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Technical Doctor's insights and information collated from various sources on EHR selection, EHR implementation, EMR relevance for providers and decision makers
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ICD-10 Success for Large Practices, Problematic for Small

ICD-10 Success for Large Practices, Problematic for Small | EHR and Health IT Consulting | Scoop.it

Several weeks following the implementation of the ICD-10 code set, the progress of the transition appears to vary according to size of the practice. While many large practices are reporting success with the transition, some smaller ones are reporting difficulty.


According to a blog post by the Coalition for ICD-10, many of the group’s members -- which happen to be larger healthcare providers -- are reporting great success with the transition. Many, like Centegra Health System, credit this success to the ample time for preparation they received.


“Centegra Health System was prepared for a smooth ICD-10 transition after two years of careful planning. Our information technology systems have been updated and our educational plans were deployed to help with the initial roll-out,” said Centegra’s Executive Vice President, Chief Financial Officer, and Chief Information Officer David Tomlinson.



Additionally, some coalition members stated that their success on October 1st is due in large part to their early implementation of the code set.


“Northwest Community Healthcare’s transition to ICD-10 has been smooth. This is due, in part, to our early clinical rollout of ICD-10 with our Epic Go-Live date of May 1, 2015,” said President and Chief Executive Officer of Northwest Community Healthcare Stephen Scogna.


Other members of the coalition, such as insurer Blue Cross Blue Shield of Michigan, reported a few bumps in the road amidst a generally smooth transition.


““BCBSM’s ICD-10 implementation went very smoothly. Call center volumes and overall inquiries are very low. Professional and facility claims are processing as expected. A few issues noted, which we are resolving, but nothing major to report,” the insurer said.


BCBSM also reported that it was the first private insurer to reimburse the hospitals it serves.


“Received kudos from our hospitals stating that BCBSM was the first payer to pay ICD-10 claims and these claims are paying as expected. Hospitals are not reporting any major issues. Other Payers (Priority, Cigna, Aetna) are reporting the same experience in that they are not seeing any major issues.”


However, this success is in contrast to what some other smaller providers are reporting. The impact of ICD-10 on smaller providers is a little bit more weary as these providers have fewer resources to work with.

For example, Linda Girgis, MD, FAAFP, told EHRIntelligence.com that due to how small her practice is -- she and her husband are the only physicians in the family practice -- its workload has grown much larger. This work includes changing patient problem lists from ICD-9 codes to ICD-10.

"The doctors are doing it right now," she says. "I'm doing it as I come across different patients, but definitely it's adding time on to the workday."


Smaller practices are especially affected by ICD-10 troubles because much of their revenue comes from the Centers for Medicare & Medicaid Services (CMS), and the agency has been reportedly unreachable throughout the transition.


"My biller tries to call every day. Since October 1, they have messaged that they are down due to technical difficulties so it's impossible to get through to any person there,” Girgis said.


Not receiving CMS payment is problematic for small practices like Girgis’ because those payments may amount to almost 30 percent of hospital revenue. While a larger hospital, like those mentioned above, may be able to do without 30 percent of its revenue for a month or two, this kind of issue could be potentially detrimental for a practice like Girgis’.


"Big organizations, hospitals, and groups can go a few months without 30 percent of their reimbursement coming in. But for small practices, that can be devastating," argues Girgis.


CMS set a timeline for rolling out ICD-10 payments, stating that those claims would be reimbursed within the first 30 days of the new code set. As that 30-day timeline draws to a close, small practices will be waiting to see if their claims are reimbursed.

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CMS Administrator Welcomes Providers to ICD-10 Compliance

CMS Administrator Welcomes Providers to ICD-10 Compliance | EHR and Health IT Consulting | Scoop.it

On October 1, the healthcare industry began ICD-10 compliance after countless months of preparation. In a CMS post, Deputy Administrator and Director of the Centers for Medicare & Medicaid Services (CMS) welcomed providers to ICD-10 and provided words of guidance to industry stakeholders on the transition day.

According to Cavanaugh, it may take a little while before CMS is able to assess how the transition to ICD-10 is proceeding. The reasons for this are twofold: first, most providers do not file claims on the same day as a service has been provided, and second, it takes a few weeks for CMS to process Medicare and Medicaid claims.


“Even after submission, Medicare claims take several days to be processed, and Medicare -- by law -- must wait two weeks before issuing  payment. Medicaid claims can take up to 30 days to be submitted and processed by states,” Cavanaugh wrote.


It is most likely that CMS will be able to assess ICD-10 progress following the first complete billing cycle. This is consistent with other CMS claims. In aconference call with industry stakeholders which took place a week before the October 1 deadline, CMS Principal Deputy Administrator Patrick H. Conway, MD, MSc, confirmed the same timeline for checking ICD-10 progress.

Until then, Cavanaugh explained, CMS plans to closely monitor the transition. Furthermore, CMS will be managing problems and questions that are submitted to the ICD-10 Coordination Center, which is staffed by several Medicare, Medicaid, billing, coding, and health IT experts to assist during the transition. In addition to the ICD-10 Coordination Center, Cavanaugh points providers toward other ICD-10 assistance resources, including William Rogers, MD, the ICD-10 ombudsman, and Medicare Administrative Contractors (MACs).


Cavanaugh also discussed the potential benefits of the ICD-10 transition, including the promise of more detailed health data reporting and and better healthcare delivery. By increasing the detail with which medical care is reported, policy changes can be more specific to the needs of populations.


“The change to ICD-10 allows you to capture more details about the health status of  your patients and sets the stage for improved patient care and public health surveillance across our country,” he wrote. “ICD-10 will help move the nation’s health care system to better, smarter care.”


These hopes for ICD-10 have been mirrored by many industry stakeholders, including AHIMA CEO Lynne Thomas Gordon, MBA, RHIA, CAE, FACHE, FAHIMA. Thomas Gordon recently stated howICD-10 will be of great benefit for patients because it will allow for better healthcare innovation due to the extensive detail of health records.

“As an active leader, supporter and advocate for ICD-10, AHIMA is pleased that the greater detail inherent in the code set will reverse the trend of deteriorating health data and tell a more complete and accurate patient story,” she said.


As providers continue with their transition to ICD-10, CMS is expected to report any major issues and provide guidance in fostering the smoothest transition possible.

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CMS Confirms Readiness to Assist During ICD-10 Transition

CMS Confirms Readiness to Assist During ICD-10 Transition | EHR and Health IT Consulting | Scoop.it

The ICD-10 compliance deadline of October 1 is less than a week away, creating a frenzy of preparation amongst coders, billers, and providers. The Centers for Medicare & Medicaid Services (CMS) senior officials recently held a conference call to answer questions regarding implementation, and specifically addressed the issue of CMS as a resource come October 1.


The September 24 call included CMS Principal Deputy Administrator Patrick H. Conway, MD, MSc, and ICD-10’s recently appointed ombudsman William Rogers, MD.


The bulk of the call consisted of a question and answer session which generally revolved around the roll of CMS as a resource for clinician practices experiencing issues with transition. Specifically, many callers were concerned with the potential government shutdown that could occur on October 1 if Congress cannot reach an agreement on the federal budget.


“In the event of a shutdown, we will continue -- and I want to be clear on this -- to pay claims,” Conway said. “We will continue to implement the ICD transition.”


Rogers made it clear that the Medicare administrative contractors (MACs) would still be working in the event of a shutdown, so claims will be accepted and paid during that time.


Conway elaborated on that point during another question, stating that payment systems are an essential part of the Medicare program and would still function in the event of a shutdown.


“In terms of staffing, we do have the flexibility to ensure core operations are operational and in effect,” Conway stated. “And obviously, our payment systems are a core piece of the Medicare program that will continue to be fully operational.”


Conway also addressed the issue of claims processing timelines and how that will affect real-time assessments of the transition. Although it would be ideal for CMS to have a clear idea of the state of the transition as soon as it occurs, Conway explains that due to the typical billing timeline, it will in reality take about one billing cycle.


“The Medicaid claims can take up to 30 days to be submitted and processed,” he said. “This end can take approximately two weeks. The Medicaid claims can take up to 30 days to be submitted and processed. For this reason, we expect to have more detailed information after a full billing cycle is complete.”


The questions on the call revolved around the cost of ICD-10 implementation, especially considering systems upgrades. According to Conway, the cost greatly relied on the specific circumstance of the practice or facility. Rogers shed light on the costs for smaller practices.

“[M]ost smaller practices just use a super bill,” Rogers explained. “t requires a little bit of an expansion of the number of diagnoses on the superbill. But they can easily cross walk their ICD-9 based super bill to an ICD-10 super bill.”


Rogers also assured callers that CMS has ample resources to ensure a smooth transition, and that they themselves will be able to serve as a resource for clinician practices. He explained that he, along with all of CMS, can serve as a major resource for providers who have questions regarding the transition process, and encourages providers to contact the ombudsman email address when in need of assistance.

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Clinical Documentation Improvement Vital for Patient Care

Clinical Documentation Improvement Vital for Patient Care | EHR and Health IT Consulting | Scoop.it

Clinical documentation improvement programs lie at the heart of quality patient care and should accurately show a patient’s clinical status as well as inform which services were provided. According to the American Health Information Management Association (AHIMA), clinical documentation improvement programs transfer patient’s medical information into coded data, which is then part ofquality reporting, claims reimbursement, public health information, and disease tracking.


Health information management (HIM) professionals work as both coding experts as well as clinical documentation improvement strategists within their organizations to ensure meaningful information is captured.


In particular, clinical documentation improvement experts remain dedicated to ICD-10 implementation and the adoption of strong EHR systems across the healthcare continuum. HIM professionals work to assist physicians in remaining compliant with all patient documentation requirements.


Some policies that need to be followed when implementing clinical documentation improvement programs are hiring staff with the right education, experience, and credentials as well as ensuring ongoing education and training for such staff, according to AHIMA. The major roles that healthcare providers have in ensuring their clinical documentation is solid are reporting medical decision making, diagnostics, treatment plan, and outcomes of tests, treatments, and other procedures.


One partnership that is targeting clinical documentation improvement is Nuance Communications, Inc. and medical care predictive analytics company Jvion, according to a joint press release. The two companies are looking to better assist healthcare providers in meeting the requirements of a value-based reimbursement model.


Many medical facilities will likely experience various challenges when transitioning from a fee-for-service payment model to value-based care. Advanced Practice CDI from Nuance Communications should assist providers in this transition.


“We want to get paid for the quality of care and services we provide,” says Joann Hatton, director of Utilization Management and Clinical Documentation Management at Heritage Valley Health System, in western Pennsylvania. “It’s not about the money, it’s about improving patient care, but the positive financial impact of Nuance’s CDI program was clearly evident.”


When it comes to implementing clinical documentation improvement strategies and clinical quality metrics, Heritage Valley Health System saw a significant drop in their predicted mortality rate. This particular rate decreased by 27 percent after integrating clinical documentation improvement programs.


“Data drives our practice,” explains Jennifer Woodworth, director of Clinical Documentation Integrity Program at Swedish Health Services. “Physician and hospital compensation is tied to quality metrics, which means to prove that you are providing high quality care you need data. This real-time reporting allows us to drill down to ICD-9 and ICD-10 codes, complications and other specialized details to see how we are doing with the accuracy of physician documentation, and this enables us to create proactive initiatives that maximize our current resources.”


As more health IT tools are developed to assist providers with clinical documentation improvement programs, the healthcare industry will be ready to effectively transition to a value-based care payment model.

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Is Dual Coding an Effective ICD-10 Training Strategy?

Is Dual Coding an Effective ICD-10 Training Strategy? | EHR and Health IT Consulting | Scoop.it

With the October 1 deadline only a mere three months away, following an effective ICD-10 training strategy is of the utmost importance in order to receive standard reimbursement from the Centers for Medicare & Medicaid Services (CMS) as well as other insurers.

One ICD-10 training strategy that a particular medical care organization followed is to dual code diagnostic records and claims in both ICD-9 and ICD-10 coding sets. The Journal of AHIMA reported that the health information management department at Baystate Health has been coding records in ICD-9 and ICD-10 since the beginning of 2014.


This type of dual-coding ICD-10 training strategy has been effective at showing healthcare professionals how the new coding set compares with the older ICD-9 codes. Recently, the organization has taken it one step further. Baystate Health’s new ICD-10 training strategy is to spend one day per week coding in only ICD-10.


This extra time spent on only coding via the new diagnostic and procedural codes will help the healthcare staff at this facility understand what their workflows will be like by the ICD-10 transition deadline on October 1, 2015.


It may benefit more healthcare organizations to use this ICD-10 training strategy and spend some time coding in only ICD-10 before the deadline takes place. The way Baystate Health has developed the new strategy is by having one individual complete the necessary codes in ICD-10 one day per week while another professional codes the same record in ICD-9 immediately afterward.


There are a variety of benefits when it comes to coding in only ICD-10 and preparing for the October 1 deadline. Instead of having to switch back and forth between two coding sets, healthcare professionals will be able to focus more on the new codes during a longer time period.

Healthcare providers should be prepared for the October 1 deadline as it is unlikely any more ICD-10 delays will take place. While there are a variety of organizations that have attempted to postpone the deadline or put an end to the coding transition altogether, the Centers for Medicare & Medicaid Services (CMS), the Coalition for ICD-10, and other federal agencies seem focused on sticking to the deadline regardless.


“Calls for a safe harbor or grace period based on code specificity appear to be a reaction to physicians’ fears that there will be a huge uptick in claims denials if non-specific codes are reported,” the Coalition for ICD-10 reported. “However, these fears are refuted by the results of CMS’ recent end-to-end testing, which showed only a 2% denial rate associated with ICD-10-related errors, thus demonstrating that the transition to ICD-10 will have a minimal impact on the rate of claims denials.”


“A safe harbor for the use of non-specific codes is unnecessary and detracts industry attention from getting ready for the ICD-10 compliance date. There is no evidence supporting the need for a safe harbor,” the Coalition for ICD-10 continued.

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Physician Organizations Fear ICD-10 Integration Disruptions

Physician Organizations Fear ICD-10 Integration Disruptions | EHR and Health IT Consulting | Scoop.it

While the Centers for Medicare & Medicaid Services (CMS) continue to urge healthcare providers to prepare for the coming ICD-10 integration, many stakeholders are concerned that the healthcare industry will encounter large disruptions to patient care services and financial reimbursements if the ICD-10 compliance deadline remains steadfast.


In its latest mailing, CMS encourages providers to train their staff on ICD-10 coding with the Quick Start Guide. In the meantime, representatives from the California Medical Association, Florida Medical Association, Medical Society of the State of New York, and the Texas Medical Association sent a letter to Andy Slavitt, Acting Administrator at CMS, asking for additional assistance with the ICD-10 integration.


In particular, the organizations are asking CMS to develop a two-year ICD-10 integration period during which doctors will not be penalized for any coding mistakes or system malfunctions. Additionally, the letter asks for a two-year ICD-10 transition period that prevents audits from taking place due to ICD-10 coding errors. The medical organizations are urging CMS to prevent physician payment reductions due to ICD-10 coding mistakes throughout the two-year period.


“The Oct. 1 mandatory implementation of the ICD-10-CM coding system is a looming disaster,” the letter to CMS exclaimed. “The results of the recent end-to-end tests give us little confidence that the nation’s physicians, electronic health records, claims clearinghouses, commercial insurance companies, and government agencies will be ready when we ‘throw the switch’ to ICD-10.”


“The voluminous technical problems associated with the far simpler adoption of the National Provider Identifier and the HIPAA 5010 transaction standards give us even further cause for concern,” the letter continues. “Even those practices that are most prepared for this transition tell us they worry about the confusion and reduced productivity they expect to accompany ICD-10.”


Since many physician organizations and healthcare providers are concerned with meeting the deadline for the ICD-10 integration and a multitude of bills are coming out to support a modified transition period, the American College of Rheumatology created a policy brief that outlines six myths and facts about the ICD-TEN Act (H.R. 2247).

First, there is a general misconception that the ICD-TEN Act will undermine coverage and healthcare quality, the organization explained. However, the bill made a “distinction between diagnosis code errors and sub-code errors.”


Additionally, many believe that the ‘Safe Harbor’ provisions discount the fact that CMS must make sure providers are paid appropriately for their services. However, medical coverage and medical necessity can be assessed using the correct ICD-10 diagnosis codes instead of the sub-codes, which is what the ICD-TEN Act focuses on.

Along with these potential myths, many feel that the ‘Safe Harbor’ provisions could lead to incomplete documentation. However, the American College of Rheumatology explains that the ICD-TEN Act will remain accountable for ensuring “coding specificity is achieved without disrupting patient care.”


“Sub-codes most often indicate subtypes or locations of disease. While this specificity is beneficial for disease surveillance and some treatment decisions, it is not relevant to determination of coverage or medical necessity, and should not be used to deny payment for services rendered,” Dr. William Harvey, a practicing rheumatologist and chair of the ACR Government Affairs Committee, said in a public statement. “The ICD-TEN Act is carefully worded to allow Medicare to continue to accurately determine medical coverage and medical necessity using the new base ICD-10 diagnosis codes.”   

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Final Steps to Take Before the ICD-10 Implementation Deadline

Final Steps to Take Before the ICD-10 Implementation Deadline | EHR and Health IT Consulting | Scoop.it

As the countdown to the ICD-10 implementation deadline continues and the healthcare industry gets closer to October 1, those ready for the new diagnostic coding set will stand out from the rest of the crowd. An article by Pam Jodock, Senior Director at the Healthcare Information and Management Systems Society (HIMSS), describes three types of medical organizations that are either moving forward with the ICD-10 implementation deadline or are behind in their ICD-10 preparations.


The healthcare entities that have implemented new system upgrades and trained their staff on the ICD-10 coding set while ignoring any ICD-10 delays should be more ready than others once October 1, 2015 hits.


The second type of provider likely stopped his or her ICD-10 preparationsonce the 2014 ICD-10 delay was announced but resumed at the beginning of this year. Those who began in January or February should still be in good shape to meeting the ICD-10 implementation deadline. The third type of provider, however, may have difficulty being completely prepared for the new coding set by October 1 if they postponed all plans in hopes of another ICD-10 delay.


Jodock continued to explain that there are a number of steps that well-prepared healthcare providers should have already completed. These include:


  • Remediating systems to identify ICD-10 codes for any services performed on October 1, 2015 and after
  • Completed or undergoing testing with partners and payers
  • Coding staff trained and tested on the ICD-10 codes
  • Contingency plans developed to prepare for any potential reimbursement delays
  • Reassurance from payers, clearinghouses, and other partner entities that they are prepared for the ICD-10 implementation deadline
  • Full training of the medical team on any new clinical documentation procedures


Following these steps among others will ensure greater success among healthcare providers in being well-prepared for the ICD-10 implementation deadline. However, any medical organizations that are behind in their ICD-10 preparation efforts should not worry, Jodock explains.


The Centers for Medicare & Medicaid Services (CMS) offers a variety of services to help providers better prepare for the new diagnostic and procedural coding set. For example, Medicare Adminstrative Contractors (MACs) are offering free billing software to providers and more than 50 percent of MACs are providing physicians and healthcare professionals the ability to submit ICD-10 claims via their provider portals upon the ICD-10 implementation deadline.


A presentation offered by CMS called “ICD-10: Preparing for Implementation and New ICD-10-PCS Section X” discussed further steps on moving forward with ICD-10 preparation.


 “ICD-10 is really foundational to our nation’s healthcare. We really want to make sure everyone is prepared,” Denisia Green, Deputy Director of the National Standards Group, said during the presentation. “We have free resources, tools, and testing available to everyone.”


“ICD-10 is set. The date is set for October 1, 2015. What we want you to understand is that there are not that many codes,” Green explained. “Yes, you have to take a look at the codes that you use. Over half of the codes are laterality. If you look at the code set by category, some of the codes have actually been streamlined in ICD-10. I think one of the things that we have to keep in mind is who are the patients that we take care of and that will help to dictate what codes you’re going to be using.”

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ICD-10: A Patients Perspective

ICD-10: A Patients Perspective | EHR and Health IT Consulting | Scoop.it

With ICD-10 coming in 111 days, as a patient I start to stress out about how it might impact me.  A physician once told me that “90% of physicians are already doing the required ICD-10 documentation, but they just need to add laterality in order to be more specific”.  Sounds simple, but is this statement truly accurate?  And if not, what will the downstream impact be to patients?


Let’s deep dive into the patient experience in the current ICD-9 world.  A simple health maintenance exam with vital signs (pulse oximetry included) and a urine dip would generally be covered by many insurers.  In the ideal world, this occurs without any added hassle to the patient, but what if the urine dip is “abnormal” and gets sent for a culture with an ICD-9 code of V70.0 (Routine General Medical Examination)?  The culture likely won’t be covered and the patient may eventually receive a bill for services that otherwise would have been covered by the insurance company had the test been associated with the correct supporting diagnosis.  A patient without insight into medical billing may just pay out of pocket without further research into why the services were not covered by the insurer.  In some cases however, a patient with a medical background may be savvy enough to recognize the problem was related to an incorrect ICD-9 code assignment. 


Given the abnormal urine dip, the culture should have been billed with a problem code and not a health maintenance code.  Had this been done, the patient may not have been responsible for the entire balance of the culture. The patient in this example notified her provider’s office of the problem, and even explained to the billing personnel how to fix the problem.  Six months later, she was still stuck in the midst of what I will label as “healthcare gridlock”.  The insurance company would pay for the culture if a problem code were submitted, but the billing office couldn’t change the code without the doctor first adding the appropriate documentation to the record.


If provider documentation isn’t clear and concise enough to get to an appropriate ICD-9 code now, then fast forward to October 1, 2015 when ICD-10 is relevant, who suffers?  Sure the provider’s office will not receive adequate payment (or none at all) for services rendered, but will the patient be left to pick up the pieces?  If we can’t get it right in ICD-9 (and the aforementioned scenario seems to happen far too often) then how are we so confident that those 90% of providers will get it right in ICD-10?  Rather than assuming that risk and potentially putting patients in difficult financial situations, wouldn’t it be helpful to add prompts to your existing EHR so that providers are clear on what MUST be documented to reach an appropriate ICD-10?  With all of the initiatives and mandates that providers are subjected to these days, we can help ease their transition to ICD-10 by customizing your EHR templates to support thorough and efficient ICD-10 documentation workflows.


When all is said and done, if it isn’t correctly documented, then it wasn’t done (at least that is what a coder might have to assume) and chances are that the patient will have to eat some portion, or even the entirety, of the bill.  With Galen’s Clinical Documentation Improvement service offering, our goal is simple – to make sure your organization is well prepared for ICD-10 so you can get paid and patients do not have to suffer.

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Does the ICD-10 Transition Need a Two-Year Grace Period?

Does the ICD-10 Transition Need a Two-Year Grace Period? | EHR and Health IT Consulting | Scoop.it

As healthcare providers become more ingrained in preparing for the coming ICD-10 transition on October 1, some legislators continue to push forward new bills that may more gently ease the healthcare industry into using the new ICD-10 diagnosis codes. On May 12, Representative Diane Black (R-TN) introduced the ICD-TEN Act, which proposes developing an elongated ICD-10 transition period.


At the end of April, Representative Ted Poe (R-TX) introduced a bill that essentially called for stopping and eliminating the ICD-10 transition and keeping ICD-9 as the healthcare sector’s main diagnostic coding set.


On June 4, according to the Journal of AHIMA, a new bill was brought forth into the House of Representatives that proposes a two-year grace period for healthcare providers when it comes to submitting ICD-10 codes. Representative Gary Palmer (R-AL-6) introduced the bill called H.R. 2652, Protecting Patients and Physicians Against Coding Act of 2015.


Neither Poe’s nor Black’s bills have received too much attention in the House of Representatives. Currently, Black’s bill only has five cosponsors while Poe’s has a total of nine, which is significantly lower than the 46 cosponsors Rep. Ted Poe had when he introduced similar ICD-10 transition legislation in 2013.


Essentially, the new bill from Palmer would give providers a two-year grace period during which any claims submitted to the Centers for Medicare & Medicaid Services (CMS) “would not be denied due to coding errors.” Palmer feels this grace period would give providers time to successfully transition to the new coding set and wouldn’t penalize them in the meantime.


This bill is not looking to delay the ICD-10 transition deadline any further. The new coding set would still be applicable on October 1, 2015 and afterward. However, providers would be reimbursed regardless of inaccurate coding or simple coding mistakes. In a letter to Congress, Palmer stated that the grace period would help doctors “grow accustomed to ICD-10 over a period of time without being penalized for unintentional errors.”


Palmer believes that smaller, rural physician practices have not had adequate time to prepare for the ICD-10 transition and will need this type of legislation to allow them to receive fair reimbursement and ensure high quality healthcare services among their patient base.

However, officials from the American Health Information Management Association (AHIMA) have stated they are adamantly against passage of this bill, as it “would lead to inaccurate coding, improper payments, and potential medical billing fraud.”


“With no official repercussions for inaccurate coding, AHIMA officials said they feel it would open the door to both intentional and unintentional coding errors—improperly paid claims at best and rampant fraud at worst—since proper payment of claims depends on accurate coding,” The Journal of AHIMA stated. “Also, claims data are used for many purposes beyond payment, including health policy decisions, assessment of quality of care, patient outcomes and safety, and evaluation of costs. Allowance of miscoding on claims will render claims data useless for any purpose.”

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ICD-10 Compliance a Struggle for Some Physician Practices

ICD-10 Compliance a Struggle for Some Physician Practices | EHR and Health IT Consulting | Scoop.it

October 1 has come and gone, and nearly two weeks in to ICD-10 compliance most of the healthcare industry is relatively mum on the transition to the newer clinical diagnostic and procedural code set. More than likely, healthcare organizations and professionals are busy enough adapting to ICD-10 and its more specific set of codes.

That’s not to say some are not speaking out or in support of ICD-10 compliance.


Two recent weekend reports in the Florida’s Crestview News Bulletin and Maine’s Bangor Daily News paint two very different pictures of ICD-10 compliance at the two-week mark.


Apparently, some physician practices in the Florida panhandle are going through the motions in adapting to the federal mandate for ICD-10 compliance which began back on October 1. Brian Hughes reports that medical offices are encountering difficulties with the code set.


“Large practices and medical companies, such as Peoples’ Home Health, usually have coders on staff. Their only job is to enter the numbers into billing records and insurance reimbursement forms,” he writes. “For smaller offices like Dr. Herf’s and Mir’s, the increased coding tasks take away staffers’ time with patients.”


Betty Jordan, the manager of physician practice of Abdul Mir, MD, views ICD-10 as more of a hindrance than a help.


“It requires so much extra work. If my doctor treated someone for rheumatoid arthritis, there’s hundreds of codes. It’s got to be specific,” she told the Crestview News Bulletin.


“It is horrible for a primary care doctor,” she further revealed. “For a specialist, they deal with the same things over and over. For us in family practice, we see all kinds of things. It’s overwhelming.”

For an administrator at the practice of David Herf, MD, the challenge of ICD-10 compliance is the result of increased specificity being married to an increase amount detail.


“It’s really, really detailed,” Andrew Linares told the news outlet. “Instead of just saying, ‘cyst of the arm or trunk,’ you have to get really specific.”


For one of the physician practices, adapting to ICD-10 is akin to learning a whole new language.


The climate in Maine appears much sunnier regarding ICD-10 compliance. Jen Lynds reports high levels of preparation among Maine healthcare organizations and professionals leading to a smooth transition.


“Health care providers across the state began working Oct. 1 with a new system of medical codes that has them describing illnesses and injuries in more detail than ever before, and officials from hospitals and medical associations said earlier this week that they are prepared for the challenge,” she writes.


According to Gordon H. Smith, the Executive Vice President of the Maine Medical Association, complaints are scarce as are ICD-10 implementation delays. Director of Communications for the Maine Hospital Association reports the same situation.


That being said, leadership at Eastern Maine Medical Center are preparing for transition-related productivity decreases for coders and billers used to the previous code set. However, things are still proceeding as planned.


“Our transition to ICD-10 has gone very smoothly here at Eastern Maine Medical Center,” Director of Coding and Clinical Documentation Improvement Mandy Reid told the Bangor Daily News. “We are using nine contract coders through outside vendors to support the ICD-10 go-live, and we secured them several months ago to be prepared. We also have added three positions in the outpatient area to help support growing volume, as well as ICD-10 coding.”


The lesson learned so far is that a clinical practice’s ability to invest in ICD-10 preparation (e.g., training) correlates to its present-day confidence in ICD-10 compliance.

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Four ICD-10 Myths from a Critical Doc

Four ICD-10 Myths from a Critical Doc | EHR and Health IT Consulting | Scoop.it

Have you ever stood near the tracks and listened to a train coming? When the train is far away all you can hear is the distant echo of the whistle. It’s easy to ignore.  As the train gets closer you hear the engine and see the smoke. As the train comes to the station it becomes a thundering, screeching, hissing mass of steel.

If you are close enough, it can even startle you.


With an Oct. 1 start date imminent, the ICD-10 train is getting awfully close. Anyone harboring hopes of Congress rescuing us at the last minute is kidding himself. If your practice is not prepared, there are plenty of health IT companies out there who will gladly take your money to rescue you safely away from the tracks.


The supporters of ICD-10 —bureaucrats, health IT vendors, and medical academicians —have been assuring us this is for our own good. The era of big data in healthcare is coming, so they say, and ICD-10 is the perfect vehicle for collecting the rich, detailed data that will bring the next big age of medicine. ICD-9 is decades old and needs to be replaced by a system which can accommodate the advances in diagnostic acumen of recent years. Privately, these groups ridicule our misgivings and assume that we’ll complain for a while and just get over it.


Last February, Congress held hearings on ICD-10. This was supposed to be the last decision-making step before committing to the program. In reality, it was a choreographed farce designed to suppress the concerns of real-world physicians. The witnesses included two health IT vendors, two lobbyist groups, one academic physician, and two private practice physicians. All but one of the witnesses, the late urologist and president of the Medical Association of the State of Alabama, Jeff Terry, supported ICD-10.  Most of the remaining witnesses either stood to benefit financially from ICD-10 or were insulated from its effects by the academic environment.


But there is more to ICD-10 than the propaganda peddled by supporters.  Let’s look at some of the myths about ICD-10:


1. ICD-9 is outdated and needs to be replaced.  The former is true.  The latter is not.  The structure of ICD-9 (five numeric placeholders) theoretically allows for 100,000 codes.  ICD-9 could have been easily expanded by adding one or two placeholders and allowing letters to be used. This would expand capacity to over two billion codes. It would have allowed horizontal expansion (i.e., the addition of Ebola infection to the appropriate category —a favorite example of ICD-10 supporters) as well as vertical expansion (the breakdown of otitis media into left vs. right).  This could have been done without rendering any ICD-9 codes obsolete. 


2. ICD-10 based big data will improve patient care.  ICD-10 supporters would have us believe that ICD-10 based data will lead to medical miracles falling from the sky.  These utopian fantasies fail to consider the implications of the scientific method.  Medical advancements come only from experiments based on hypotheses.  Hypotheses dictate experimental design, including the methods and structure of data collection.  Lacking any hypotheses, ICD-10 creates a one-size-fits-all data collection method for all fields of medicine.  This makes absolutely no sense.


3. ICD-10 will improve quality of data collection.  I almost believed this until I began to prepare my practice for ICD-10 months ago.  Instead of a rational expansion of diagnoses I found —for my specialty, at least —a haphazard, nonsensical collection of codes created seemingly at random.  I’m not talking about the “burned by water skis on fire” stuff we have all heard about.  I discovered that every code related to ear pathology is obsessively divided into left ear, right ear, or both.  Even “vertigo of central (nervous system) origin,” which by definition does not involve the ears, requires a choice of left or right ear!  But other diagnoses —facial paralysis, head and neck cancers, sinusitis, and others —have no ICD-10 division by side.  The diagnosis of vocal cord paralysis, in which the side of involvement has long been recognized to be clinically significant, is not separated by side.  In fact ICD-10 has fewer codes for vocal cord paralysis than does ICD-9.  Does this mean that ear disorders are more worthy of big data research than sinusitis, head and neck cancer and vocal cord paralysis?  Who decided that?  There is no way, for otolaryngology at least, that such a poorly designed coding system will yield any useful data.  Don’t hold your breath waiting for any big data medical miracles.


4. Third-party payers are ready.  Who are they kidding?  Didn’t CMS claim that healthcare.gov was ready two years ago?  How many test payments to providers were sent?  There is no way to adequately test a system this complex before it goes live. Remember that CMS and private insurers have no risk on the table.  If their systems “mysteriously” fail to pay claims, they benefit by keeping the cash they would otherwise have paid out.  On the other hand, physicians will be unable to pay rent and make payroll if payments on claims are interrupted more than a few days.


The only rationale that explains ICD-10 is the desire of its supporters for a top-down, big government, centrally controlled healthcare system that regards doctors and patients as nothing more than cogs in the machine.  The folks at the top fancy themselves worthy of conscripting the rest of us into becoming uncompensated data collectors.  Doctors know that quality of care starts from the bottom, not the top —with a doctor, a patient, an exam room, and a conversation.  At best, ICD-10 will be an expensive distraction that draws money and time away from patient care.  At worst, it will paralyze the health care system.

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ICD-10 Implementation Progresses; Doc Practices Lag

ICD-10 Implementation Progresses; Doc Practices Lag | EHR and Health IT Consulting | Scoop.it

The latest ICD-10 readiness survey from the Workgroup for Electronic Data Interchange (WEDI) shows industry-wide progress in preparing for the ICD-10 implementation deadline although physician practices continue to lag behind health IT vendors, health plans, and health systems.


"We assert that if the industry, and in particular physician practices, do not make a dedicated and aggressive effort to complete their implementation activities in the time remaining, there is likely to be disruption to industry claims processing on Oct 1, 2015," the organization states in a letter to the Department of Health & Human Services Secretary Sylvia Mathews Burwell.


Speculation about another ICD-10 delay contributed to the industry's ICD-10 preparation, WEDI claims.


"Uncertainty over further delays was listed as a top obstacle across all industry segments. While the delays provided more time for the ICD-10 transition, it seems that many organizations did not take full advantage of this additional time," the letter reads.


According to WEDI, the joint announcement by the Centers for Medicare & Medicaid Services (CMS) and American Medical Association concerning ICD-10 flexibilities after October 1 — which appeared after the survey was concluded — should go a ways toward removing this obstacle.


"Physician practices may now be working more quickly toward compliance, since the potential for further delay has been removed," it adds.


The survey included nearly half as many respondents as a similar survey conducted earlier this year in February 2015 yet still shows good progress across the healthcare industry with respect to ICD-10 compliance.


Health IT vendors demonstrated good progress over the past few months, particularly in the area of product availability:


Three-quarters indicated their production-ready software or services were available to customers. This is an increase from less than three-fifths in the February 2015 survey.  One-quarter responded that their products would not be available until the second or third quarter of 2015, but no one responded that their products would not be ready by the compliance date.


The findings reveal a dip in the percentage of health plans having completed impact assessment — from four-fifths to two-thirds — which WEDI attributed to the respondent makeup of this latest survey. That being said, health plans excelled in external testing activities with close to 75 percent of these respondents reporting having completed external testing.


Echoing the findings of AHIMA and the eHealth Initiative on provider ICD-10 readiness in July, the WEDI survey has found room for improvement for physician practices.


As compared to seven-eighths of hospitals and health systems ready for October 1, less than a half of physician practices indicated they would be ready.


This disparity was also evident in the area of provider impact assessments. Only one-sixth of physician practices had undertaken the assessment versus three-fifths of hospitals and health systems. "This lack of progress is cause for concern as it will leave little time for remediation and testing," says WEDI.


In an accompanying letter to HHS Secretary Burwell on the subject of enhancing the ICD-10 transition, WEDI calls on the federal agency to make publicly available information about the readiness levels of Medicaid agencies and offer additional educational outreach to aid the healthcare industry through the historical change.

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AMA, CMS Help Providers Meet ICD-10 Transition Deadline

AMA, CMS Help Providers Meet ICD-10 Transition Deadline | EHR and Health IT Consulting | Scoop.it

With regard to the ICD-10 transition taking place later this year, the Centers for Medicare & Medicaid Services (CMS) has partnered up with the American Medical Association (AMA) to assist healthcare providers in preparing for the coming ICD-10 deadline.


According to a press release from the AMA, CMS will continue to provide additional guidance for providers around the nation. In particular, information on claims auditing and quality reporting will be offered.


“As we work to modernize our nation’s healthcare infrastructure, the coming implementation of ICD-10 will set the stage for better identification of illness and earlier warning signs of epidemics, such as Ebola or flu pandemics.” Andy Slavitt, Acting Administrator of the Centers for Medicare and Medicaid Services, said in a public statement. “With easy to use tools, a new ICD-10 Ombudsman, and added flexibility in our claims audit and quality reporting process, CMS is committed to working with the physician community to work through this transition.”


Both AMA and CMS are working together to ensure providers are ready for the ICD-10 transition well ahead of the October 1 deadline. Both organizations will be holding webinars, on-site training, and provider calls to ensure the ICD-10 transition goes smoothly.


“ICD 10 implementation is set to begin on October 1, and it is imperative that physician practices take steps beforehand to be ready,” said AMA President Steven J. Stack, MD. “We appreciate that CMS is adopting policies to ease the transition to ICD-10 in response to physicians’ concerns that inadvertent coding errors or system glitches during the transition to ICD-10 may result in audits, claims denials, and penalties under various Medicare reporting programs. The actions CMS is initiating today can help to mitigate potential problems. We will continue to work with the administration in the weeks and months ahead to make sure the transition is as smooth as possible.”

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Staff Training Crucial in ICD-10 Conversion Preparations

Staff Training Crucial in ICD-10 Conversion Preparations | EHR and Health IT Consulting | Scoop.it

Healthcare providers who are behind in their ICD-10 conversion preparations may benefit from following the ICD-10 Quick Start Guide provided by the Centers for Medicare & Medicaid Services (CMS).


The five steps that providers will need to take when it comes to their ICD-10 conversion preparations are the following: (1) developing a plan, (2) training the healthcare staff, (3) updating system processes, (4) working with vendors and health insurers, and (5) testing workflow processes and systems.


When it comes to training the clinical staff (including nurses, doctors, and medical assistants) and moving forward with ICD-10 conversion preparations, it’s vital to focus on new clinical concepts and documentation obtained through ICD-10 codes. When training coding and administrative staff including coders, billers, and practice management employees, the focus should be on ICD-10 fundamentals.


CMS provides a variety of resources including webinars, national provider calls and presentations, the Road to 10 website, and email updates. Physician groups, healthcare organizations, hospitals, payers, and vendors also offer a variety of resources for medical providers who are still behind with some common ICD-10 conversion preparations.


The very first step to take is to identify the top 25 most common ICD-9 codes used in one’s medical facility. Common diagnosis codes are also available on the Road to 10 website and other resources.


Teach your healthcare and coding staff how to code the most common cases using the ICD-10 coding set. Using reports via one’s practice management software and billing documents, providers can better identify the most commonly used ICD-9 codes.


Once the top 25 codes are gathered and there is still time before the ICD-10 implementationdeadline, providers are encouraged to expand ICD-10 coding of typical cases past an additional 50 or more codes. This would ensure the majority of a provider’s cases are managed effectively under ICD-10.


Even though the ICD-10 coding set has expanded to more than 68,000 codes, providers will only need to use a small section of the set. Along with training staff, updating system processes is vital for one’s ICD-10 conversion preparations. All hardcopy and electronic forms need to be updated while information gaps should be resolved before the October 1 deadline.


Clinical documentation will need to include laterality, the number of encounters (initial or subsequent), kinds of fractures, and other information about related complications. It is useful to put together a documentation checklist detailing new concepts that should be captured with ICD-10 codes. Once systems are in place, ICD-10 end-to-end testing is crucial to ensure a healthcare facility is prepared for the October 1 deadline.


“With four months remaining to correct issues discovered during testing, the high rate of successful submission of ICD-10 codes is especially encouraging for physician offices since half the claims submitted for end-to-testing were professional claims,” the Coalition for ICD-10 commented on CMS’ latest ICD-10 end-to-end testing results. “These results indicate that significant progress has been made since the January end-to-end testing with the overall rejection rate dropping from 19 to 12 percent and ICD-10 rejections dropping from 3 to 2 percent.”

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Direct Reimbursement Solutions's curator insight, July 1, 2015 10:10 AM

Excellent advice for ICD-10 preparedness.

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The ICD-10 Coding Transition Deadline is Only 99 Days Away

The ICD-10 Coding Transition Deadline is Only 99 Days Away | EHR and Health IT Consulting | Scoop.it

The deadline for the ICD-10 coding transition is only 99 days away and healthcare providers are scrambling to finish preparing for the implementation. The Centers for Medicare & Medicaid Services (CMS) continues to stress the need to be as prepared as possible for the coming ICD-10 coding transition.


Even though providers and payers have only 99 days left, there is still time to get ready if one gets started immediately. CMS is helping providers who are behind in their ICD-10 coding transition preparations by offering the ICD-10 Quick Start Guide.


The five steps a provider needs to take right now if they haven’t begun preparing for the ICD-10 coding transition are:


1) Develop a plan


2) Train healthcare and coding staff


3) Update system processes and workflows


4) Discuss issues with vendors and health payers


5) Perform system and processing testing


With only 99 days left until the ICD-10 coding transition, it’s vital to set target dates for completing the steps outlined above. At the very beginning stages of making a plan, providers would benefit from downloading and obtaining ICD-10 codes via the CMS website. These codes are available in a multitude of formats including print and electronic either through practice management systems or upgraded EHR products.


CMS encourages providers to obtain access to the ICD-10 codes. Other formats that the ICD-10 codes can be retrieved through include code books, digital media like compact discs or digital video discs, online at cms.gov/ICD10 under the “2016 ICD-10-CM and GEMS” category, or even via smartphone applications.


Some common workflows and system processes that will be affected by the ICD-10 coding transition include patient registration or scheduling, clinical documentation, billing, coding, public health reporting, order entry, authorizations, and referrals.


Additionally, it’s vital to decide how one’s clearinghouse will assist in preparing providers for the ICD-10 coding transition. It may benefit some providers who are behind in their preparations to contract with a clearinghouse in order to test submitting the ICD-10 code claims. A clearinghouse can be useful when it comes to helping identify why claims were rejected as well as offering assistance in how to revise rejected claims.


“Practices preparing for the October 1, 2015, ICD-10 deadline are looking for resources and organizations that can help them make a smooth transition. It is important to know that while clearinghouses can help, they cannot provide the same level of support for the ICD-10 transition as they did for the Version 5010 upgrade,” CMS stated in a pamphlet. “As you prepare for the October 1, 2015, ICD-10 deadline, clearinghouses are a good resource for testing that your ICD-10 claims can be processed and for identifying and helping to remedy any problems with your test ICD-10 claims.”


In order to be properly reimbursed, healthcare providers will need to be ready for the ICD-10 coding transition by October 1. In the meantime, it’s important to continue using ICD-9 codes for all services rendered before the deadline.

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ICD-10 PCS - We Don't Know What We Don't Know

ICD-10 PCS - We Don't Know What We Don't Know | EHR and Health IT Consulting | Scoop.it

After decades of experience with ICD-9, we have learned and come to grips with its quirks. We do not yet have that comfort level with ICD-10—after all, it’s still pretty new to most of us in the U.S. I’m not really concerned about the diagnosis side of ICD-10 and its clinical modification, ICD-10-CM. But what does concern me is ICD-10-PCS (procedure coding system). So far, we don’t have a good idea of how this is going to impact reimbursement, and what documentation requirements are really going to be needed. We really don’t know what we don’t know.


ICD-10-PCS coding demands a new level of documentation and coding specificity. There are few procedure codes in ICD-10 that will allow nonspecific or “not otherwise specified” codes, as are allowed in ICD-9. In the ICD-9 coding environment, it is still possible to generate a code and get reimbursed even with minimal specificity. But under ICD-10, if specificity is lacking, there may not be a procedure code that can be used, and the reimbursement will therefore suffer.


Let’s look at “lysis of adhesions” to see how this applies. If a surgeon performs a laparoscopic procedure to free up something in the abdomen that’s trapped in scar tissue and the operative note concludes that the patient performed a “laparoscopic lysis of adhesions in the peritoneum,” that would be enough information to use ICD-9 code 54.51. But there is no direct equivalent for this in ICD-10, no code that is as vague as the one in ICD-9. Instead, the surgeon needs to describe exactly what organ or organs were “released” or freed up during the procedure. If it was a loop of small bowel caught up in adhesions, then the appropriate ICD-10 code would 0DN84ZZ (release small intestine, percutaneous endoscopic approach). It would require specific mention of the small bowel in order to be coded.


So where does the problem or uncertainty come into play with this?

Well, let’s suppose (as is likely to happen) that the surgeon writes his or her usual comprehensive operative note that describes the procedure that includes a description of the dissection that was done around the small intestine. But the note itself simply states in the closing summary that the operation was a “laparoscopic lysis of adhesions in the peritoneum.” Can the coder use the description of the dissection around the small bowl to go ahead and code 0DN84ZZ? This seems to still be open to interpretation, and the last thing coding managers want as we prepare to enter the ICD-10 era is uncertainty.

As I have traveled around the country speaking with various professional groups including national and local AHIMA chapters, ACDIS chapters and coding societies, the opinions on this subject vary. Many boldly state that they would be comfortable coding from this scenario, while others want the physician to be responsible for stating the details explicitly.


Where does this leave the clinical documentation specialist? Will they be left with the responsibility for creating and managing the thousands and thousands of queries that are going to be needed to get the necessary clarification from the surgeons?

We don’t yet know.

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Why a ‘Safe Harbor’ ICD-10 Transition Period is Harmful

Why a ‘Safe Harbor’ ICD-10 Transition Period is Harmful | EHR and Health IT Consulting | Scoop.it

The healthcare industry is at the tipping point when it comes to the ICD-10 transition period. With only 3.5 months to go until the ICD-10 implementation deadline, various new bills have cropped up within the House of Representatives looking for either another ICD-10 delay, a complete stop to the transition, or an ICD-10 transition period called “safe harbor.” For example, both RepresentativeDiane Black (R-TN-6) and Representative Gary Palmer (R-AL-6) introduced bills that would require an ICD-10 transition period - with Palmer’s lasting two full years - during which providers would not be penalized for coding errors.


The Coalition for ICD-10 has released a statement on their perspective regarding the “safe harbor” bills. The bills are meant to help providers from being harmed financially by preventing reimbursement denials due to solely ICD-10 code inaccuracies. This type of ICD-10 transition period is also meant to ease the burdens put on physicians and medical providers.


However, since these bills apply to all providers including hospitals, the Coalition for ICD-10 showed some concern. The coalition explains that the bills rest on false assumptions such as the idea that “ICD-10 detail is not readily known or available in the medical record.”


According to the coalition, the amount of physician payments are determined by the reported CPT codes and not by the ICD-10 diagnosis codes or any potential ICD-10 errors. Additionally, there is currently no proof that healthcare providers will in fact suffer from a large amount of claim denials upon the ICD-10 implementation deadline.


The latest results from end-to-end testing performed by the Centers for Medicare & Medicaid Services (CMS) show that denial rates pertaining to ICD-10 errors were only two percent. Additionally, these bills assume that switching to the new coding set will cause undue burden on physicians. The coalition explains that the rise in the number of available codes in the new set is largely due to reporting the side of the body affected, which is information that should be recorded in any medical record.


The Coalition for ICD-10 is especially concerned with the potential fraud and abuse that the “safe harbor” ICD-10 transition period could lead to. By allowing errors to be accepted by CMS without fear of audit, the agency could see a rise in deliberate reporting of incorrect information.


“This is analogous to allowing a tax form to be submitted with erroneous or conflicting information that does not support a refund and prohibiting the IRS from validating the information before issuing a refund check,” the Coalition for ICD-10 stated.


Additionally, these bills could lead to “widespread system disruptions” since inconsistent reporting of ICD-10 codes could affect standard system functions. The bills do not clarify whether all payers will be required to adopt a “safe harbor” system of payment or only CMS. If it is only CMS and other payers are welcome to adopt this style of payment reporting, it would bring very inconsistent coordination of reimbursements throughout the healthcare industry nationwide. Based on these assertions by the Coalition for ICD-10, it may be better for the healthcare sector to move forward with the ICD-10 implementation without any further disruptions.

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History, Challenges, and Considerations of ICD-10 Transition

History, Challenges, and Considerations of ICD-10 Transition | EHR and Health IT Consulting | Scoop.it

In the midst of ICD-9 to ICD-10 transition, it is beneficial to cover the history and challenges of this dramatic change in healthcare coding.

The United States healthcare industry first adopted the World Health Organization’s ICD-9 medical coding system in 1979. The first meeting set by the World Health Organization for the Ninth Revision of ICD (ICD-9) took place in Geneva from September 30 to October 6, 1975.

The revisions included much greater detail at the four-digit subcategory levels and an elective procedure for classifying diagnostic statements called the dagger and asterisk system. Additionally, coding rules for mortality were changed marginally and new definitions for the statistics of perinatal mortality were introduced.

While the ICD-9 code set was useful for several decades, it no longer satisfies the needs of today’s healthcare community, as major advances have transformed the industry since the 1970s. The first modifications to ICD-9-CM volumes 1, 2, and 3 occurred in 1986 and the ICD-9-CM Coordination and Maintenance Committee (C&M) has made regular updates since then. Specifically, ICD-9 does not meet the health information requirements of the 21st century. By relying on this outdated system, the medical community would be negatively influencing the quality of healthcare data.

The American Health Information Management Association (AHIMA) states that most countries have transitioned to the 10th revision of the International Classification of Diseases (ICD) and the US is positioned to transfer over by the October 1, 2015 compliance date.

In 1992, it was decided that an alphanumeric, multiaxial, seven-digit system would be the best solution for keeping up with diagnostic advances, as the former four-digit coding set has various limitations. The entire revision of the coding system was concluded after one year and informal testing was begun the following year. A final draft of ICD-10 was completed and submitted in 1998.

AHIMA urges the medical community to quickly and efficiently transfer over to ICD-10 in order to reverse a potential drift toward low-quality healthcare data. While making a jump over to a new medical coding set is costly, some proponents point toward the industry costs associated with delaying the implementation. Three years ago, the Centers for Medicare & Medicaid Services (CMS) predicted that a one-year delay could lead to more than $1 billion in costs to the healthcare industry.

Most importantly, many healthcare initiatives such as meaningful use requirements are associated with ICD-10 implementation, which means a delay in one could impair the other. By implementing the latest diagnostic coding set, the healthcare industry will experience a number of benefits such as value-based purchasing, payment reform, meaningful use, and enhanced reporting.

Some of the potential challenges of transitioning to ICD-10 have been ensuring that hospital staff members are adequately trained on how to properly use the code, spending significant capital on health IT resources, and incorporating a more complex business approach, according to the Healthcare Information and Management Systems Society. For instance, the ICD-10 code set mandates healthcare payers to change business processes according to their own interpretation in order to improve efficiency and data quality.

However, all of these challenges also present significant opportunities. For example, a more robust code set offers well-defined and more focused wellness and care management programs. Additionally, the extra detail lends itself to a more accurate pricing structure and higher automation in data reviews.

“There are enormous differences in complications and the cost for repairing the aorta vs other types of arteries, but we’re lumping it under the same [ICD-9] code,” Sue Bowman, AHIMA’s senior director of coding policy and compliance, told Medscape about one benefit of the new coding system. “On the procedure side [with ICD-10], we can really fine-tune information about the cost of treatment, which then links to the appropriate reimbursement.”

Healthcare organizations will gather substantial gains when switching over to ICD-10 by the October 1, 2015 compliance deadline. The benefits vary from higher coding accuracy and better capabilities for measuring outcomes to improved tracking ability and fewer claim denials.


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