A Physician Roadmap to ICD-10 - 55 Days & Counting!

Written by  Donald Bialek, MD, MPH and Tom Ormondroyd

• http://www.roadto10.org/

  With the sustainable growth rate (SGR) bill now signed into law, it is time for physicians to really focus on their preparations for the upcoming ICD-10 implementation. ICD-10 will affect every aspect of a physician’s practice, including patient encounters, clinical and financial workflow, as well as compensation and reimbursement. It requires more accurate documentation and gives physicians more diagnostic choices to capture new data in order to ensure they are paid for the complex work being performed.

An ICD-10 roadmap can help physicians minimize productivity loss, avoid financial pitfalls, and ensure they receive proper financial and quality credit for the care they provide. Physicians will require a focused education and training plan, tailored to the “need-to-know” aspects of ICD-10. Just as it was unnecessary to use all of the codes in ICD-9, this will certainly be true of ICD-10.

Physicians first should focus on the clinical conditions that they see most frequently, then concentrate on specialty and common co-morbidities of their patients. Attention to clinical documentation is critical. ICD-10 is meant to capture more detail, and it is mandatory that the documentation supports this granularity to ensure accurate reimbursement and the capturing of the true severity of each patient’s illness. Also, getting it right the first time helps avoid time-consuming questions from coders and clinical documentation improvement specialists later in the process. Education is a personal experience, not a one-size-fits-all approach. Educating oneself in ICD-10 strategies varies from person to person, but usually the process takes 3-12 hours. Planning for that time and choosing an approach that fits are both crucial to ICD-10 success.

When beginning ICD-10 education, a physician should have four training goals:

• Focus on large topic areas – ICD-10 has 8-10 core documentation concepts that can be applied to any disease, such as site, specificity, laterality, timing, manifestations, stage, and status.
• Target risk-heavy and high-volume areas – only address gaps in current practice.
• Concentrate on specificity and underlying conditions – document more than the first diagnosis to establish severity of illness and medical necessity.  
• Incorporate electronic medical record (EMR) training to be optimized for ICD-10 with the use of templates, prompts, and automatically incorporated data already in the EMR in the clinical note. Using documentation templates improves physician efficiency and helps the physician be more timely and complete in documenting each visit. 

It is important for physicians to spend time preparing for ICD-10 now in order to avoid repeatedly correcting denied claims or enduring bad outcomes from an audit due to incomplete or inaccurate documentation. A good initial design generally is preferable to trying to repair things after the fact. ICD-10 presents significant changes to the medical coding vocabularies. It is focused on clinical needs so that essential clinical information about each patient can be captured. It is important to ensure that EMRs capture the necessary information to do this.

The ICD-10 transition deadline is just months away, and it is time to address these areas of concern.


About the Authors
Donald Bialek, MD, MPH, is a member of the Precyse Advisory Council. A seasoned expert in the healthcare field, he has been instrumental in bringing clinical and operational perspective to his work in quality, physician engagement, clinical operations, and informatics. 

Tom Ormondroyd is the vice president and general manager of Precyse Learning Solutions and is the creator of Precyse University and Precyse University DNA. He also oversees several business lines, including ICD-10 Consulting and Educational Services. 

ONLY NURSES CAN CODE ICD10 . . . READ THIS!

ICD-10 transition is not just about Oct. 1

by CARL NATALEJUN 24, 2015 - 06:00 AM

  

Many healthcare organizations are focusing on being ready for the ICD-10 changeover on Oct. 1. Just as important is what will come after that.

Productivity losses

This is legend. The fear is that ICD-10 code set is so large and complex that medical coders aren't going to be able to keep up with their current coding output.

ICD-10 opponents like to point to Canada's 40 percent drop in coding productivity after their ICD-10-CA implementation. But they also switched from a paper-based system to PC-based system at the same time. Canadian coders had a lot to learn and get used to.

Whether American coders will face comparable challenges is something we won't know until after Oct. 1. But those challenges could be mitigated by strong ICD-10 training and clinical documentation improvement (CDI) programs. These investments could help preserve medical claim productivity.

After Oct. 1, medical practices could look for other ways to streamline medical coding workflow. Remove inefficiencies. Add automation.

Denials

This is another legend. The American Medical Association (AMA) is predicting denial and rejection rates as high as 20 percent. Which is the basis of their call for an ICD-10 grace period.

Before medical practices panic over that possibility, they need to know their denial statistics now so they can compare what happens to claims after Oct. 1. They need to track:

• Days in accounts receivable by healthcare payer
• Denial rates
• Amount of reimbursements denied
• If reimbursements match the contracted rates

If tracking waits for Oct. 1, medical practices won't know if the numbers reveal problems or business as usual. Weekly tracking could help keep small problems from becoming big ones at the end of the month.

And if tracking spots problems, there needs to be a process to contact healthcare payers for find out what is the status of claims.

ICD-10 denial management starts now. Medical practices need to understand what triggers denials now and what could cause problems with ICD-10 claims. This will help prevent crippling reimbursement delays.

Queries

If physicians aren't documenting at a level that supports ICD-10 specificity, the number of queries from medical coding staff will increase. And that's going to affect productivity for coders and clinicians. To keep the documentation process moving smoothly, medical coders can improve their queries to make them as efficient and useful as possible:

1. Write in clear, concise and precise language
2. Use evidence specific to the case
3. Avoid asking leading questions
4. Include query in the clinical documentation
5. Start using ICD-10 language
6. Avoid writing queries

 Unfortunately these issues will require resources after Oct. 1. That date is not the finish line. Medical practices need to keep running long after the ICD-10 deadline.

Picking the Value-Based Care Path: Is Medicare Risk Right for You?

Written by  Kai Tsai

Last month, the U.S. Department of Health and Human Services (HHS)released an independent evaluation report indicating that the Pioneer accountable care organization (ACO) model has generated more than $384 million in savings to Medicare during its first two performance years. For many, this is the beginning of the emergence of proof that the ACO model just may work – this, in addition to evidence that the Medicare Shared Savings Program (MSSP) ACO model also worked for some, having generated savings for 52 of the total 220 participants.

These results are encouraging, as the Pioneer ACO program was able to save an average of approximately $300 per participating beneficiary annually while still providing for the delivery of high-quality care to patients. But major decisions are on the horizon for the broader ACO landscape: by mid-2015, the first 220 ACOs to participate in the MSSP will decide if they will continue in the program or if they need to head in a different direction.
As providers successfully participating in risk-sharing arrangements stand at this precipice, they should consider not only whether to continue participation in their existing program – they should evaluate whether to expand to more financially rewarding choices. Because Medicare ACOs, both Pioneer and MSSP, already have made significant investments in clinical integration, network development, and redesigned care models, those providers that generated savings in either Medicare ACO model are uniquely poised to add a risk-based Medicare Advantage (MA) contract. And since shared savings measured against a provider's own past performance continuously deflates performance, a MA model will help enhance savings while continuing to increase care quality.
MA risk contracting offers three significant advantages for providers:

• The network is closed, allowing ACOs to focus further on improving quality and reducing costs.
• Patients are attributed as members to physicians, allowing ACOs to develop a patient-provider relationship that supports a comprehensive care model.
• Savings that are generated stay within the risk-bearing entity, which in this case is the ACO.

Healthcare providers all over the country are continuing to assess their ability to implement and deliver value-based care. To determine if they are ready to take on Medicare risk, providers should:

• Conduct a market assessment. Evaluate county benchmarks to understand your base payment rate and compare payments with those that other local MA plans and providers are receiving. Benchmarking MA penetration against national figures also can enable a provider to realize fully the opportunity that exists in the market.
• Establish comparable Medicare ACO and MA financials. While there might always be Medicare beneficiaries who opt for the open care delivery model in fee-for-service, providers should model how quickly fee-for-service beneficiaries might migrate to a MA plan to enhance budget planning, resource allocation, and capability development.
• Conduct an internal capabilities assessment. Quality programs, care models, and information technology infrastructure all should be evaluated to understand if the organization has the right systems in place to further reduce costs and manage care.

Providers considering adding a risk-based MA contract need to evaluate how four factors will impact the organization:

• Geographical county benchmarks will establish a base payment rate based on location. While current Medicare ACO benchmarks are determined by the assigned population's historical claims data, MA benchmarks are driven by county-level MA payment rates.
• Thoughtful, cautious risk adjustment yields the greatest opportunity under MA to increase a provider's revenue. The MA risk adjustment is recalculated each year and compared to the Medicare ACO risk adjustment, which is recalculated following every three-year contract period.
• Medicare leverages data from paid encounters, member satisfaction surveys, and health plan reporting to give plans an overall performance rating. These Star Ratings, which reflect factors such as outcomes and patient experience, determine what plans are eligible for a 5-percent payment bonus.
• Deep MA penetration may be advantageous, as provider practice patterns and behaviors likely already are well-aligned with MA incentives. A competitive MA market can give Medicare ACO leaders confidence that physicians in their market are well-acquainted with coding procedures and quality reporting activities. However, if a Medicare ACO operates in a market with little MA penetration, leaders should identify if there is resistance to managed care as well as consider planning for a longer ramp-up period to educate both healthcare providers and patients on the offering.

When it comes to MA plans, managing well-informed, well-planned risk is not as risky as it seems. There are a wide variety of tools and approaches available to providers that can limit the financial risk of arrangements they enter into – whether MA or others. Most importantly, advances in technology and predictive modeling have evolved to enable providers to apply proven actuarial analyses without maintaining a full staff of actuaries. Visibility into financial risk, and thus the ability to account for it, has never been more available and actionable for providers.
With a range of different health systems already positioned as MA providers, industry experts realize that just about any provider organization can be successful in this transformation. Those providers that move first to take clinical and financial control of their Medicare populations also likely will see a significant competitive advantage in their markets.

About the Author
Kai Tsai is Valence Health's vice president of consulting services and strategic initiatives. With deep expertise in Medicare and senior markets, he's responsible for leading the operations of the company's consulting practice and managing key client relationships, and is a government programs industry leader. Kai earned his master's of health services administration from the University of Michigan.
Contact the Author
information@valencehealth.com

Medical-Necessity Audits Gain Steam, Hit On Chemo, Cardiac; Watch for New LCDs

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Written by Nina Youngstrom Created on Wednesday, 03 June 2015 22:37

EDITOR'S NOTE: This is a summary of RAC University's live Webinar, "Is That Service Necessary? The New Medical Necessity Target," presented by Ronald Hirsch, MD, Vice President of the Regulations and Education Group at Accretive Physician Advisory Services. The article appears courtesy ofThe Report on Medicare Compliance.

If hospitals and physicians are not already reviewing their use of chemotherapy drugs to determine if they are reasonable and necessary, now is the time, experts say.

Medicare auditors are all over them as part of their growing scrutiny of the medical necessity of providing and billing for various expensive drugs, procedures and tests.

With auditors dwelling less on patient status, there is more attention paid to whether documentation supports the rationale for the services, and whether a less conservative treatment would minimize the risk of harm to the patient and the Medicare trust fund.

Chemotherapy fires on all of these compliance cylinders, along with cardiac procedures, radiology, cataract surgery, back surgery and other pricey or high-volume services, said Ronald Hirsch, vice president of Accretive Physician Advisory Services, during a recent webcast sponsored by RACmonitor.

“One area that will be a big target and is starting to grow is denials for chemotherapy in the outpatient setting,” he said. “We have to look at chemotherapy and make sure it’s medically indicated.”

The Medicare administrative contractor for California, for example, has probe audits underway of many chemotherapy drugs and biologics. Noridian Healthcare Solutions selected the drugs because “data analysis identified a potentially high use,” the MAC said on its website. Targets include the following: 

• Denosumab injection, 1mg (HCPCS code J0897)
• Pegfilgrastim injection, 6mg (HCPCS J2505)
• Aflibercept injection, 1mg (HCPCS J0178)
• Bortezomib injection, 0.1 mg (HCPCS J9041)
• Rituximab injection, 100 mg (HCPCS J9310)
• Cetuximab injection, 10 mg (HCPCS J9055) 

“It’s starting to happen,” Hirsch says. “Noridian is doing 100% prepayment claim audits.” The focus on

Neulasta (pegfilgrastim) is worrisome, he noted, because payment for the drug, which builds white blood cells, is $6,000 to $8,000 per dose, so denials will hit providers hard. “You may want to pull out criteria and see how much you are billing.” Then look at medical records: how doctors are documenting, whether lab results are there, and whether the health information management staffers know when they get chart requests, find all the documentation “and send it all along with the chart” to auditors at their request, Hirsch said.

Medicare bases medication coverage on the patient’s condition, the appropriateness of the dose/route of administration and the standard of practice for the drug’s effectiveness for the diagnosis and condition, Hirsch says. Cost doesn’t factor into Medicare coverage decisions, which is where Medicare diverges from the commercial payers, he says. Medicare requires providers to select drugs according to protocols listed in accepted compendia ratings, such as the National Comprehensive Cancer Network and American Hospital Formulary Service-Drug Information. 

There Are High Rates of Denial for Chemo 

Apparently providers don’t always comply with Medicare billing rules for chemotherapy drugs, at least in the eyes of auditors. For example, Palmetto GBA, another MAC, recently audited claims of the chemo drug Bevacizumab, 10 mg (J9035) submitted by providers in South Carolina, North Carolina, Virginia and West Virginia.

According to findings posted on its website, the MAC partly or completely denied 81 of 97 claims reviewed in South Carolina. That means $431,708 was deemed noncovered out of $677,251. The chief reason for the denials: documentation did not support the medical necessity of services billed. Providers in the other states didn’t fare much better. 

Chemotherapy is far from the only service on the medical-necessity chopping block. Medicare has been cracking down on other services that don’t rise to the level of medical necessity. The Social Security Act states that Medicare doesn’t cover items and services that “are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.” Just because they’re FDA-approved doesn’t mean they’re covered by Medicare and/or other payers, Hirsch says.

Medical necessity, according to Hirsch says, is often set forth in national coverage determinations (NCDs) and local coverage determinations (LCDs). CMS publishes NCDs, which set forth the circumstances in which they will cover a particular drug or procedure. In the absence of an NCD, MACs may publish LCDs for the same purpose, but they’re applicable only to hospitals in their jurisdiction.