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What Would Make Us Not Delay ICD-10 in 2015?

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While at the HFMA ANI conference in Las Vegas, I talked to a lot of people about the future of healthcare reimbursement. Talk of ICD-10 and the ICD-10 delay came up regularly with most of us rolling our eyes that ICD-10 was delayed again. Some argued that we still need to be prepared, but from what I’m seeing the majority of the market just pushed their plans out a year and will pick them up again later this year or early next year.

With that said, we all agreed that every organization will be much more hesitant preparing for ICD-10 next year since they’re afraid that ICD-10 will just be delayed again.

As I had these discussions, I started thinking about what will be different in 2015 when it comes to ICD-10? As I asked people this question, all of the same arguments that we made in 2014 are what we’re going to have in 2015. Some of them include: the rest of the world adopted this years ago, we’re falling behind on the data we’re capturing, we need more specificity in the way we code so we can improve healthcare, etc etc etc.

Considering these arguments, what will be different next year?

All of the above arguments for not delaying ICD-10 were valid in 2014 and we’ll be just as valid in 2015. Can you think of any reasons that we should not delay ICD-10 in 2015 that weren’t reasons in 2014? I can’t think of any. The closest I’ve come is that with the extra year, we’re better prepared for ICD-10. Although, given people’s propensity to delay, does anyone think we’ll be much better prepared for ICD-10 in 2015 than we were in 2014? In some ways I think we’ll be less prepared because many will likely think the delay will happen again.

Given that the environment will be mostly the same, why wouldn’t we think that ICD-10 will be delayed again in 2015?

Personally, I’ll be watching CMS and HHS closely and see what they say. I think this year they looked really bad when they very publicly proclaimed that ICD-10 was coming at HIMSS just to be hit from the side by the ICD-10 delay. I’d hope that this time CMS will work with Congress to know what they’re planning or thinking before they make such strong assertions. Of course, this would mean that they’d have to understand what Congress is thinking (not an easy task).

What’s unfortunate is that many of the things you need to do to prepare for ICD-10 can also benefit you under ICD-9. The smart organizations understand this and are focusing on clinical documentation improvement (CDI) as the best way to prepare for ICD-10, but still benefit from the program today.

July 3, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 6000 articles with John having written over 3000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 14 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John launched two new companies: InfluentialNetworks.com and Physia.com, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus. Healthcare Scene can be found on Google+ as well.

Outfitting for the ICD-10 Voyage – Breakaway Thinking

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The following is a guest blog post by Laura Speek from The Breakaway Group (A Xerox Company) and Honora Roberts from Xerox. Check out all of the blog posts in the Breakaway Thinking series.
ICD-10 Boat
These are challenging times for healthcare providers in every imaginable vessel – and the whitewater ride is not over yet. Just around the bend looms the transition to ICD-10, scheduled for October 1, 2014. Most providers know the wisest course is to start preparing now, yet few have dared to navigate these uncharted waters.

For many, a major problem is not knowing where to start. Others may be suffering from protracted procrastination. And still others may be well on the road to ruin via the path of good intentions.

An effective way to put some wind in your ICD-10 sails is to get real about the serious costs of noncompliance. After October 1, 2014, claims must be submitted using ICD-10 coding to be eligible for reimbursement. In other words, if you don’t bill with ICD-10 codes, you simply won’t get paid. And that’s the cold, hard truth.

The transition to ICD-10 will affect every facet of healthcare, but it begins with understanding the basic differences between ICD-9 and ICD-10. First and foremost, ICD-10 is not just a simple expansion of ICD-9. There is no reliable one-to-one mapping system. Some ICD-9 codes equate to multiple ICD-10 codes, while some do not correspond to any.

ICD-10 codes include much greater specificity; care providers must document etiology, laterality, exact anatomical site, and other information. Patient encounter documentation must include proper detail to enable coders to locate the correct ICD-10 diagnosis and procedure codes. Physicians and mid-level providers should begin to assess their documentation today to identify where ICD-10 coding requirements are already being met and where improvement is needed.

Because clinical documentation is at the core of every patient encounter, it must be complete, precise, and accurately reflect the scope of care and services provided. Assuring depth and consistency of documentation represents a challenge for many organizations.

ICD-10 encompasses a huge increase in accessible codes. The ICD-10-CM diagnostic code set, used in all healthcare settings, increases from roughly 13,000 to 68,000 codes. The ICD-10-PCS procedural code set, used within inpatient settings only, expands from roughly 3,000 to 87,000 codes. It should be noted that ambulatory settings will continue to use CPT (Current Procedural Terminology) procedural codes.

Given this massive growth in coding scope, the importance of detailed clinical documentation becomes even more pronounced. Physicians and other healthcare providers typically are not trained to develop proper documentation skills in medical school or residency; nurse practitioners (NPs) and physician assistants (PAs) generally do not receive such training during graduate school or clinical rotations. Hospitals and healthcare systems need to compensate for this training deficiency by instituting educational programs and tools that align healthcare providers with proper documentation practices to clear the decks for successful transition to ICD-10.

ICD-10 requires physicians, NPs, and PAs to thoroughly document each and every patient encounter to a much greater level of specificity than is needed in ICD-9. Nonspecific or incomplete documentation within ICD-10 will cause delays, claim denials, cash-flow interruptions, and inaccurate quality reporting. Definition and terminology changes inherent in ICD-10, particularly for surgical procedures, will also require focused education and training.

At the end of the day, providers aren’t coders. They are far less concerned with ICD-10 codes than they are with improving quality of care. This is where ICD-10 can be viewed as a welcoming beacon on a rocky shore. It gives healthcare providers an incentive to establish a clinical documentation improvement (CDI) program. In fact, implementing and sustaining an effective CDI initiative should be a top priority for all healthcare organizations preparing for ICD-10. For those with no CDI program in place, the time to begin is now. Consider improved clinical documentation as essential equipment for maneuvering through the twists, turns, and churns that accompany the voyage to ICD-10.

Honora Roberts - Xerox
Honora Roberts is Vice President of Healthcare Provider Services at Xerox.

Laura Speek  - The Breakaway Group
Laura Speek is a Learning and Development Specialist at The Breakaway Group (a Xerox company).

Xerox is a sponsor of the Breakaway Thinking series of blog posts.

November 19, 2013 I Written By

For Providers, Revenue Assurance through the ICD-10 Transition is Key

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The following is a guest blog post by Vik Anantha, Vice President – Financial Management Solutions, Edifecs, Inc.
Anantha Vik - Edifecs
We all know ICD-10 is a complex and costly initiative. One of the promises of ICD-10 is the potential for enhanced granularity, laterality and overall reporting accuracy. This is particularly important to providers because health plans use the ICD code set to determine reimbursements based on the medical condition of the patient and procedure(s) used for treatment.

With promise comes risk. ICD-10 not only exponentially increases the number of diagnostic and procedure codes, it changes the structure of the coding scheme and introduces new clinical concepts, terminology and granularity. These widespread changes will force business process and policy changes in areas such as benefits, medical management, and payer contracting. In other words, ICD-10 will affect almost every operational, clinical and financial process.

On the business side of ICD-10, revenue neutrality is a big concern for healthcare CFOs and revenue cycle management leaders. While it’s unrealistic to expect revenue neutrality at a claim level (there will always be some variation), it’s entirely possible to achieve revenue neutrality in aggregate. And this should be the goal.

It won’t be easy. Improper and incomplete coding can increase denial rates, causing significant revenue loss. Even error-free claims hold financial risk, particularly for healthcare organizations that depend on DRG (diagnosis-related group) methodology for reimbursement. The process of mapping ICD-9 codes to their counterparts in ICD-10 can be very complex, and there is often no single, one-to-one relationship.

The DRG for a certain claim is selected based on the ICD code(s) present on the patient claim. Therefore, the reimbursement on every claim depends on the assignment of diagnosis codes and inpatient procedure codes to specific DRGs.: As a result, migration to ICD-10 could result in significant over- or underpayment when using DRG-based reimbursement if providers use the wrong code.

Here are a few real-world examples:

  • ICD-9 procedure code 38.12 (extirpations of upper arteries with an open approach) is grouped to DRG 039. The same procedure in ICD-10 has 31 mapping options. Thirteen of these map to the same DRG and will generate the same reimbursement. However, the remaining 18 ICD-10 codes group to DRG 027, which generates a higher reimbursement. Selecting one ICD-10 code over another could result in nearly a 100% payment increase ($5,927.14 for DRG 039 vs. $12,409.74 for DRG 027.)
  • ICD-9 procedure code 2754 (repair of cleft lip) groups to DRG 134. This procedure has six potential ICD-10 codes, all of which group to a lower-weighted DRG 138, which represents a more generic procedure. This could reduce reimbursement by approximately $1,000 ($5,269.34 for DRG 134 vs. $4,203.28 for DRG 138.)
  • ICD-9 diagnosis code 86.01 (traumatic pneumothorax with open wound into thorax) is grouped to DRG 201. In ICD-10, this claim maps to a combination of two ICD-10 codes. Together, the two codes group to DRG 199, which increases reimbursement by 276% ($3,910.60 for DRG 201 vs. $10,816.98 for DRG 199.)

These examples show that payment variation under ICD-10 can cut both ways. If a provider organization can’t quantify its risks, it may end up dealing with unfavorable payer contracts, longer collection cycles and uncertain financials.

Of course, this type of analysis can be very time- and labor-intensive. Providers and payers should work together to identify and prioritize areas of risk, based on actual historical data. Analyzing a provider’s own data based on reality-based ICD-9 to ICD-10 mapping scenarios delivers the “street-level view” of the real operational and financial risks posed by ICD-10 to the organization, rather than just a list of every possible risk.

Many providers already have clinical documentation improvement (CDI) initiatives underway, and coding improvements made by these teams can be a key part of the financial analysis as well. The CDI process will narrow the number of ICD-10 codes to those the provider will actually use, which can then be used to build financial modeling maps specific to that provider, rather than using generic maps such as GEMs.

Providers looking to ensure consistent revenue cycle management through the ICD-10 transition should take the following steps:

  • Identify high-level risks at the outset, using historical data
  • Integrate with physician/clinical/coding training and CDI efforts
  • Refine analysis and prioritize risk with refined, “reality-based” mapping
  • Iterate, validate and improve to allocate resources based on real risk
  • Test and transition with highest possible degree of confidence

ICD-10 does hold promise for the healthcare industry. The transition period is likely to be bumpy and somewhat painful. But with some foresight and commitment to working with each other, providers and payers can assure themselves of financial neutrality in both directions.

July 16, 2013 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 6000 articles with John having written over 3000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 14 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John launched two new companies: InfluentialNetworks.com and Physia.com, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus. Healthcare Scene can be found on Google+ as well.

Tips on Dealing with Copy and Paste EMR Concerns

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The following is a guest post by Deborah J. Robb, BSHA, CPC. You can read more of Deborah’s work on her blog.

Deborah has served TrustHCS since 2007, where she developed the professional services department providing physician coder education related to CMS guidelines. She has also managed 34 coding staff that provide coding services to a variety of multiple specialty clinics nationwide. With over 35 years in the healthcare profession, she is a frequent speaker on Medical Coding, including appearances at State and National AHIMA conferences. Deborah is also a five time author for Direct Learning On-line courses in Medical Terminology and Medical Coding and has written numerous articles in national publications including, but limited to, For the Record, Physician Practice Magazine and Journal of AHIMA. Deborah is a graduation of Central Texas College and Columbia Southern University.

The OIG is concerned that inappropriate E/M service payments may be linked to cutting and pasting encounter notes within EMRs. As a result, their 2013 Work Plan includes the identification of redundant documentation and improper billing of multiple E/M services. Practices can mitigate their risk of OIG audits and fines by implementing the following five steps for proper E/M level documentation within an EMR.

Red Flag Redundant Documentation

Practices should conduct regular reviews of physician documentation to ensure duplication is kept to a minimum. Reviews should include a broad sample of E/M services and compare each provider’s results. Findings and anomalies can be discussed as a team with results used as a learning tool to improve documentation, coding and billing practices.

Two particular areas for review include error rate for incident-to services performed by non-physicians and the E/M coding of “new” patient for patients seen prior. The “incident-to” designation pertains to services and supplies performed incident to the professionals services of a physician. When Medicare first took a look at these billings, they discovered half of the services delivered and billed were not performed by a physician.  The OIG will review “incident-to” services to determine whether payment for such services carries a higher error rate than that for non-incident-to services; or if redundant documentation is to blame. They will also be assessing Medicare’s ability to monitor such services.

Secondly, Medicare contractors have identified the use of a “new patient” E/M code for patients seen within three years by the same provider or within the same practice as an area of scrutiny. Internal audits and documentation reviews should include both of these OIG issues.

Evaluate Cut and Paste Policies

Practices should also assess organizational policies and procedures around cut and paste functionality. Initial EMR implementations promoted copy/paste with little foresight into the downstream documentation, coding and billing issues. Policies and procedures should state what is acceptable to be brought over from previous notes. Practices are encouraged to consult the American Health Information Management Association’s (AHIMA) Copy Functionality Toolkit. It includes valuable case scenarios, sample policies, checklists and audit guidelines.

Raise Awareness of Risk

The ability to copy and paste a patient note from a prior visit into a new encounter is so easy within most EMRs, that providers may unknowingly risk patient safety. The following risks are noted within the AHIMA toolkit and should be shared with all documenters.

  • Copying information into the wrong patient chart
  • Inaccurate or outdated information
  • Inability to determine current information
  • Inability to identify the author or intent of documentation
  • Inability to identify when the documentation was first created
  • Inability to accurately support or defend E/M codes for professional or technical billing notes
  • Propagation of false information
  • Internally inconsistent progress notes
  • Unnecessarily lengthy progress notes

Implement Clinical Documentation Improvement (CDI)

Similar to hospital CDI initiatives, an effective CDI program for physician practices includes phases for assessment, education and monitoring. Findings from initial assessments and ongoing monitoring should serve to focus education and training efforts throughout.

Every Encounter on Its Own

Finally, every encounter’s documentation must stand on its own. There must be valid documentation within each note to support the visit. Questions to ask of each note include:

  • Does the documentation prove the visit was done?
  • What has changed from the previous visit?
  • Does the documentation demonstrate what was done?

Conclusion

Cut and paste saves time for clinicians, but may unintentionally skew E/M documentation, coding and billing. The review of this practice within the 2013 OIG work plan is a significant motivator for practices to tighten policies and mitigate risk.

January 24, 2013 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 6000 articles with John having written over 3000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 14 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John launched two new companies: InfluentialNetworks.com and Physia.com, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus. Healthcare Scene can be found on Google+ as well.