EHR and Health IT Consulting
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EHR and Health IT Consulting
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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Clinical Documentation Improvement Vital for Patient Care

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

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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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 |

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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Why can't we use ICD-9 and ICD-10 codes after Oct. 1?

Why can't we use ICD-9 and ICD-10 codes after Oct. 1? | EHR and Health IT Consulting |

When the U.S. House Energy & Commerce Subcommittee on Health held its hearing "Examining ICD-10 Implementation" last month, dual coding came up.

No not the kind of dual coding that allows healthcare providers to practice ICD-10 codes until Oct. 1. But politicians kept asking why ICD-9 codes and ICD-10 codes couldn't be used at the same time.

And none of the witnesses could answer the question. You could hear the screaming across town coming from the Department of Health and Human Services (DHHS) building.

I could understand the reluctance of everyone who did not want to speak for the Centers for Medicare and Medicaid Services (CMS). But for Pete's sake, they're already there to sing the praises of ICD-10 coding. Why couldn't someone try to explain that the differences between assigning ICD-9 codes and ICD-10 codes is not the same as choosing between a Blackberry or iPhone?

CMS tried to explain it in a revised guidance statement last week:

"No, CMS will not allow for dual processing of ICD-9 and ICD-10 codes after ICD-10 implementation on October 1, 2015. Many providers and payers, including Medicare have
already coded their systems to only allow ICD-10 codes beginning October 1, 2015. The scope of systems changes and testing needed to allow for dual processing would require significant resources and could not be accomplished by the October 1, 2015, implementation date. "

Except the committee noticed that depending on dates of services, ICD-9 codes will need to be used after Oct. 1. That kind of makes me wonder too. Makes me wonder if healthcare payers are going to be able to handle a few days of ICD-9 codes.

But we get a little closer to the problem here:

"Should CMS allow for dual processing, it would force all entities with which we share data, including our trading partners, to also allow for dual processing. In addition, having a mix of ICD-9 and ICD-10 codes in the same year would have major ramifications for CMS quality, demonstration, and risk adjustment programs."

There's the rub. Things will be crazy enough not being able to compare ICD-9 years to ICD-10 years. But mixing both code sets in the same year will make data analysis about useless.

And if healthcare providers figure out that reimbursement rates are different for an ICD-9 code compared to an ICD-10 code, they're going to choose the higher paying code for medical claims.

Would it be possible for healthcare payers to deny an ICD-10 claim if they can offer lower rates for ICD-9 claims?

No, CMS wants to rip off the bandage quickly Sept. 30. It's may sting Oct. 1. But it's going to hurt worse if they try to pull it off a tiny bit at a time.

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No true crosswalk' exists between ICD-9 and ICD-10

No true crosswalk' exists between ICD-9 and ICD-10 | EHR and Health IT Consulting |

A study from Vanderbilt University further suggests that mapping codes between ICD-9 and ICD-10 could be a problem.

The research, published in the Journal of the American Informatics Association, involves records from 100 patient visits to the Vanderbilt Adult Primary Care Clinic. Those records were manually coded in both ICD-9-CM and ICD-10-CM, then compared with general equivalence mappings (GEMs) and reimbursement mappings (RMs).

The Centers for Medicare & Medicaid Services and the Centers for Disease Control and Prevention created the GEMs and RMs to help organizations make the transition to ICD-10. They're designed for consistency in record-keeping both going forward and backward.

The analysis found that while the GEMs/RMs were consistent with manual encodings more than 80 percent of the time in both directions, a significant fraction of manual mappings were inconsistent with the GEMs and RMs. Of those mismatched mappings consisting of only one ICD-9 and one ICD-10 code, at least half did not match the GEMs due to subtle differences within the same hierarchical category, according to the research.

"These results should reinforce the notion that no true crosswalk exists between ICD-9 and ICD-10. Whether this consistency rate is sufficiently high to avoid significant changes in reimbursements or public health statistics is beyond the scope of this study," the authors say.

They say its vital for healthcare organizations to perform their own analysis with their most commonly used codes to determine how that will affect reimbursement and care statistics.

A study from the University of Illinois at Chicago suggested pediatricians could take a financial hit in the switch to ICD-10. It found that 26 percent of ICD-9 codes used in that specialty are convoluted in their mapping to ICD-10.

In addition, University of Illinois at Chicago researchers warned that the switch to ICD-10 poses the risk of under-reporting and over-reporting adverse events due to mismatches in codes for Patient Safety Indicators.

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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 |

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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Bracing for ICD-10 Implementation Deadline amid ICD-9 Shortfalls

Bracing for ICD-10 Implementation Deadline amid ICD-9 Shortfalls | EHR and Health IT Consulting |

With the ICD-10 implementation deadline only three and a half months away, it is beneficial for healthcare providers to continue their last-minute preparations for the coming ICD-10 transition. The Centers for Medicare & Medicaid Services (CMS) includes a variety of tools and resources for providers to utilize when getting ready for the ICD-10 implementation deadline.

From the Road to 10 website to videos and expert columns, CMS is working toward preparing healthcare providers for the coming ICD-10 implementation deadline on October 1, 2015. In a video called “ICD-10: Getting from Here to There – Navigating the Road Ahead,” Dr. Ricardo Martinez, Fellow of the American College of American Physicians, discussed how the International Classification of Diseases (ICD) version 10 is a significant improvement over the more outdated ICD-9 codes being utilized across healthcare facilities today.

The video also went over key steps that small medical practices should incorporate when preparing for the ICD-10 implementation deadline. In particular, providers will need to understand how the new codes will differ from the older ICD-9 codes.

“As a practicing physician, I see the limitations of ICD-9 every day and why input from the medical community into the development of ICD-10 has been so valuable,” Martinez explained. “ICD-9 is outdated – even antiquated by today’s practice standards – and it limits the speed and accuracy with which I can gather information, gain insights, and, more importantly, care for my patients.”

“Today, ICD-9 doesn’t even address laterality, which signifies if a condition affects the left or the right limb,” continued Martinez. “On a professional note, when recently faced with a complex patient who had an acute stroke in history of a previous stroke, we had to search through many old records to determine whether that old stroke was left or right side, wasting valuable time that could have been dedicated to patient treatment. With a single code, ICD-10 will provide us with more detail. Better data makes better care possible.”

“To help small provider practices and other healthcare professionals with the transition to ICD-10, the Centers for Medicare & Medicaid Services is actively working with physicians, industry leaders, and others,” Martinez mentioned. “Healthcare has been using the international classification of diseases for over a century to identify and track diseases and help us improve our care for our patients.”

“Although most of the world transitioned to ICD-10 years ago, the currently used version of ICD-9 is fundamentally unchanged since its implementation in the United States in 1979,” Martinez stated. “One major limitation of ICD-9 is that it predates many modern technological advances and clinical terminology reflecting the use of CT scans, for example, which were also invented in 1979. Therefore, an update was necessary to account for these innovations in medicine.”

“For years, practitioners noted the need for increased specificity within clinical terminology, documentation, and coding to accurately represent the care provided to their patients,” Martinez clarified. “Under sponsorship of the World Health Organization (WHO), a group of physicians developed the basic structure for ICD-10. Then, each specialty provided input on the subset of procedure or diagnosis code needed. Addressing both the changes in medicine and the need for increased specificity, ICD-10 will capture greater detail in the clinical encounter for each patient.”

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Researchers Unveil Bidirectional ICD-9 to ICD-10 Mapping Tool

Researchers Unveil Bidirectional ICD-9 to ICD-10 Mapping Tool | EHR and Health IT Consulting |

A team of researchers has unveiled a bidirectional ICD-9 and ICD-10 mapping tool which it claims will enable healthcare organizations, providers, researchers, and other professionals to compare diseases during the upcoming ICD-10 transition.

Two kinds of tools emerged from the work of Boyd et al published in the Journal of the American Medical Informatics Association. The first is a web portal tool for converting ICD-10-CM to ICD-9-CM. The second is a set of tables annotated with levels of translation complexity. “Examining the network graphs of individual ICD-10-CM diagnosis codes from the online tool can provide a quick view of the challenges facing administrators evaluating high-cost diagnoses,” the authors claim.

Boyd et al. used publicly available 2014 general equivalence mappings (GEMs) to create a bidirectional map of ICD-9 and ICD-10 codes. Next, the researchers identified 36 network patterns for translating ICD-10-CM to ICD-9-CM and place them into one of five categories of translation complexity: identify, class-to-subclass, subclass-to-class, convoluted, and no mapping.

Of all the codes analyzed, only 4127 ICD-10-CM codes had straightforward translations to ICD-9-CM:

Unsurprisingly, as ICD-10-CM is more comprehensive than ICD-9-CM, an additional 536 class-to-subclass relationships were found. Similarly, 7478 subclass-to-class translations were identified. Importantly, a substantial number of relationships were convoluted (57 013) or had no mapping to ICD-9-CM (669).

According to Boyd et al., the need for the tools is necessary for when stylistic differences in choosing appropriate ICD-10-CM codes become commonplace following the October 2015 transition to the next code set.

“While standards and guidelines are taught to professional medical coders9 who attempt to normalize the stylistic differences, many clinics and physicians create a punch sheet, or a list of codes, that will likely introduce biases in the use of ICD-10-CM codes,” the researchers maintain.

The stylistic differences are likely to become problematic as healthcare organizations and providers work with replacement coders or coding agencies. “The evolution of ICD-10-CM coding will occur as well as new individuals joining teams in the future will learn from their colleagues and predecessors,” claims Boyd et al.

Additionally, the team of researchers is calling on future studies to observe inconsistencies across and variations between healthcare organizations to determine how coding styles affect reimbursement and the usefulness of coding data for secondary and tertiary purposes.

Another impetus for the construction of a new bidirectional ICD-9 to ICD-10 conversion tool is the usefulness of single GEMs files for analyzing patient cohorts, posing potential challenges to the evaluation of residencies, fellowships, practices, and physicians because of what is missing.

“Due to the way the GEMs files are designed, a researcher or evaluator will miss 30% of the ICD-9-CM diagnosis codes and potentially miss patients, as well, if only the ICD-10-CM GEMs files are used,” the team of researchers observes.

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Hoping for ICD-11 is “Waiting for Godot,” ICD-10 Coalition Says

Hoping for ICD-11 is “Waiting for Godot,” ICD-10 Coalition Says | EHR and Health IT Consulting |

Clinging on to the current outdated ICD-9 code system until ICD-11 is ready for use at some unspecified point in the future is akin to the endless idle loitering of Vladimir and Estragon in Samuel Beckett’s classic play Waiting for Godot, says the Coalition for ICD-10 in a new opinion piece.  After waiting more than twenty years for the implementation of ICD-10, the healthcare industry simply cannot afford another two or three decades for the newest code set to be finalized and ready for use.

“Based on the World Health Organization’s (WHO) current timeline, ICD-11 is expected to be finalized and released in 2017,” the commentary explains. “For the US, however, that date is the beginning, not the end.  As with every WHO version of the ICD codes, ICD-11 would need to be adapted to meet the detailed payment policy, quality assessment and other regulatory requirements of US stakeholders.”  The country could be waiting until 2041 for the entire pre-implementation process to be completed, the Coalition adds.

Meanwhile, the healthcare industry will be forced to continue to use a significantly outdated code set that cannot account for many emerging health threats or new advances in technologies, diagnoses, and procedures.  That’s just fine with representatives from the American Medical Association (AMA), whose House of Delegates voted to reject an internal report noting that implementing the changes inherent in ICD-10 would provide an important foundation for the eventual adoption of ICD-11.  The report concluded that skipping ICD-10 all together was “not recommended” as a viable course of action, yet the AMA continues its resistance to the ICD-10 codes – and the Coalition continues to fight back against their reticence.

“The US simply cannot wait decades to replace ICD-9, a code set that was developed nearly 40 years ago,” the Coalition states. “US healthcare data is deteriorating while at the same time demand is increasing for high-quality data to support healthcare initiatives such as the Meaningful Use EHR Incentive Program, value-based purchasing, and other initiatives aimed at improving quality and patient safety and decreasing costs.”

The AMA argues that the expense of ICD-10 implementation is overwhelming for smaller physicians struggling keep their doors open, pinning the costs at anywhere from $50,000 to $225,000 for a small provider.  Despite contradictions from AHIMA, the cost of the switch has been a major selling point for opponents.

However, after two one-year delays, the tide seems to be turning in support of ICD-10.  Not only is the Coalition growing, but Congress has stepped in to enforce the idea of a 2015 due date.  Will the wait for Godot be over in October?  The Coalition would certainly like to see an end to the “unending barrage of excuses” and continual delays.

“Waiting for ICD-11 is simply not a viable option,” the blog post concludes. “The absurdity of the endless waiting in Waiting for Godot culminates in frustration: “Let us not waste our time in idle discourse! Let us do something, while we have the chance!” Yes, the wait needs to be over. It’s time to stop wasting time. It’s time to get ICD-10 implemented.”

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