Ambulatory Surgery/Same Day Surgical (SDS)
Vee Technologies coders review medical records and operative reports, assigning appropriate diagnosis and procedure codes for simple to complex surgeries that are performed.
Our education modules train coders on complex surgery coding skills: neurosurgeries, orthopedic surgeries, spine surgeries, and IR procedures.
Our teams remain up to date with code changes and NCCI coding requirements, preventing up coding/un bundling.
Certified surgery coders identify physician documentation deficiencies to improve medical record quality, optimizing reimbursement.
Healthcare in general, and surgery/interventional care in particular, is evolving through rapid advances in technology and increasing complexity of care, with the goal of maximizing the quality and value of care. Whereas innovations in diagnostic and therapeutic technologies have driven past improvements in the quality of surgical care, future transformation in care will be enabled by data. Conventional methodologies, such as registry studies, are limited in their scope for discovery and research, extent and complexity of data, breadth of analytical techniques, and translation or integration of research findings into patient care. We foresee the emergence of surgical/interventional data science (SDS) as a key element to addressing these limitations and creating a sustainable path toward evidence-based improvement of interventional healthcare pathways. SDS will create tools to measure, model, and quantify the pathways or processes within the context of patient health states or outcomes and use information gained to inform healthcare decisions, guidelines, best practices, policy, and training, thereby improving the safety and quality of healthcare and its value. Data are pervasive throughout the surgical care pathway; thus, SDS can impact various aspects of care, including prevention, diagnosis, intervention, or postoperative recovery. The existing literature already provides preliminary results, suggesting how a data science approach to surgical decision-making could more accurately predict severe complications using complex data from preoperative, intraoperative, and postoperative contexts, how it could support intraoperative decision-making using both existing knowledge and continuous data streams throughout the surgical care pathway, and how it could enable effective collaboration between human care providers and intelligent technologies. In addition, SDS is poised to play a central role in surgical education, for example, through objective assessments, automated virtual coaching, and robot-assisted active learning of surgical skill. However, the potential for transforming surgical care and training through SDS may only be realized through a cultural shift that not only institutionalizes technology to seamlessly capture data but also assimilates individuals with expertise in data science into clinical research teams. Furthermore, collaboration with industry partners from the inception of the discovery process promotes optimal design of data products as well as their efficient translation and commercialization. As surgery continues to evolve through advances in technology that enhance delivery of care, SDS represents a new knowledge domain to engineer surgical care of the future.
Chemists analyze illicit fentanyl down to its atoms to find out who makes it.
When agents at the US Drug Enforcement Agency (DEA) need a chemist’s perspective on fentanyl, they turn to John Casale and Jennifer Mallette. The two scientists run the DEA’s fentanyl profiling program. All the fentanyl seized by the agency comes through their lab to be analyzed, profiled, and potentially linked to other cases. Since starting the project two years ago, the team has processed 1,800 samples of illicit fentanyl and made 59 connections between samples.
Fentanyl, a synthetic opioid, is particularly dangerous because of its potency—it’s up to 50 times stronger than heroin and up to 100 times stronger than morphine. Just two milligrams of pure fentanyl, as much as a few grains of table salt, is a deadly dose for most people. This is causing an unprecedented number of overdose deaths in the United States. To stem this tide, DEA agents need to know as much as possible about the fentanyl they seize.
Chemists’ expertise helps agents
The chemical profiles generated by the project reveal whether fentanyl brought into the lab is connected to any previous DEA cases. Casale and his team pass that information on to the responsible agents. “We’re basically just giving them a lead, and they look and figure out what the connection is,” said Casale. “The agents we’re doing these samples for are ecstatic about it.”
That’s because just knowing that two fentanyl seizures are related is often enough to move a DEA investigation forward. In one case, the lab connected the manufacturer of illicit fentanyl tablets, to a distributor, all the way down to tablets seized on the streets. “It does make an impact,” said Casale, “and investigations are recognized based at least in part on the work that we do.”
Fentanyl seized by the DEA is analyzed down to its atoms
The first thing the chemists do when a sample is brought to their lab is determine how much fentanyl is actually in it. Because fentanyl is so powerful, the samples are mostly made up of other compounds. Typically, fentanyl smuggled into the US across the Mexican border is five to seven percent fentanyl. “We do see direct shipments coming from China that are very high purity, but those are rare,” says Casale.
The analysis goes down to the atomic level—fentanyl’s isotopic signatures vary depending on the ingredients used to produce it. The team also examine what components other than fentanyl are in the sample and find traces of the solvents used in the manufacturing process.
One thing Casale can’t tell from the chemical signature alone is where the fentanyl he’s analyzing was produced. “People always ask if we can tell whether this fentanyl came from China or Mexico,” says Casale. “The answer is no.” Plant-based drugs like heroin and cocaine have signature molecules that reveal where the plants used to make them were grown. That doesn’t work with fentanyl, because it’s completely synthetic. The ingredients could come from anywhere.
But the group is working to expand the project and extract other useful information from the fentanyl they analyze. For example, they’re exploring a way to identify synthetic impurities associated with different production methods. This would tell investigators to be on the lookout for someone buying specific starting materials.
The DEA data may also have public health applications. “It shows what the samples look like, what people are using on the street,” Mallette explains. The scientists’ analysis can also provide information about where fentanyl is being seized, purity levels by state, and the various fentanyl analogues they’ve seen.
Other forensic scientists are taking notice
The impact of Casale and Mallette’s work reaches beyond the DEA. It’s being followed by forensic scientists at law enforcement agencies around the world, including Hong Kong, Germany, and Brazil. “Either for handling fentanyl and fentanyl derivates in case of seizures, or in aspects of analyzing them, I need as much information as possible,” said Thorsten Rößler, an analytical chemist at Germany’s Federal Criminal Police Office who subscribes to the project’s updates on ResearchGate.
Benny Lum of the Broward County Sheriff’s Office in Fort Lauderdale, Florida also follows the DEA scientists’ progress. “We strongly believe in the work John’s team is doing, because it gives us insight as to why the selection of different chemical compounds are used to dilute or add to the case samples. His resources are vast compared to our regional resources, and his findings aid us in keeping on top of trends,” he said.
Researchers have discovered a new gene called SCN3A which helps us speak and swallow.
The discovery of SCN3A came with the help of a handful of families who all have a rare brain disease called polymicrogyria. By looking at genetic similarities across the families, researchers found that a mutated SCN3A gene was the culprit.
The SCN3A gene is primarily active during fetal brain development but when mutated it causes a language area of the brain to develop lots of small folds, like a cauliflower. People with the disease often have impaired oral motor development, resulting in difficulties with swallowing, tongue movement and word articulation.
By linking a new gene with polymicrogyria and speaking and swallowing, researchers are just beginning to understand the role this gene plays in the human brain and in speech development.
We spoke with Richard S Smith from Boston Children’s Hospital about the work.
What is polymicrogyria?
Richard Smith: Polymicrogyria is a brain disease in which the outer regions of the cerebral cortex generate too many peaks and valleys (gyri and sulci). The literal Greek translation is many (poly-), small (-micro), folds (-gyri).
Supplier discounts and staffing strategies are all well and good, but if you’re looking to combat rising business costs in a meaningful way your best bet is effective coding. The procedural (CPT) and diagnostic (ICD-9) codes used to submit claims for reimbursement dictate how much – and whether – your providers get paid for the work they do. Thus, it’s important to ensure your front- and back-office coding procedures are optimized for success.
That means taking steps to minimize denials, training to ensure you’re not undercoding (a common problem), and readying your defenses to appeal rejected claims as needed. Such efforts can make or break your bottom line as the industry transitions to the more complex ICD-10 code set this fall.
Here’s how billing and coding experts say practices can begin to code more accurately, and effectively:
- LEARN FROM DENIALS
According to the Medical Group Management Association (MGMA), better-performing practices report a claims denial rate of fewer than 5 percent. If your rate is higher, you must diagnose the problem. The most common reasons for rejected claims can be easily remedied by using software that flags errors and omissions before they go out the door, says Mary Pat Whaley, a certified professional coder and medical practice consultant with Manage My Practice in Durham, N.C. That includes missing information, (such as prior authorization or dates of service), insufficient documentation, coding errors related to the place of service, missing modifiers, and late submissions (each payer has its own deadline for filing claims).
Confusion over primary and secondary insurance may also contribute to kicked-back claims. Secondary payers will usually deny a claim that gets submitted without the primary payer’s explanation of benefit information. You may also get denied for Medicare claims that do not include a signed Advanced Beneficiary Notice of Noncoverage, or a waiver of liability, which documents if the patient is willing to assume financial responsibility for services not covered by insurance.
Finally, Medicare and other payers frequently deny claims for services deemed “not medically necessary,” either because the diagnosis does not align with the service or because it’s covered only at certain frequencies. Such denials can be minimized by confirming insurance coverage and authorizations prior to each visit, says Whaley.
Some payers are more particular than others. It pays to identify those that deny reimbursement most often, so you can ensure those claims are clean the first time around. Indeed, the process of resubmitting is a drain on productivity.
- COMMUNICATE WITH PATIENTS
By understanding the payment policies of their payers, front-desk staff can work more closely with patients to verify correct insurance information, explain the coverage policies of each plan, and submit claims accurately so the claim adjudicates correctly on the first submission, says Laura Palmer, director of professional development at the MGMA. Be knowledgeable and transparent about your policies and communicate them with your patients, she advises.
- TRAIN YOUR PHYSICIANS
To benefit from better coding both before and after the switch to ICD-10, additional training is likely required. Perhaps the best way to help physicians improve their coding accuracy is to spend 10 minutes per month at physician meetings having them read a blinded note and coding it together with a certified coder, says Whaley. “Sometimes, physicians can also benefit from having a coder shadow and scribe the visit in addition to the physician’s documentation to compare what each comes up with,” she says. “You would be surprised how often a physician forgets to say, ‘I reviewed the … lab results, X-rays, consultation report, etc.’ It’s something very simple, but, if it wasn’t documented, it wasn’t done.” Such omissions result in undercoding, which leaves money on the table.
- IDENTIFY A CODING CZAR
Consider, too, appointing a coding czar – someone in-house who is trained to track and trend claims, says Rachel Mitchell, director of client services for Applied Medical Systems, a medical practice management firm in Durham, N.C. As they do for claims submissions, most payers have deadlines for resubmitting claims and filing appeals. Your coding point person should flag any claims that have not been paid as the filing deadline draws near, in case the payer never received it, or rejects it with no time left to resubmit.
- STAND YOUR GROUND
In an era of shrinking reimbursement, practices must also be prepared to fight for what’s rightfully theirs. It takes time and effort, but appeals often pay dividends. “Sometimes you have to go to bat when you keep getting things denied and you know it’s wrong,” says Whaley. “You may have to go a couple of levels up the chain of command to appeal and let the payer know they have something wrong in their system. Don’t overlook the idea that the payer’s system may be wrong.”
Finally, Palmer adds that practices should review the list of payable diagnoses when their claim is denied for medical necessity or the service is not covered as part of the benefits. And always appeal in writing following the provider manual guidelines. “Be specific about why the claim should be paid,” she says. “Submit supporting documentation. Track appeal results and timing.”
If you haven’t made proper coding a top priority for your practice, there’s no time to lose. Indeed, successful coding is your single best defense against rising costs and shrinking reimbursement. Amid the pending conversion to ICD-10, it is also the best way to minimize disruption to your future income stream.
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