Delay on ICD-10 Compliance Date

Posted on February 17, 2012 by Admin

Your thoughts on the announcement below?  Surprised, expected, indifferent?

HHS Announces Intent to Delay ICD-10 Compliance Date

In a new press release from HHS, Secretary Kathleen Sebelius announced that HHS will initiate a process to postpone the compliance date by which certain health entities have to comply with ICD-10. The press release can be found below.

Press Release: HHS Announces Intent to Delay ICD-10 Compliance Date

As part of President Obama’s commitment to reducing regulatory burden, Health and Human Services Secretary Kathleen G. Sebelius today announced that HHS will initiate a process to postpone the date by which certain health care entities have to comply with International Classification of Diseases, 10th Edition diagnosis and procedure codes (ICD-10).

The final rule adopting ICD-10 as a standard was published in January 2009 and set a compliance date of October 1, 2013 – a delay of two years from the compliance date initially specified in the 2008 proposed rule. HHS will announce a new compliance date moving forward.

“ICD-10 codes are important to many positive improvements in our health care system,” said HHS Secretary Kathleen Sebelius. “We have heard from many in the provider community who have concerns about the administrative burdens they face in the years ahead. We are committing to work with the provider community to reexamine the pace at which HHS and the nation implement these important improvements to our health care system.”

ICD-10 codes provide more robust and specific data that will help improve patient care and enable the exchange of our health care data with that of the rest of the world that has long been using ICD-10. Entities covered under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) will be required to use the ICD-10 diagnostic and procedure codes.

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Hospitalists Play an Important Role in Good Documentation

Posted on February 9, 2012 by Paul Weygandt

If we can improve our documentation skills, both physicians and hospitals can get credit where credit is due.  This becomes critical as Medicare ramps up its claims denial and recovery business to help “clean up” the system. 

This includes the national rollout of the Recovery Audit Contractor (RAC) Initiative as well as the new Medicare Administrative Contractors (MACs). These both rely on accurate documentation as well.  The RACs will penalize hospitals and physicians financially for documentation lacking in specificity and accuracy while the MACs will deny physician payment for claims erroneously submitted (technical errors) or those lacking documentation of medical necessity justifying the clinical service.

What makes many physicians even more uncomfortable in this new environment is that Medicare is striving to better align the priorities and financial incentives of hospitals and physicians.  Alliances between the two are being strongly encouraged through such programs as the Acute Care Episode (ACE) Demonstration Project (the precursor to hospital-physician bundled payments) and the establishment of Accountable Care Organizations (ACOs).  The federal government firmly believes these coalitions with shared financial incentives will foster a cooperative environment with the common goal of better, more efficient, higher quality healthcare.  And they may well be right!

This emerging healthcare environment presents a unique set of both challenges and opportunities to hospitalist groups. 

For one, hospitalists are historically more aligned with hospital administration as compared with most other specialties.  And for another, they are being asked to participate in the care of an increasingly large percentage of patients across all specialties.  This could well be an opportunity to be rewarded for embracing both of these trends.  Hospitalists are uniquely positioned to function as the “documentation improvement clinical team leaders,” working closely with other physicians across all specialties and the hospital administration to fulfill all these documentation requirements and to be rewarded for doing so. 

Though hospitalists should have a general understanding of the language and rules of documentation, a system must be in place which helps them identify and capture all the pertinent aspects of the medical record without the need to become clinical documentation specialists or coders themselves.  To this end, a clinical documentation improvement (CDI) program is critical … but may not be enough. 

What is needed is a “clinical integration” program, an enhancement of traditional CDI.  This approach requires the participation of ED physicians, along with clinical integration specialists, to document accurately and completely from the start.  The clinical integration specialist ensures that medical necessity for inpatient admission and patient risk is being addressed and established, conditions are appropriately being identified as being present on admission (POA), and all diagnoses are being properly recognized and documented thoroughly and accurately.  Clinical integration through collaborative documentation then continues throughout the hospitalization, with diagnostic authority and oversight from the hospitalist, all the way through discharge. 

Hospitalists should welcome and champion this type of program.  As documentation becomes the key to survival a complete medical record, reflecting severity of illness, demonstrating quality and safety of care, will stand up to any and all potential scrutiny by Medicare or others are the benefits.  As for the negatives, there are none.

 

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ACOs, a Bonafide Answer?

Posted on February 6, 2012 by Admin

A January 2012 Wall Street Journal article asked a diverse group of health-care policy experts to discuss, in an exchange of emails, whether ACOs are an answer to what ails the health-care system.  Their panelists were:

Donald M. Berwick, who stepped down Dec. 2 as administrator of the Centers for Medicare and Medicaid Services. In that role, Dr. Berwick helped oversee the agency’s efforts to structure ACOs created by the federal health-care law.

Tom Scully, the Center for Medicare and Medicaid Services administrator from 2001 to 2004. Mr. Scully is a former chief executive of the Federation of American Hospitals, which represents investor-owned and managed hospitals. He also is currently a partner at Welsh Carson Anderson & Stowe, a private-equity firm in New York.

Jeff Goldsmith is president of Health Futures Inc., a health-care consulting firm, and an associate professor of public-health sciences at the University of Virginia, in Charlottesville.

If you haven’t had a chance to read this article, it’s highly recommended.

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Open Medicare Database, Good or Bad for Healthcare?

Posted on February 3, 2012 by Paul Weygandt

On December 5, 2011 CMS finalized a regulation that will allow its extensive claims database to be used by employers, insurance companies and consumer groups to produce report cards on local doctors and hospitals. 

Pursuant to section 10332 of the Affordable Care Act, the Social Security Act is amended requiring “standardized extracts of Medicare claims data under parts A, B, and D to be made available to “qualified entities” for the evaluation of the performance of providers and suppliers.”  The intent is to share the information in order to generate public reports regarding quality performance, that is, to generate report cards.

Such research had been off-limits until now because of a decades-old court ruling that releasing the information would violate the privacy of doctors. Insurance companies tried to fill the gap using their own claims data, but their files were nowhere near as comprehensive as Medicare’s.

The result has led to allegations that due to limited claims volume, physician profiles from insurance companies have been prone to error.

The release of the CMS claims data presents a challenge to organized medicine.  On the one hand, the database is vast, has more statistical validity than limited insurance company databases and should be more representative of comparable care across the US.  For example, by analyzing a large volume of billing records, experts can glean critical information as to how often a doctor has performed a particular procedure and identify potential clinical problems such as preventable complications. 

On the other hand, the AMA has challenged that the final rule failed to create the necessary safeguards to assure the accuracy of published information.  CMS has asserted, in the final rule, that data will only be released to “qualified organizations,” which can demonstrate their experience in evaluating performance measures, analyzing claims data and protecting personal health information. 

CMS currently expects about 25 qualified organizations to purchase the data at a cost of approximately $40,000.  The rule also suggests a provision which would allow qualified organizations to purchase a national “benchmarking” dataset.

There has been considerable public support for “transparency” in healthcare.  This rule assures the release of the vast CMS database which will result in a proliferation of physician “report cards.”  The statistical challenge facing all physicians is that no matter the quality of care provided, 50% of physicians nationally can be characterized as “below average.”  That is, in fact, the definition of average – the 50th percentile.  While most physicians provide high quality professional care, we are likely to see considerable conflict as the initial profiles are released.

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Making ICD-10 Less Daunting

Posted on January 19, 2012 by Admin

As there becomes a heightened awareness and acceptance of our inevitable transition to ICD-10, many of you may be wondering how to approach the task of preparing your key stakeholders, coders, clinical documentation specialists and providers, for the change.

Certainly we all realize the need for additional education, but just where do you begin? 

The HIM profession typically approaches change—such a change to a new payment methodology, by focusing on the differences between the current method and the new method.

While this would work for the transition to ICD-10-CM too– there are certainly far more similarities between ICD-9-CM and ICD-10-CM than differences. Another viable option is a bit more holistic and focuses on the foundation of ICD-10-CM referred to as the “axis of classification”. 

Next week, Angela Carmichael, a frequent guest blogger, will expand on this in an article on ICD10monitor.com.   In this article, she’ll provide detail on the use of axis of classification to make learning ICD-10-CM a little less daunting.

By comparing current documentation to the axes of classification available for the same diagnoses in ICD-10-CM, you will be able to identify those areas where current documentation is inadequate to fully take advantage of the granularity available in ICD-10-CM. 

Is your interest piqued?  Check out her full article next Tuesday on ICD-10 Monitor.

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Webinars on Bundled Payment

Posted on January 17, 2012 by Admin

ADLS Webinars on Bundled Payment

As part of the ADLS series, Centers for Medicare and Medicaid Services (CMS) is hosting a number of webinars particular to the topic of bundled payment. Developed independently by the American Institutes for Research, the ADLS for Bundled Payments series provides an opportunity for businesses, state agencies, and clinical leaders to deepen their understanding of how to improve care delivery and population health while reducing growth in costs by redesigning care within a bundled payment program.

Implementing Bundled Payment: Ready, Set, Go

Wednesday, January 18, 2012

3:30PM-5:00PM ET

In the first ADLS webinar of this series, senior leaders from two very different organizations—one, a three-hospital health system with a provider-owned health plan, the other a large group practice of orthopedic surgeons—will outline the strategic and operational path each followed to implement bundled payment.

Evan Benjamin, MD: Improving Value with a Bundled Payment Program.

As the Chief Quality Officer for Baystate Health in Springfield, Massachusetts, Dr. Benjamin helped transform healthcare within the three hospital system.

Steven Schutzer, MD: Bundled Payment:  It’s Not That Hard.

Dr. Schutzer is founding member and Co- Medical Director for the Connecticut Joint Replacement Institute, the largest joint replacement facility in the region.

See more details on this webinar

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ICD-10 To-Dos for Early 2012

Posted on January 11, 2012 by Admin

by Guest Blogger: By Angela Carmichael, MBA, RHIA, CCS, CCS-P, AHIMA Approved ICD-10-CM/PCS Trainer

We’re inching closer to the ICD-10 Deadline.  Where should you be by now?

You should be starting the developmental training phase.

Developmental training includes assessing and acquiring core skills, commonly referred to as biomedical skills. Biomedical training would include medical terminology, anatomy and physiology, pathophysiology, and pharmacology. Skills in these areas are critical to learning and working successfully with ICD-10-CM/PCS. While some doubt that both the CDS and coder should have advanced knowledge of biomedical subjects, there are many reasons why an assessment of this knowledge, and additional training, is of great value in preparing for ICD-10-CM/PCS.

First, most of us in the CDS and coding roles received our biomedical training decades ago. This is concerning because research indicates that when we are exposed to an idea one time, at the end of 30 days most of us would have retained less than 10 percent of that material.

Much of the education acquired in biomedical courses during those early college years was not utilized while working with ICD-9-CM due to its lack of specificity. The same cannot be said for either ICD-10-CM or ICD-10-PCS. In fact, ICD-10-CM/PCS has tens of thousands of more terms than ICD-9-CM.

So, to use ICD-10-CM/PCS effectively coders and CDS’s must know:

  • Greek and Latin prefixes, suffixes, roots and combining forms used as the basis of most medical terms
  • Commonly accepted and approved medical abbreviations
  • Eponyms and names of syndromes
  • Alternative names and descriptions for diseases
  • Adjectives used to describe and define diseases and disorders (purulent, necrotic, etc.)
  • Verbs and terms used to describe surgical approaches and techniques (resect, dissect, incise, excise, aspirate -scopic, -otomy, -ectomy, etc.)
  • Technology driven and manufacturer given names for tests, devices and procedures

For these reasons, your developmental training should begin either in 2012, or early 2013, prior to the start of the next phase of training, referred to as “role specific training.”  Are you where you want to be?

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5010 Deadline January 1, 2012, but Enforcement Later

Posted on January 9, 2012 by Admin

The Version 5010 deadline was on January 1, 2012; however, because of the 90-day enforcement discretion period for all HIPAA covered entities upgrading to Version 5010 (ASC X12 Version 5010), the Centers for Medicare & Medicaid Services (CMS) will not initiate enforcement action until April 1, 2012. CMS made this decision based on industry feedback that many organizations and their trading partners were not yet ready to finalize system upgrades to be compliant.

CMS has a new fact sheet: Version 5010: How Health Care Providers Can Ensure a Smooth Transition to help.

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Trimming Costs Without Sacrificing Quality – Part Two

Posted on January 5, 2012 by Paul Weygandt

Per my last blog post, a recent H&HN Daily article cited a list of six ‘wedges’ which held the possibility of improvement in healthcare as noted by the recently departed Centers for Medicare & Medicaid Services Administrator Don Berwick.   Berwick’s six ‘wedges’ are said to be: Coordination Failures, Process Failures, Overtreatment, Administrative Burdens, Price Variation and Fraud and Abuse.

Here is part two of my response to these six ‘wedges.’   The original text is in italics and my response follows.

Price Variation
The gap between the cost of a given health care procedure in the United States and elsewhere in the world is “stunning,” Berwick said. While health care analysts often scrutinize care delivery models to look for inefficiencies, Berwick says there is tremendous room for improvement at the beginning of the process, when providers of all stripes purchase equipment and devices.

“Why is there not a commoditization of the production of things that are relatively standardized to do?” Berwick asked.

For instance, when CMS implemented a competitive bidding process for durable medical equipment, Berwick said, costs fell by 32 percent. If the program had been implemented nationally, it would have saved Medicare $28 billion.

My view: Perhaps the greatest opportunity for commoditization would arrive when physician leadership, through an organization such as an ACO, assumes financial risk for the cost/quality quotient. 

Fraud and Abuse
The final category, fraud and abuse, is a well-known and reported area of concern for Medicare and other payers. While CMS has typically used law enforcement strategies to target and investigate fraudulent billing, Berwick says the agency is beginning to take a more proactive approach, predictive analytics that help the system prescreening suppliers and other vendors. Every dollar that’s spent on fraud detection and prevention, Berwick said, has roughly a sixfold return on investment.

My view: Fraud and abuse arise, at least in part, through the perverse incentives of our current system.  We have seen issues of overutilization of cardiac stents leading to criminal prosecution.  CMS has initiated pre-payment audits for certain procedures due to acknowledge “creep” in clinical indications.  With medical students emerging with hundreds of thousands of dollars in debt, is it truly surprising that some individuals on completing residencies do as many procedures as possible, when volume is the determinant of their “unit-based” reimbursement?

You are on the cusp of history’
At the end of his keynote, Berwick challenged attendees to take up the charge to reduce costs, arguing that real movement on cost containment must come from health care providers. Despite the political challenges that surrounded his 16 months in Washington, Berwick argued that the health care system can meaningfully tackle the challenges ahead if it systemically addresses the concerns he cited.

“You are on the cusp of history…not Washington,” Berwick said. …Our quest may not be quite as magnificent as the quest for human rights or a sustainable earth, but it’s immensely worthy.”

My view: Perhaps Don Berwick’s most powerful observation is that cost containment can, should, and must be led by the medical profession.  We have the opportunity to regain much of the lost professionalism of medicine, but that effort will require a willingness of physicians to address those challenges presented by Dr. Berwick.

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Trimming Costs Without Sacrificing Quality – Part One

Posted on January 3, 2012 by Paul Weygandt

In a recent H&HN Daily article, the author cited a list of six ‘wedges’ which held the possibility of improvement in healthcare as noted by the recently departed Centers for Medicare & Medicaid Services Administrator Don Berwick.   Berwick’s six ‘wedges’ are said to be: Coordination Failures, Process Failures, Overtreatment, Administrative Burdens, Price Variation and Fraud and Abuse.

Here is part one of my response to these six ‘wedges.’   The original text is in italics and my response follows.

Failures of Coordination
By this, Berwick refers to activity or investment “that doesn’t help the person you were intending to help.” He cited patient handoffs that aren’t communicated well, letting vital patient information slip through providers’ fingers, which can lead to both poor care and higher downstream costs.

“This is the waste that comes with people, especially with chronic illness, fall through the slats,” Berwick says. “They get lost, forgotten, confused. The result: complications, decays in functional status, hospital readmissions and dependency.”

My view: The current “unit-based” reimbursement system has driven extensive development within “silos” of health care with little incentive to coordinate efforts to enhance the value of delivered healthcare services.  Consider, for example, the separate silos of inpatient hospital care and post-acute services.  ED physicians are frequently challenged with the management of patients transferred from nursing facilities to the ED with chronic medical conditions not requiring inpatient hospitalization.  Patients are often returned (via ambulance) to the skilled nursing facility only to be “bounced back” to the ED within several hours.  A veritable game of patient ping-pong ensues.  Few within the silos consider the cost of ambulance transport between facilities ,which can amount to $500-700 or more per transport episode, greatly multiplying costs of care with no patient benefit.

Process Failures
While best practices for reducing or even eliminating many health care-acquired infections — or standardizing once-risky processes — are well publicized, Berwick says there’s still plenty of work to be done to improve their execution. For instance, Berwick refers to the vast number of health care-acquired infections where proven best practices are either not used or implemented incorrectly.

“Whatever health care fails to do scientifically, the cost goes up and the quality goes down,” Berwick said.

My view: Process failures can arise from lack of knowledge, barriers to application, or failures of communication or execution.  Current efforts to coordinate care are critical.  The patient care team has become even more important than in the past as the amount of information in the medical record vastly increases.  Physicians simply cannot individually monitor all documentation in the medical record, including labs, rad reports, PT, OT, RT, dietary, nursing, and other notes.  With the complexity of the medical record and current care processes, process failures are inevitable unless coordinated care practices are endorsed by all care-givers and communicated using consistent and accurate terminology.

Overtreatment
Citing everything from aggressive end-of-life care to patients who receive antibiotics for viral colds, Berwick argued that the health care delivery system devotes far too much time to “subjecting people to care that cannot possibly help them — care rooted in outmoded habits, supply-driven behaviors and ignoring science.” In particular, Berwick cited patients who receive a series of inconclusive tests without a resolution.

“This is the Odysseus complex,” Berwick said. “You take a bunch of tests, and one is abnormal. Then you take another set, and one is abnormal. You keep going until you head home, like Odysseus.”

My view: The current healthcare reimbursement model rewards those involved in marketing, selling, delivering, and brokering additional units of service.  There is no dis-incentive to doing exactly what Dr. Berwick describes.  Consider Odysseus in the modern world of healthcare.  While he may be wanting to ultimately return home (providing high quality care), every additional step he takes (procedure he performs or orders) results in additional wealth (fee for service).  If Odysseus’ journey were more rewarding than his destination, would he be highly motivated to take the shortest, least expensive path?

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