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CPBJ Extra Blog

Frustration: A tale of specifics

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Frustration is a tattered topic in health care these days, and yet this still draws me like a magnet.

Maybe it's because it centers not on a consumer interaction but on one between a hospital and Medicare. Also, said hospital is local: WellSpan York Hospital.

The report is 14 pages, titled "WellSpan York Hospital Incorrectly Billed Medicare Inpatient Claims With Kwashiorkor." And yes, Medicare has an answer to your first question.

"Kwashiorkor is a form of severe protein malnutrition," it said. "It generally affects children living in tropical and subtropical parts of the world during periods of famine or insufficient food supply."

Cases in the United States are rare, but for calendar years 2010 and 2011, Medicare paid hospitals $711 million for claims including a kwashiorkor diagnosis, so it started reviewing hospitals with claims including that diagnosis code. WellSpan had $1,910,259 in reimbursements, of which Medicare reviewed $1,846,382 for 107 claims. It found that the diagnosis code was correct in exactly none of those claims, and that WellSpan had consequently been overpaid $204,226.

"Hospital officials attributed these errors to a misinterpretation of the coding guidelines for malnutrition because of a lack of clarity in the guidance," Medicare said.

WellSpan returned the money, but it also wrote a letter, part of which follows.

"ICD-9 code260 has caused much confusion in the healthcare industry. If one looks purely at the tabular coding index in the ICD book, documentation of 'protein malnutrition' points to code 260. There is no other option listed for 'protein malnutrition'. However, when you read the detail for code 260, it says Kwashiorkor which is then defined. Although that code may not appear appropriate in all cases, the code book does not provide another clear option. Given the lack of clarity in the code book, a York Hospital coder asked this specific question of the AHA Central Office on ICD-9-CM. On March 27, 2009, AHA answered that it was appropriate to code 260 when the physician documents only 'protein malnutrition'."

Unfortunately, I somehow doubt that the advent of ICD-10 will solve the issues here. But if it did, that would be lovely.

• • •

As the March 31 Obamacare enrollment deadline approaches, I hear that the push is on to get people to take action. If you know someone who is interested but for whatever reason reluctant to start at, one local resource designed to help them understand more about the law and their options is Transforming Health's "Getting Covered: The Affordable Care Act in PA."

• • •

I can't tell you I fully understand how this fits into the big picture on the evolving health care industry, but that doesn't keep it from being worth knowing.

"American Realty Capital Healthcare Trust, Inc. announced today that adjusted funds from operations for the year ended December 31, 2013 increased 255.9% to $57.3 million from the comparable 2012 period ... As of December 31, 2013, the Company owned a total of 114 properties containing 5.8 million rentable square feet purchased for an aggregate purchase price of $1.6 billion. As of December 31, 2013, the properties were 97.1% leased on a weighted average basis and have an average remaining lease term of 9.9 years, excluding the seniors housing communities."

• • •

You want to know which health care services are most frequently excluded from Obamacare-compliant plans, right? And how that list differs from the way things were?

The answers to those rhetorical questions are "yes" and "not as much as you might think," respectively. The one that really caught my eye was adult dental services, which moved from No. 10 on the pre-Obamacare-list to No. 3 on the Obamacare list. Eighty-nine percent of plans now exclude it, below only cosmetic surgery at 92 percent exclusion and long-term care at 99 percent exclusion.

If I had time, I'd ask some dentists what they think of that.

• • •

The Burick Center for Health and Wellness in Hampden Township has been certified as a preventive care center by EHE International.

EHE describes itself as "the recognized leader in preventive medicine and annual physical exams," with a mission "to protect the health of your company's employees while helping you to manage healthcare costs through the early detection of preventable disease and the management of risk factors and lifestyle behaviors that drive disease." According to its website, close to 100 locations across the country are part of its network.

• • •

If you are insatiably curious to see what comments the public is submitting to CMS on Pennsylvania's Healthy Pennsylvania application, you will no doubt be thrilled to learn that you can read them here. For free! Could life get any better?

• • •

Finally, two recent Obamacare changes — of sorts — caught my eye. (Here is where I express my retrospective wish that, way back when, I had started a weekly tally of the changes. Alas for opportunities for greatness lost.)

• As you should know, was not alone in having difficulties; some state-run Obamacare Marketplace sites have also, um, trod rough roads. HHS just decreed that in those situations, people who bought policies outside the Marketplace could get federal tax credits. Here's my favorite sentence in the story: "Kitzhaber announced the change after the federal Health and Human Services Department posted it on one of its websites without further elaboration."

• Almost a year ago, I wrote, "Three years after signing of PPACA, restaurant chains await guidance on labeling." I haven't been checking up on that guidance compulsively (or, honestly, at all), but that's OK, as you will see when you read the first three paragraphs of this story.

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