Month: November 2014

Will ICD-10 be Delayed Again?

Jason Gottlieb

by Dan Haley, VP of Government and Regulatory Affairs

See full article here.

Is the October 2015 deadline real this time? Are the feds going to punt again? They aren’t ever going to pull the trigger on ICD-10, right?

All reasonable questions, especially after the October 2014 deadline — supposedly a hard-and-fast date — was unceremoniously kicked down the road by a year.

When it comes to ICD-10, providers fall generally into two categories: Those who actually invested time and money to be ready for October 2014, and, having been burnt once badly, are leery of approaching the ICD-10 stove again. Then there are providers who feel validated that they had correctly bet the feds would blink — and may be more comfortable making that bet again next year.

The policy meteorologists uniformly predicted stormy weather. Yet a whole lot of people went outside without an umbrella and ended up enjoying a beautiful, sunny day. Why shouldn’t the same scenario play out again in 2015?

Despite all of the time I spend in the company of federal health IT policymakers, I have precious little insight to offer. The people in DC who are in charge of the transition are emphatic, both in public and behind closed doors: this time, they say with uniform certitude, the deadline is real. Count on it. Tomorrow the sun will rise in the east, this winter the New England Patriots will make the playoffs (hey, I’m in Boston), and in October 2015, the nation will switch over to ICD-10.

Considering past performance as an indicator of future action, skeptics can certainly be forgiven for their lack of faith. So how can we at athenahealth say, with a straight face, we think this thing might just be real this time? A few reasons:

  1. The 2014 delay was almost certainly political. With the nation just barely over the calamitous roll-out of healthcare.gov, there was no way the White House would implement a massive code switchover that could well have rendered a majority of the country’s providers temporarily unable to be paid for their services, just one month before the midterm elections. Unequivocal statements by everyone including Centers for Medicare & Medicaid Services (CMS) head Marilyn Tavenner notwithstanding, this year’s delay was entirely predictable. 2015, on the other hand, is not an election year. Even if providers are not appreciably better prepared for ICD-10 next year than they were in 2014, it may not matter — chaos is more politically palatable in an off year.
  2. The recent Ebola scare lends a new degree of urgency to upgrade U.S. systems to match the code set already in use in much of the world, to better enable the disease identification and tracking necessary for a global health crisis response. Nothing motivates change in Washington like an emergency.
  3. Of course, there is the Affordable Care Act. With the rolling implementation of the law, provision of and reimbursement for care is getting more complex. At some point, the continued use of a code set rolled out in the Watergate era, and long-retired in much of the modern world, becomes untenable.

Regardless of the continued uncertainty surrounding the October 2015 deadline, at athenahealth we are encouraging providers to get ready for ICD-10 and are preparing and testing on our clients behalf. Our cloud platform had our entire provider base ready well before October 2014, and will have it ready again months before October 2015, at no additional cost to those clients. And we are working hard — again — to make the transition as easy and painless as possible.

Like meteorologists, political prognosticators are often wrong, sometimes radically so. Even though we sometimes get to enjoy unexpected blue skies, eventually it pays to dress for stormy weather. DC is again confidently predicting a switch to ICD-10 on October 1, 2015, and there is no upside to bet against that happening. No matter when it does, athenahealth will be holding the umbrella for providers.

Responding to Physician Criticism of ICD-10

Jason Gottlieb

Written by

See full article here.

For those physicians who have studied ICD-10 extensively, the overall impression among them is that it is a vast improvement over ICD-9. The most common criticism, the increased number of codes, should be addressed first.

It is true that the number of diagnosis codes in ICD-10 increases by approximately a factor of five over ICD-9. Many physicians bemoan the fact that they will have to learn five times as many terms as they knew under ICD-9. Yet this simply reflects a lack of knowledge. Consider, for example, a non-traumatic subarachnoid hemorrhage. Under ICD-9, this diagnosis fell under the categorical single code for subarachnoid hemorrhage. In ICD-10-CM, there is a specific category for non-traumatic subarachnoid hemorrhage featuring 20 specific codes. Going from one to 20 codes is a big leap. Does this reflect a lot of new learning for physicians?

Hopefully not.

What the code expansion actually represents is huge advances in clinical medicine made in the 35 years since ICD-9 was drafted. Specifically, we now have technology (CT/MRI/angiography) that can identify the specific artery involved (middle cerebral, basilar, anterior communicating, etc.) as well as laterality for many of those blood vessels. It is basic, responsible practice of medicine to identify the nature of the non-traumatic subarachnoid hemorrhage, in today’s clinical world.

Cardiology is a specialty for which terminology has improved significantly. The “new” terms for acute myocardial infarctions in ICD-10-CM are STEMI and NSTEMI (terminology that, incidentally, has been used by cardiologists, internists, and others for the last couple decades).

One area of legitimate concern among cardiologists relates to specificity regarding type of heart failure (acute or chronic, systolic, diastolic, or combined). Many cardiologists historically have not made such a differentiation, but they should acknowledge that this terminology is not new under ICD-10-CM – it’s also the codeable terminology found in ICD-9.

Is there a high degree of specificity in ICD-10-CM? Absolutely. And it is perhaps nowhere better exemplified than in orthopedic diagnoses. Just as an example, there are a myriad of codes for fractures of the femur. That sounds extreme until one actually learns how ICD-10-CM works. The new coding system includes terminology that every orthopedic resident must learn: the Gustilo classification of open fractures, the Salter-Harris classification of epiphyseal fractures, as well as other essential information such as specific anatomic site, type of fracture (spiral, etc.), and of course, laterality.

For neurosurgeons and trauma surgeons, ICD-10-CM includes provisions for the documentation of attributes of head injuries such as duration of loss of consciousness for cerebral edema as well as Glascow coma scores.

A comment from an internist in Anchorage, Alaska put ICD-10-CM into sharp perspective. He said (and I agree) that ICD-10-CM is exactly what we should expect from a resident in a morning report. So should we expect any less from practicing physicians? This observation should be reassuring to most physicians. I will admit, however, that the challenge is not the same for all specialties. Generalists, whether they are trained in family medicine, internal medicine, or emergency medicine, treat patients with a broad scope of diagnoses and will require more assistance transitioning to ICD-10-CM.

I should also mention ICD-10-PCS, the procedural coding system. Here we have a far greater increase in the number of codes. The marked expansion in the number of codes in ICD-10-PCS is primarily due to the architecture of the PCS system. ICD-10-PCS codes capture information impossible to capture in ICD-9, such as specific body parts, types of operations, types of devices left in a patient, and more. While this seems like it might present a lot more work for the physician, in most instances a quality operative report will include all the necessary information for coding, particularly if physicians are educated on basic code structure. It is unnecessary and absolutely not recommended that physicians memorize any ICD-10-PCS codes.

Let me share an observation from dealing with hospitals and medical staffs from across the country. The strongest physician advocates of ICD-10 appear to be those working in academic medical centers. That is, perhaps, because specificity and accuracy of diagnoses and procedure documentation are key components of residency and fellowship training. Additionally, most academic physicians recognize the lack of utility of ICD-9 for clinical research or epidemiology. ICD-10 provides much better information for such purposes.

I will conclude with one final observation. ICD-10 presents different challenges to different constituencies. I am very sympathetic to coders. They are essentially learning a new language, and they need to learn it for all specialties, all diagnoses, and all procedures. And here is where some of the confusion may have arisen for physicians who have not as yet learned much about ICD-10. We, fortunately, do not face the same challenges. For the vast majority of physicians, we can constrain our focus to our specialty areas.

In so doing, we quickly realize that the information needed for ICD-10 generally mirrors that which is required for high-quality patient care.

ICD-10 holds true promise for improved clinical terminology

Jason Gottlieb

Written by Dr. Abhishek Jacob

See full article here

It is common knowledge that ICD-10 CM & PCS code sets will increase granularity, improve axes of classification and provide a more scientific approach to coding, opening up tremendous growth in our understanding of disease conditions and associated treatment protocols.

For the first time in 36 years, we have the opportunity to revamp the clinical terminology being used to measure effectiveness of healthcare services, refine clinical grouping and associated reimbursement methodologies and enhance capability to conduct public health surveillance.

Today’s Challenges

  1. Many provider organizations believe that because ICD-10 has been characteristically complex to implement and includes many new and potentially amusing codes (e.g. W59.22XD – “struck by turtle, subsequent encounter”), the increased quantity may not be very useful from a treatment and re-imbursement perspective. These issues significantly undermine the potential benefits ICD-10 will have on documenting and reporting clinical conditions, enhancing clinical terminologies and, most importantly, measuring the effectiveness of treatments for better disease surveillance – like the current course of action and treatment during the recent outbreak of Ebola cited later.
  2. Though a competing priority, Meaningful Use (MU) implementation has a mutual dependency and benefit to ICD-10. One of the most important drivers of meaningful usage of EMR is allowing clinical data to be effectively utilized and shared between EHR systems. To accomplish this objective of using standard clinical terminologies, ICD-10 and MU requirements must be incorporated into EHR systems concurrently. This would help achieve comprehensive system interoperability and shed light on the benefits of a national health information infrastructure. ICD-10 and MU implementation are complimentary and are required to be applied together, and therefore should not be viewed as conflicting priorities.
  3. Last, rather than being used as a counterpoint to discredit the tremendous potential benefit of ICD-10 implementation, many of the so-called irrelevant codes, such as “struck by turtle, subsequent encounter,” fall in external causes of injury chapter and are not necessarily required for reimbursement of diseases surveillance, which means their usage can be restricted on a case to case basis.

ICD-10: The Next Generation of Clinical Terminology and Coding

ICD-10 holds true promise to expedite a much needed revamp of existing clinical terminologies and coding for high value patient encounters. Below is an analysis of a simple example that compares how ICD-10 provides significant enhancement to our ability to measure healthcare services and how increased sensitivity would assist in refining existing grouping and reimbursement methodology.

With more than 650,000 procedures per year, angioplasty in one of the most commonly performed operations, contributing approximately $13 billion per year to U.S. healthcare spending. According to a study published in The Journal of the American Medical Association in 2012, almost half of the angioplasties conducted in non-emergency situations may not benefit patients. In ICD-9 CM, angioplasty is represented by only 1 code- 39.50 and since ICD-9 CM lacks the granularity, it might not be possible to relate the clinical outcomes of the procedure with the associated reimbursement.

ICD-9-CM

Angioplasty – 1 code (39.50)

ICD-10-PCS

Angioplasty – 854 codes

ICD-10 CM not only specifies the body part the procedure was conducted on but also the approach, the device used and the type of stent placed. This granularity allows for correlation between clinical outcomes and a specific type of procedure, thereby improving the overall efficacy of the treatment.

Some examples of ICD-10 granularity of Angioplasty codes include:

  • 047K04Z – Dilation of right femoral artery with drug-eluting intraluminal device, open approach
  • 047K0DZ – Dilation of right femoral artery with intraluminal device, open approach
  • 047K0ZZ – Dilation of right femoral artery, open approach
  • 047K34Z – Dilation of right femoral artery with drug-eluting intraluminal device, percutaneous approach
  • 047K3DZ – Dilation of right femoral artery with intraluminal device, percutaneous approach

The granularity that comes with ICD-10 is critically important to the future of our healthcare system. The outbreak of Ebola has allowed many analysts and experts in the field to stress how ICD-10 and improved clinical terminology intensifies the need and benefits of the new code set. ICD-10 could allow healthcare providers to measure the effectiveness of treatments for better disease surveillance and outbreak response.

ICD-9 CM has no specific code for reporting Ebola hemorrhagic fever (EHF). The closest match is 065.8 “other specified arthropod-borne hemorrhagic fever.” ICD-10 CM has a specific code, A98.4 “Ebola virus disease.” In ICD-9 CM Ebola is classified under “arthropod-borne viral diseases” whereas in ICD-10 it is classified as “arthropod-borne viral fevers and viral hemorrhagic fevers.”

There is currently no drug or vaccine available to treat Ebola and most of the treatment is based on experimental drugs. Since the outbreaks, until now, have appeared prominently in Africa, where there is a very restricted use of standard clinical terminology and modern EHR systems, little information is available about the natural reservoir host of Ebola virus.

And as we’ve witnessed, because physicians aren’t able to accurately document the causative factors, strains of virus and treatment protocols, our response to the outbreak has been restricted to a tactical stoppage of spread. ICD-9 CM does not have any codes to document Ebola accurately, and though ICD-10 CM has only one code to report Ebola, the ability to expand the categorization in ICD-10 ensures that researchers, authorities and care providers can better prepare for response, resulting in potential lives and millions of dollars saved. This is a classic example of how accurate usage of clinical terminology for disease surveillance associated with ICD-10 implementation holds true promise.

Continued use of ICD-9-CM as a medical code set standard threatens to jeopardize the ability of the U.S. healthcare industry to effectively collect and use accurate, detailed healthcare data and information for the betterment of domestic and global healthcare. Clinical terminology modernization and standardization are amongst the most important steps required to maximize the power of healthcare data and, in doing so, build a better healthcare system for the 21st century.

ICD-10 and Value Based Purchasing (VBP)

Jason Gottlieb

Written by Gregory M. Adams, FHFMA

See full article here

According to the group Catalyst for Payment Reform, of the value-based payment models in action, 53 percent of commercial payer VBPs put providers at some financial riskif they fail to contain costs or improve care.

However, on the flip side, many value-based payments still fall into the category of pay-for-performance, which offers providers only potential financial rewards and no risk. I believe that the progression of VBPs will move quickly away from this model into models that will penalize providers for poor quality.

This is already being done by the Medicare program, which is seeing to it that hospitals are slapped with big penalties that experts say are only increasing. A recent study from CipherHealth shows a mounting $1.6 billion in Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and readmission penalties facing hospitals today. That’s $1.6 billion! The survey calculated that at more than 500 hospitals nationwide, the three-year at-risk amounts were $3,500 per inpatient bed.

Based on a study by the PWC Health Research Institute, the financial impact of these value-based reforms is expected to have a significant impact on low-performing hospitals. For example, a 300-bed hospital with poor quality metrics would be penalized approximately $1.3 million a year, beginning in 2015, under Centers for Medicare & Medicaid Services (CMS) value-based reforms. And this doesn’t consider the impact of reduced payments from commercial payers. In this example, if we assume that another 30 percent of the hospital’s revenue is commercial, using the same penalty relationship, the hospital would lose over $2 million a year.

Now, let’s put that number into perspective – while profitability for hospitals increased overall in 2012, there was a wide disparity in hospital performance, with over 30 percent of hospitals running at a loss. For those hospitals, even a small decrease in payments will strain resources. So, how does a hospital fix any quality issues through changes in operational practices, which will cost money, while receiving less in payments? It will not be easy, and keep in mind that any quality comparisons, at least at the federal level, are a moving target. Under the current CMS formula, not only do providers need to improve their scores, they need to improve at a faster rate than other hospitals nationally to benefit.

Now how does VBP relate to ICD-10? Well, the accuracy and completeness of coding drives many of the quality and severity-of-illness indicators that in turn determine value-based payments or penalties. And with the increased complexity of coding under ICD-10, the potential for inaccurate coding increases exponentially. On top of that is the uncertainty of how both CMS and commercial payers will change their measurement criteria for quality and value with the increased specificity of the ICD-10 codes. With all of these unknowns, one thing is clear – clinical documentation is, or should be, a top priority for every provider. The accuracy and preciseness of the coding of a patient’s record ultimately will affect VBP payments and whether reimbursement decreases, increases, or stays the same during the ICD-10 transition. Millions of dollars are hinging on your clinicians and coders, so here are two tactics to help you tackle these transitions.

Workgroup for Electronic Data Interchange (WEDI) releases latest ICD-10 readiness survey results

Jason Gottlieb

The Workgroup for Electronic Data Interchange (WEDI), the nation’s leading nonprofit authority on the use of health IT to create efficiencies in healthcare information exchange, announced the release of its findings from its August 2014 ICD-10 Industry Readiness Survey. The latest survey results are based on responses from 514 respondents, consisting of 324 providers, 87 vendors and 103 health plans.

Since 2009, WEDI has conducted nine ICD-10 readiness surveys in an effort to gain a broad perspective on the readiness status for different sections of the industry, and to gauge how quickly they are progressing towards the Oct. 1, 2015 implementation deadline. The full survey results are contained in WEDI’s September 19 letter to the Department of Health and Human Services (HHS) which can be viewed online via the WEDI website. Highlights from the latest survey findings include:

  • Vendor product development: About 40 percent of vendors indicated they are complete with product development. This is an improvement over the October 2013 survey.
  • Vendor product availability: More than 25 percent of vendors responded that their products would not be ready until 2015 or responded ‘unknown.’
  • Health plan impact assessments: Nearly 75 percent of health plans had completed their impact assessment.
  • Health plan testing: More than 50 percent of health plans have already begun external testing compared to less than 25 percent in the prior survey.
  • Provider impact assessments: About 50 percent of the providers indicated they have completed their impact assessment—essentially the same number as in the October 2013 survey.
  • Provider testing: About 35 percent of providers have begun external testing, while in the October 2013 survey about 60 percent had expected to begin by the middle of 2014.
  • External testing approach: About 60 percent of health plans expect to test with a sample of providers, while about 20 percent indicated they will test with a majority of providers.

“Based on the survey results, all industry segments appear to have made some progress since October 2013, but the lack of progress by providers, in particular smaller ones, remains a cause for concern as we move toward the compliance deadline,” said Jim Daley, WEDI chairman and ICD-10 Workgroup co-chair. “Delaying compliance efforts reduces the time available for adequate testing, increasing the chances of unanticipated impacts to production. We urge the industry to accelerate implementation efforts in order to avoid disruption on Oct. 1, 2015.”

WEDI will continue its efforts to move the industry forward and plans to continue its surveys to gauge industry readiness. WEDI has conducted several ICD-10 forums—the most recent of which was in July 2014—and plans to hold additional events in 2015, as well as continue to provide educational opportunities and produce work products to assist the industry in preparing for ICD-10 implementation. More information on WEDI events and ICD-10 work products are available on the WEDI website.

- See more at: http://www.wedi.org/news/press-releases/2014/09/25/Results-from-WEDI-ICD-10-Industry-Readiness-Survey-Released#sthash.y5QeiaRr.IPe8lLJa.dpuf

ICD-10 Readiness Spotlight: Electronic SuperBill Implementation

Lauren Hartstein

You may have heard the term “SuperBill” tossed around at meetings but may not know exactly what one looks like or its importance to ICD-10 readiness. A SuperBill is simply an itemized form healthcare provider’s use to reflect services rendered in a patient visit. It is generally customized for a provider’s practice and contains patient information, as well as several diagnoses and procedures from which to choose, currently all in ICD-9 (see Exhibit 1). In short, SuperBills are the backbone of charge capture and integral to ensuring that ICD-9 CM, CPT-4, HCPCS codes and appropriate modifiers are billed.

Exhibit 1: Original ICD-9-CM SuperBill

(from the AAFP, https://www.aapc.com/icd-10/superbills.aspx)

superbill

At NYP, the initiative to convert all areas from paper SuperBills, also known as encounter forms, to electronic SuperBills capable of interfacing to our billing system began in 2010. This has been part of an ongoing effort towards a paperless revenue cycle. As NYP prepares for the implementation of ICD-10, it is critical that all clinical areas on paper encounter forms are transitioned onto the electronic SuperBill to facilitate conversion of the ICD-9 diagnosis codes to the equivalent ICD-10 options. This is because the increased complexity and granularity of ICD-10 coding will exponentially increase the volume of ICD-10 codes, no longer allowing paper to be a viable option charge and code capture. For example, a two-sided 8 ½ x 11 inch paper encounter form in ICD-9 might require a 15+ page form once converted to ICD-10. Multiple page encounter forms are not only impractical, but also costly and time consuming to complete. If your clinical staff is still using paper forms to capture important diagnosis, charge, and billing information, prepare your practice for the transition to ICD-10 and convert to electronic SuperBill. Contact project leaders, John Tallent (jot9032@nyp.org) and Jerilyn Loria (jel9085@nyp.org) for more details.