Welcome to the 6 th Annual ACMA Kentucky / Tennessee Chapter Case Management Conference
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1 Welcome to the 6 th Annual ACMA Kentucky / Tennessee Chapter Case Management Conference
2 The ICD-10 Coding System & Impact on CM/SW/UM 3M Health Information Systems ACMA KY/TN Chapter Education Joyce Mosier, MBA, RN, CPHQ, ACM September 6, M All rights reserved. Confidential and Proprietary.
3 Objectives Explain the premise of ICD-10-CM/PCS ICD-10 impact for Case Management, Social Work and Utilization Management Assess ways Case Management, Utilization Management and Social Work can benefit from this system 2
4 3M Health Information Systems 3M Health Information Systems Global use of ICD-10: US Catching up with the Industrialized World Canada United States Iceland Sweden Norway Finland Denmark Poland Ireland UK Germany The Netherlands Czech Republic Austria France Switzerland China Japan Costa Rica Colombia Venezuela Thailand Brazil Singapore Argentina Australia New Zealand 3
5 Overview The United States has been using ICD-9-CM since 1979 and is the last industrialized nation to move to ICD-10. On January 16, 2009, CMS published final rule CMS-0013-F mandating the adoption of the ICD-10-CM and ICD-10-PCS code sets to replace ICD-9-CM under HIPAA. The original compliance date for implementation was October 1, 2013, however CMS has announced a delay for some entities--the date of implementation is pending. The delay allows more time for hospitals and physicians to prepare for the ICD-10 transition. 4
6 The Need for ICD-10 The ICD-9-CM code set is 30+ years old. ICD-9 is no longer supported or maintained by the World Health Organization (ICD-10 was adopted by WHO in 1990). Difficulty in assigning new codes Many chapters of ICD-9-CM are full Valuable new codes are not implemented due to insufficient space. ICD-9 is not able to provide sufficient codes for healthcare encounters for reasons other than disease (e.g. preventive care). Terminology often insufficient, obsolete and inconsistent with current medical practice and the medical technology being developed and in use today. ICD-9-CM does not meet all HIPAA requirements for adopted standards. 5
7 Federal Register January 16, 2009
8 The Need for ICD-10 ICD-10 is needed to obtain full benefit for: Updated medical terminology more consistent with the 21 st century Tracking of diseases/procedures/preventative care Better measuring of quality outcomes - Improved data allows for more accurate severity of illness and risk of mortality data for profiling Data exchange Full use of HIT tools and technology (e.g. computer assisted coding, computer assisted coding for clinical documentation improvement, computer assisted coding for physician documentation) Better specificity of medical necessity criteria Improved data allows for more accurate reimbursement for services provided Procedure coding system allows for expansion and addition of new technology 7
9 Requirements for ICD-10-CM and ICD-10 PCS Use of ICD-10-CM and ICD-10-PCS applies to all covered entities (health care providers, health plans, and healthcare clearing houses) that transmit electronic data based on the Health Insurance Portability and Accountability Act (HIPAA) transaction standards. ICD-10-PCS codes are only required to be used by hospitals to report inpatient procedures. CPT codes will continue to be used for outpatient and physician billing. However, some entities (hospitals, ambulatory surgery centers, etc) are choosing to assign ICD-10- PCS codes in their ambulatory settings even though it is not mandated.. 8
10 New Code Set Effective? Diagnosis ICD-9 CM ICD-10 CM In & Outpatient In & Outpatient # of Codes ~13,000 ~70,000 # of Characters 3-5 Alphanumeric 3-7 Alphanumeric Procedures ICD-9 CM Inpatient Only ICD-10 PCS Inpatient Only # of Codes ~4,000 ~72,000 # of Characters 3-4 Numeric 7 Alphanumeric NOTE: CPT codes will continue to be used for hospital outpatient procedure coding 9
11 3M Health Information Systems ICD-10-CM Diagnosis Coding 10
12 Examples of ICD-9 and ICD-10 Diagnosis Codes Acute Anterior MI I21.09 CHF I50.9 CAD w/ Angina , I MVP I
13 Documentation for Cardiology/Cardiothoracic Diagnoses Myocardial infarction Documentation will need to include: Type of infarction STEMI NSTEMI Age of infarction If within 4 weeks coded as initial If older than 4 weeks coded as old Specific site of myocardium involved anterior wall inferior wall Coronary artery involved Information regarding treatment - initial or subsequent MI 12
14 Unique ICD-10-CM Guidelines Circulatory System Acute Myocardial Infarctions (AMI) are identified by the site of the infarction along with the coronary artery involved. The acute phase of the AMI is within 4 weeks of onset. If a patient suffers a subsequent AMI within 4 weeks, a code for both conditions is used, and sequencing depends on the reason for admission. Note the change in the age of the MI. In ICD-9-CM it was 8 weeks. In ICD- 10-CM it is 4 weeks. Think about past data comparing subsequent MI prevalence to current episodes of subsequent MI occurrence. What impact might that have on data assessment of related outcomes? A combination (single) code identifies both ASHD or CAD and angina. 13
15 Documentation Changes Combination codes - In some cases a single code has been established to classify: 2 diagnoses A diagnosis with a manifestation or secondary process A diagnosis with a complication Examples: Pathological compression fracture of the vertebrae due to osteoporosis, initial visit - M80.08xA Type 2 DM with gastroparesis E11.43 Stage III Pressure Ulcer R. Heel L CAD with unstable angina I Diverticulitis, large intestine with perforation, abscess and bleeding K
16 Documentation for Cardiology/Cardiothoracic Diagnoses Hypertension HTN and chronic kidney disease are assumed to be a causal relationship; however, it is important to document the stage of the CKD HTN and heart disease are not assumed to be linked and must be documented when related. It is also important to state if heart failure is present. Examples include: Heart disease due to hypertension Hypertensive heart disease Hypertensive heart disease and CKD with heart failure and Stage 4 CKD CHF Specify acuity - acute, chronic or acute on chronic Specify type - systolic and/or diastolic heart failure Specify if CHF is a manifestation of another etiology (cardiomyopathy, HTN heart disease, renal failure) The above documentation rules are the same in ICD-9- CM today; however this remains an area of poor compliance 15
17 Renal Diseases Chronic Kidney Failure is assigned by Stage in both ICD-9 and ICD-10. Stage I Stage II Stage III Stage IV Stage V ESRD Acute Kidney Failure is reported based on cause in both ICD-9 and ICD-10 (eg. Acute Kidney Failure due to tubular necrosis) 16
18 Dementia Dementia is classified by type, or relationship to other disease processes: Alzheimer s Dementia Early or late onset Dementia with or without behavioral disturbances Aggressive behavior Combative behavior Violent behavior Wandering off Vascular or Multi-Infarct Dementia Alcohol or drug induced Dementia Dementia with Lewy Bodies or Parkinson s Pick s Disease with Dementia 17
19 Examples of Documentation Requirements In ICD-10, respiratory failure no longer defaults to acute. Physician must specify if acute, chronic or acute on chronic Respiratory Failure Specify acuity - acute, chronic or acute on chronic Document if respiratory failure is due to a specify etiology Respiratory failure is assigned as a combination code that not only details the severity of respiratory failure, but also association with hypoxia or hypercapnia. Hypoxia insufficient oxygen reaching the tissue Hypercapnia excess carbon dioxide in the blood 18
20 Examples of Documentation Requirements Asthma Specify severity type as mild intermittent mild persistent moderate persistent or severe persistent Specify status of asthma - uncomplicated, with acute exacerbation, or with status asthmaticus Specify if the patient has any other diseases associated with asthma (COPD, bronchitis, etc.) COPD Specify if acute component such as exacerbation, bronchitis or lower respiratory infection Specify if oxygen dependent Specify if in chronic respiratory failure If Asthma and COPD are reported together, they are coded separately in ICD
21 Pneumonia Core Measure Diagnosis Pneumonia is classified by type and linked to the organism in both ICD-9 and ICD-10. Types of pneumonia: Lobar pneumonia Aspiration pneumonia Pneumonia with influenza Pneumonia due to bacteria Viral pneumonia Organizing pneumonia Hypostatic pneumonia Bronchopneumonia In ICD-10-CM is there no specific code for isolation or for flu shots. If running data related to number of patients over certain age or with specific diagnoses to see if they had a flu shot, proactively assigning an indicator may be needed. 20
22 Anemia Anemia in both ICD-9 and ICD-10 can be classified by specific type or cause Anemia due to malignancy anemia is principal diagnosis in ICD-9-CM. In ICD-10-CM it is secondary and the malignancy is principal. Take this into consideration if running data for quality or readmission reports. 21
23 3M Health Information Systems Clinical examples of DRG changes in ICD-10 Change in coding In ICD-10, malignancy must be sequenced as PDX over the anemia ICD-10 MS-DRG 182 Respiratory Neoplasms without CC/MCC R.W ICD-9 Lung Cancer Anemia $3,643 ICD-10 MS-DRG is better MS-DRG 812 Red Blood Cell Disorders without MCC R.W Anemia Lung Cancer $3,419 Assumes blended rate of $4,500 22
24 Unique ICD-10-CM Guidelines Dominant/Nondominant Hemiplegia and monoplegia codes have a digit to identify dominant versus nondominant side. If unspecified, the default code is dominant. Glasgow coma scale In a Traumatic Brain Injury or sequela of a CVA, the Glasgow coma scale can be coded along with the condition to more accurately reflect the patient s condition Musculoskeletal Conditions in the musculoskeletal system involving bone, joint or muscle are reported by type and cause and have specific designations for site and laterality 23
25 Injuries, Poisoning, Adverse Effects, Underdosing and Toxic Effects Injuries and poisonings, adverse effects, underdosing and toxic effects For many of the codes related to these diagnoses there is a character within the code to denote the episode of care for which the condition is being treated the encounters with their associated characters are: A = initial encounter D = subsequent encounter S = sequela In ICD-9 levels of the spinal cord were grouped while in ICD-10 there is specificity for levels. Example: Each cervical level is identified. Thoracic levels have T1 separate and others grouped: T2 T6, T7 T10, T11 T12. Fractures have a unique 7 th character extension which indicates open or closed fracture, initial or subsequent encounter with delayed healing, malunion or nonunion. 24
26 Injuries, Poisoning, Adverse Effects, Underdosing and Toxic Effects continued Underdosing is new in ICD-10-CM Codes for taking less of a drug, medicament or biological substance have been added to the Table of Drugs and Chemicals Specificity exists for intentional or unintentional. No funds? No access to medications? Taking less than prescribed? 25
27 3M Health Information Systems Clinical examples of DRG changes in ICD-10 Change in coding specificity Rib fractures in ICD-9 CM are classified differently in ICD-10 causing a DRG change based on the increased specificity ICD-10 MS-DRG is better ICD-10 MS-DRG 183 Major Chest Trauma with MCC R. W ICD-9 MS-DRG 205 Other Respiratory System DX with MCC R. W In ICD-10-CM, two rib fractures code to multiple rib fractures and by laterality (S2241xA) SDX of Acute Respiratory Failure $6,724 Right Rib FXs are coded in ICD-9-CM by ribs fractured (807.02) SDX Acute Respiratory Failure $5,837 Assumes Blended Rate of $
28 Fracture of femur S72021E Displaced fracture of epiphysis (separation) (upper) of right femur, subsequent encounter for open fracture type I or II with routine healing S72021F Displaced fracture of epiphysis (separation) (upper) of right femur, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing S72021G Displaced fracture of epiphysis (separation) (upper) of right femur, subsequent encounter for closed fracture with delayed healing 72021H Displaced fracture of epiphysis (separation) (upper) of right femur, subsequent encounter for open fracture type I or II with delayed healing S72021J Displaced fracture of epiphysis (separation) (upper) of right femur, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing S72021K Displaced fracture of epiphysis (separation) (upper) of right femur, subsequent encounter for closed fracture with nonunion 72021M Displaced fracture of epiphysis (separation) (upper) of right femur, subsequent encounter for open fracture type I or II with nonunion
29 Unique ICD-10-CM Guidelines Diabetes (E08 E13) A combination code identifies the type of diabetes, the associated complication or manifestation and the body system involved. Inadequately controlled, out of control and poorly controlled are coded to Diabetes, by type, with hyperglycemia. If the type of diabetes is indicated as secondary to another disease process or a drug, then that diabetic code is listed as secondary to the underlying cause 28
30 Most frequent MCC/CC changes within ICD-10 Diagnoses that are no longer MCC/CCs in ICD-10 MS-DRGs Esophageal Hemorrhage (no longer a MCC) Type II Diabetic Ketoacidosis (no longer a MCC) Malignant HTN (no longer a CC) Non-healing surgical wound (no longer a CC) Schizoaffective Disorders, Specified types (no longer a CC) Major Depression, NOS (no longer a CC) Code , Mal HTN w/ CKD (no longer a CC) Hemorrhage into bladder wall (596.7) is a CC in I-9 (no longer a CC) 29
31 Most frequent MCC/CC changes within ICD-10 Diagnoses that are CCs in ICD-10 MS-DRGs but are not in ICD-9: Bi-fasicular Block(s) Example: (RBB/LAFB) is not a CC in ICD-9, but I452 is a CC in ICD-10. Concussion, Unspecified and Unspecified Duration of LOC is a CC in ICD Cauda Equina is not a CC in ICD-9 but G834 is a CC in ICD-10. Code Behcet Syndrome (type of vasculitis) is not a CC in ICD-9 but is a CC in ICD-10 (M352). 30
32 3M Health Information Systems ICD-10-PCS - Procedure Coding System
33 ICD-10-PCS Code Structure The ICD-10-PCS code structure consists of a seven character, alphanumeric code structure 0 B Z Z Letters O and I are not used to in order to avoid confusion with the numbers 0 and 1 There are no decimal points associated with the structure Each character represents an aspect of the procedure The same value means the same thing within a section but placed in a different character position has a different meaning 32
34 System Structure: Section Characters - There are 16 sections 0 Medical and Surgical 1 Obstetrics 2 Placement 3 Administration 4 Measurement & Monitoring 5 Extracorporeal Assistance & Performance 6 Extracorporeal Therapies 7 Osteopathic 8 Other Procedures 9 Chiropractic B Imaging C Nuclear Medicine D Radiation Oncology F Physical Rehabilitation and Diagnostic Audiology G Mental Health H Substance Abuse Treatment 33
35 ICD-10-PCS Each Code Tells a Story: Section Body System Root Operation Body Part Approach Device Qualifier W Med/Surg Heart and Great Vessels Bypass Coronary Artery, Two Sites Open Autologous Vein Tissue Aorta 34 A character is a stable, standardized code component Holds a fixed place in the code Retains its meaning across a range of codes A value is an individual unit defined for each character
36 Body-System Values-Medical Surgical 0 Central Nervous System 1 Peripheral Nervous System 2 Heart and Great Vessels 3 Upper Arteries 4 Lower Arteries 5 Upper Veins 6 Lower Veins 7 Lymphatic and Hemic System 8 Eye 9 Ear, Nose, Sinus B Respiratory System C Mouth and Throat D Gastrointestinal System F Hepatobiliary System and Pancreas G Endocrine System H Skin and Breast J Subcutaneous Tissue and Fascia K Muscles L Tendons M Bursae and Ligaments N Head and Facial Bones P Upper Bones Q Lower Bones R Upper Joints S Lower Joints T Urinary System U Female Reproductive System V Male Reproductive System Anatomical Regions W General X Upper Extremities Y Lower Extremities 35
37 Body-System and Body-Part Values Body System (2 nd character) Body systems are composed of organs that work together to perform specific functions Defines the general physiological system/anatomical region on which the procedure is performed Body Part (4 th character) Body parts are those organs that combine to perform specific functions Defines the specific anatomical site where the procedure is performed 36
38 Uniqueness of ICD-10 PCS Procedures: Anatomically Driven ICD-10 PCS is more anatomically specific than ICD-9 CM procedures codes Device characteristics (examples) Autologous vein or artery tissue Synthetic substitute Nonautologous tissue substitute Drug eluting intraluminal device Intraluminal device Zooplastic Tissue Implantable heart assist system External heart assist system 37
39 Uniqueness of ICD-10 PCS Procedures require: Laterality of site Specificity of approach Open Percutaneous Percutaneous endoscopic Via natural or artificial opening Via natural or artificial opening endoscopic Open with percutaneous endoscopic assistance External 38
40 Root operations Coders are required to know the root operation definitions and apply them accurately. Physicians are not required to know the root operation definitions and should not be queried. Example root operations in Medical / Surgical section: Control Stopping, or attempting to stop, postprocedural bleeding. Destruction Physical eradication of all or a portion of a body part by the direct use of energy, force, or a destructive agent. Detachment Cutting off all or part of the upper or lower extremities Drainage Taking or letting out fluids and/or gases from a body part. The qualifier diagnostic is used to identify drainage procedures that are diagnostic. 39
41 Root Operation Examples continued Extirpation Taking or cutting out solid matter from a body part. Example: Thrombectomy. Excision Cutting out or off, without replacement, a portion of a body part. The qualifier diagnostic is used to identify excision procedures that are diagnostic. Resection Cutting out or off, without replacement, all of a body part. Repair Restoring, to the extent possible, a body part to its normal anatomic structure and function. Reposition Moving to its normal location or other suitable location all or a portion of a body part. Example: fracture reduction. Removal Taking out or off a device from a body part. Replacement Putting in or on a biological or synthetic material that physically takes the place and/or function of all or a portion of a body part. Example: Total hip replacement. 40
42 PCS Section for Bypass Bypass Altering the route of passage of the contents a tubular body part. Cardiology bypass body part is the number of distinct sites bypassed to rather than the name of the vessel. The qualifier captures the origin from of the bypass Example: Two vessel CABG using the right internal mammary artery. Other bypasses body part is the origin from of the bypass. The qualifier captures the body part bypassed to. Examples: Transverse colon to cutaneous (colostomy to skin) Right femoral artery to right popliteal artery Tracheostomy is trachea to cutaneous Stomach to jejunum 41
43 Example PCS Section for Assigning a Bypass PCS Code First Three Characters are Obtained Here 42
44 Coronary Bypass Coding Guideline B3.6b Coronary arteries are classified by number of distinct sites treated, rather than number of coronary arteries or anatomic name of a coronary artery (e.g., left anterior descending). Coronary artery bypass procedures are coded differently than other bypass procedures as described in the previous guideline. Rather than identifying the body part bypassed from, the body part identifies the number of coronary artery sites bypassed to, and the qualifier specifies the vessel bypassed from. Example: Aortocoronary artery bypass of one site on the left anterior descending coronary artery and one site on the obtuse marginal coronary artery is classified in the body part axis of classification as two coronary artery sites and the qualifier specifies the aorta as the body part bypassed from. B3.6c If multiple coronary artery sites are bypassed, a separate procedure is coded for each coronary artery site that uses a different device and/or qualifier. Example: Aortocoronary artery bypass and internal mammary coronary artery bypass are coded separately. 43
45 3M Health Information Systems 44
46 Comparison of ICD-9-CM and ICD-10-PCS Surgery Codes ICD-9-CM Procedures 3-4 digits All numeric Limited expandability ICD-10-PCS 7 characters Alpha numeric Expandable Patient ICD-9-CM Code ICD-10-PCS Codes A patient lacerates the digital artery on his/her right index finger while washing dishes requiring suture of the digital artery A patient is stabbed in the chest lacerating his/her aorta requiring an open chest procedure to suture the aorta 3931 Suture of Artery 3931 Suture of Artery 03QD0ZZ Repair right hand artery, open approach 02QW0ZZ Repair Thoracic Aorta, open approach 45
47 ICD-10-PCS Example Cholecystectomy Is this an excision or resection? Open cholecystectomy OFT40ZZ Lap cholecystectomy OFT44ZZ ICD-10-PCS Code Structure 46
48 Node biopsy If an ultrasound guided fine needle biopsy of a lymph node is done, the root operation is drainage taking or letting out fluids and/or gases from a body part. The qualifier diagnostic is used to identify drainage procedures that are biopsies. If one or more lymph nodes are removed but less than the entire chain, the root operation is excision cutting out or off, without replacement, a portion of a body part. The qualifier diagnostic is used to identify drainage procedures that are biopsies. Example: 07B53ZX Excision right axillary lymphatic percutaneous approach diagnostic If the entire chain is removed the root operation is resection cutting out or off, without replacement, all of a body part. No qualifier for diagnostic is used. Example: 07T60ZZ Resection left axillary lymphatic via open approach
49 Documentation detail on forms Administration of blood products Specificity is required for Site peripheral vein, central vein, peripheral artery or central artery Donor type as autologous or non-autologous Ventilator assistance - are forms clear with start time and end time, when weaning is in progress? ICD-10-CM/PCS delineates time as <24 consecutive hours, consecutive hours and > 96 consecutive hours. The chart must be clear with the start and end times.
50 Where are the gaps today? Largest gaps identified from readiness assessment roadmaps: Budgetary needs IT remediation Lack of physician documentation Impact to coding/cdi productivity Plans to dual code prior to October 2014 Training and education of coding/cdi staff and physicians Need for assistance in translating ICD-9 codes into ICD-10 codes 49
51 Common Question- What is the Impact to Reimbursement?? Here is what we know today: The ICD-10 version of MS-DRGs posted on the CMS website replicates the ICD-9 version of the MS-DRGs (subject to change between now and implementation date) The posted version of ICD-10 version MS-DRGs is unlikely to cause a significant redistribution of payments across hospitals Once sufficient data code in ICD-10-CM/PCS becomes available, CMS will likely use the increased specificity of ICD-10-CM/PCS to enhance the MS- DRGs If hospitals are losing money in current MS-DRG s with ICD-9-CM coding and the lack of higher specificity/documentation they will continue to lose money under ICD-10-CM/PCS Payers have not stated they will remain budget neutral Payer market is very active and ahead of provider market in preparing for ICD- 10-CM/PCS 50
52 Impact on Hospitals Hospitals and Physicians will be required to undertake significant planning efforts for ICD-10 implementation, budgeting for capital and anticipated operational expenses, a complete systems inventory and development of educational activities to prepare staff. The implementation of ICD-10 will impact every: Paper and software system Information system Functional department Scheduling preauthorization & medical necessity Admission Physician/Clinical Care Case Management Lab, Radiology and other Ancillary areas Transcription Performance management HIM Department & HIM system Billing and Accounting Contract management Payer relationships Data warehouse 51
53 Impact on Clinical Providers Clinical provider documentation is the foundation of ICD-10 specificity; incomplete documentation will impede ability to code accurately. Physicians and other Clinicians will need to undergo training to learn about the detailed documentation that ICD-10 requires of them. Training will need to be general awareness as well as specialty-based. Clinical providers will need to collaborate closely with the HIM Coding and the Clinical Documentation Improvement teams. Changes may need to be made to existing systems and processes such as clinical documentation, practice management systems, electronic billing systems, and encounter forms/superbills. 52
54 Impact to Clinical Documentation Improvement Team If your hospital has a Clinical Documentation Improvement Team, the CDI specialists (CDIS) will need to be trained on the detailed documentation requirements for ICD-10. A CDI team can be instrumental in working with clinicians/physicians to ensure the specificity and level of detail needed to support ICD-10 is captured in the clinicians medical record documentation. Existing CDI program may only touch Medicare; ICD-10 is across all payers. 53
55 Impact on Coding Staff Coding Staff will need to be extensively trained to become fully proficient in ICD-10 coding. Educational requirements will differ based on the coder s responsibility. Coding Staff will need to have a deeper knowledge of the biomedical sciences than was required under ICD-9-CM. Specifically in the areas of: anatomy and physiology pathophysiology pharmacology medical terminology In addition, staff need better comprehension of operative and procedure reports. Contrast for radiology or cardiology services Some ICD-10-PCS code descriptions for imaging procedures include the type of contrast utilized. Example: Arteriogram of left vertebral artery 54
56 Summary Physician offices and ambulatory care will continue to use CPT for procedural codes. Hospitals will team with physicians to query when more documentation is needed. Physician engagement and responsiveness to queries will assist in capturing the most accurate coding of the patient s acuity and outcomes. ICD-10 will require further documentation of specificity of diseases by all entities (inpatient, extended care facilities, physician offices or clinics). Physician offices will be impacted most in the area of medical necessity and need to provide specified diagnoses, diagnostics, and care. 55
57 Summary continued Case Management, Social Services and Utilization Management will be impacted in the area of medical necessity and the process to authorize/precert services, (OR case boarded with use of CPT code or ICD10-PCS?) obtaining readmission data, tracking avoidable day data, facilitating transfer to post discharge care providers, evaluating patients for transfer to another facility with awareness of reimbursement impacted by transfer, and tracking quality indicators. CM/SW/UM can benefit from more specific data to establish screening priority for discharge planning, assess outlier trends, quality issues, readmission drivers, medical necessity roadblocks. 56
58 Questions? Queries? Confabulation? Wishful thinking? Hopeful outcomes? 57
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