

40

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SLIDE 41

2017 I CD-10 UPDAT E S

ICD-10-CM

487 c o de re visio ns 1,928 ne w dia g no sis c o de s 305 de le tio ns

ICD-10-PCS

3,651 ne w pro c e dure c o de s Ro o t Ope ra tio n c ha ng e s

8/ 23/ 2016 41

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SLIDE 42

2017 I CD-10-PCS

Big g e st c ha ng e s/ re visio n

  • Ro o t Ope ra tio ns De finitio ns
  • Co ntro l a nd Cre a tio n
  • Ne w Ro o t Ope ra tio n
  • Pe rfusio n
  • Bo dy Pa rt T

e rmino lo g y Cha ng e d

  • He a rt a nd Gre a t Ve sse ls Bo dy Syste m.

8/ 23/ 2016 42

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SLIDE 43

2017 I CD-10-CM

8/ 23/ 2016 43

Adde nda Change s:

I nde x (90 pa g e s) T a b le o f Drug s a nd Che mic a ls (2 pa g e s), Ne o pla sm T a b le (11 pa g e s), E xte rna l Ca use I nde x (9 pa g e s), a nd T a b ula r (160 pa g e s)

Missing F ile

2017 I CD-10-CM Offic ia l Co ding & Re po rting Guide line s.

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SLIDE 44

I NDE X ADDE NDA

44

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SLIDE 45

T ABUL AR ADDE NDA

8/ 23/ 2016 45

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SLIDE 46

CHAPT E RS 1 - 5

Chapte r 1 (I nfe c tio us a nd Pa ra sitic Dise a se s) Chapte r 2 (Ne o pla sms) Chapte r 3 (Dise a se s o f Blo o d a nd Blo o d F

  • rming Org a ns a nd

Ce rta in Diso rde rs I nvo lving the I mmune Me c ha nism) Chapte r 4 (E ndo c rine , Me ta b o lic , a nd Nutritio na l Dise a se s) Chapte r 5 (Me nta l, Be ha vio ra l, a nd Ne uro de ve lo pme nta l Diso rde rs)

8/ 23/ 2016 46

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SLIDE 47

CHAPT E RS 6 - 13

Chapte r 6 (Dise a se s o f the Ne rvo us Syste m) Chapte r 7 (Dise a se s o f the E ye a nd Adne xa ) Chapte r 8 (Dise a se s o f the E a r a nd Ma sto id Pro c e ss) Chapte r 9 (Dise a se s o f the Circ ula to ry Syste m) Chapte r 10 (Dise a se s o f the Re spira to ry Syste m) Chapte r 11 (Dise a se s o f the Dig e stive Syste m) Chapte r 12 (Dise a se s o f the Skin a nd Sub c uta ne o us T issue ) Chapte r 13 (Dise a se s o f the Musc ulo ske le ta l Syste m a nd Co nne c tive T issue )

47

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SLIDE 48

CHAPT E RS 14 - 21

Chapte r 14 (Dise a se s o f the Ge nito urina ry Syste m) Chapte r 15 (Pre g na nc y, Childb irth, a nd Pue rpe rium) Chapte r 16 (Ce rta in Co nditio ns Orig ina ting in the Pe rina ta l Pe rio d) Chapte r 17 (Co ng e nita l Ma lfo rma tio ns, De fo rma tio ns, Chro mo so ma l Ab no rma litie s) Chapte r 18 (Sympto ms, Sig ns, a nd Ab no rma l Clinic a l a nd L

a b o ra to ry F inding s)

Chapte r 19 (I

njurie s, Po iso ning , a nd Ce rta in Othe r Co nse q ue nc e s o f E xte rna l Ca use s)

Chapte r 20 (E

xte rna l Ca use s o f Mo rb idity)

Chapte r 21 (F

a c to rs I nflue nc ing He a lth Sta tus a nd Co nta c t with He a lth Se rvic e s)

8/ 23/ 2016 48

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SLIDE 49

APPROACH - E VAL UAT E

8/ 23/ 2016 49

Yo ur Co mplia nc e Pro g ra m Pro vide r E nc o unte r Do c ume nta tio n to Cla ims (CPT & I CD-10 c o de s) Co re Dia g no sis a nd/ o r pro c e dure c o de s

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SLIDE 50

UCF RE C SE RVI CE S

WE PR OVIDE

  • Billing Audits
  • E

va lua tio n a nd Ma na g e me nt (E / M) Co ding & Do c ume nta tio n T ra ining

  • HI

PAA T ra ining (Annua l o r Priva c y & Se c urity Offic e r)

  • I

CD-10 T ra ining b y Spe c ia lty

  • Co ding Co mplia nc e Pla n De ve lo pme nt
  • HI

PAA Po lic y & Pro c e dure Ma nua l De ve lo pme nt

  • Se c urity Risk Asse ssme nts
  • Ope ra tio ns Ma nua l De ve lo pme nt
  • MACRA E

duc a tio n

  • E

HR Syste m E va lua tio n, Se le c tio n a nd I mple me nta tio n

  • Me a ning ful Use Suppo rt
  • Audit Pre pa re dne ss
  • Pa tie nt Ce nte re d Me dic a l Ho me (PCMH) T

ra nsfo rma tio n

  • He a lthc a re Ana lytic s

50

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SLIDE 51

QUE ST IONS?

51

T r ish Stone , R HIA, CPMA, CHSP, CPC, AHIMA Appr

  • ve d ICD-10-CM/ PCS T

r aine r Pr

  • gr

am Manage r – R e ve nue Cyc le , T r aining & E duc ation tstone @uc f-r e c .or g