A Decade in Review: Pivotal HIM Moments
ICD-10 is coming! Nope, it’s delayed. And again. And again. No, it’s really happening this time!
The infamous ICD-10 transition was compared to Y2K with over-hyped catastrophic consequences that ultimately fell flat. It took over 20 years and 3 delays before finally being implemented. Opponents to ICD-10 claimed that hospitals would be negatively impacted. They predicted a major drop in coder productivity, that would slow down payments and cause business disruption. While ICD-10 proponents highlighted the policy issues. Wacky ICD-10 codes like being struck by an orca or having problems with relationships with in-laws were mocked and used as an example of the government demanding too much detail, creating an unnecessary burden for providers. However, the transition to ICD-10 turned out to be a smooth process.
At HIA, we saw minimal downtime, and coder productivity and quality weren’t significantly compromised. We ran accuracy rates for all inpatient coders in January of 2015 and January of 2016 (after the implementation of ICD-10). We saw an increase in Total DRG accuracy from 93.16% to 94.74% and an increase in Total Codes accuracy from 93.27% to 93.47%. So, like Y2K, the ICD-10 transition was a nonevent. None of the dire predictions have come true and the healthcare industry has moved on.
ICD-10 implementation timeline within the past decade:
CMS institutes a code freeze in preparation for ICD-10. I
Facing backlash from physicians’ groups, HHS publishes a final rule that delays the compliance date for ICD-10-CM/PCS from October 1, 2013 to October 1, 2014.
The Protecting Access to Medicare Act of 2014 is enacted, which contains a provision prohibiting the HHS Secretary from adopting the
ICD-10 code prior to October 1, 2015.
CMS begins end to end testing of ICD-10.
ICD-10-CM/PCS implementation deadline.
In 2015, the number of diagnoses codes jumped from 14,567 to 69,823 and the number of procedure codes from 3,882 to 71,974.
That’s a 379.3% increase in ICD-10-CM codes and a 1,754% increase in ICD-10-PCS codes!
So just what are all these new codes? Well, ICD-10 was developed to accommodate new diagnosis and procedure codes for future clinical protocols that can improve quality measurements, patient safety, and evaluation of medical processes and outcomes.
In other words, it all centers around one word: specificity.
Following 2015, both ICD-10-CM codes and ICD-10-PCS codes only saw marginal increases, with diagnoses codes increasing 3.38% and procedure codes increasing 7.76%.
DRG’s stayed pretty consistent throughout the 2010’s, with only a 2% increase since the start of the decade.
CPT codes also didn’t see too much of a change – from 2010 to 2020, there was only a 14.87% increase.
While the Pilot Program for the Recovery Audit Contractor (RAC) technically started in 2003, it didn’t really start for everyone else until around 2010, when the Regional Contracts were awarded and many of the states started getting their first RAC denials.
The goals of the RAC program include:
- Detecting and correcting past improper payments so CMS may implement actions to prevent future improper Medicare payments
- Identifying areas of provider confusion within Medicare billing
- Assisting CMS in addressing the high error rate within Medicare – currently 11% which equates to a loss of $41 billion per year
- Helping to maintain the future solvency of the Medicare Trust Fund for the millions of seniors who rely on the program
Who is subject to a RAC Audit?
- Physician practices.
- Nursing homes.
- Home health agencies.
- Durable medical equipment suppliers.
- Any provider or supplier that submits claims to Medicare.
Below is an overview of the RAC recoveries since 2010 and the Medicare billing error rate (CERT).
The American Hospital Association (AHA) filed a suit in 2014 to try and clear a backlog of RAC appeals at the administrative law court level. There were at least 800,000 appeals at that level as of 2014. A lower federal court had dismissed the lawsuit due to lack of jurisdiction, concluding because Congress was working on trying to procure more funding to review claims, it did not yet have the authority to act further. However, the case was reinstated by an appeals court.
The AHA notes that in December 2013, with the large backlog of appeals mounting, HHS imposed a two-year moratorium on assigning new appeals of claim denials. The court’s opinion observed that the department “has the capacity to process only about 72,000 appeals per year, a far cry from the almost 400,000 appeals it received in fiscal year 2013, or from the more than 800,000 appeals that composed its backlog in July 2014. These figures suggest that at current rates, some already filed claims could take a decade or more to resolve.” That administrative logjam delays billions of dollars in Medicare reimbursements to hospitals, the AHA noted.
On October 31, 2016, CMS announced the next round of RAC contracts had been awarded.
Five new contracts have been awarded – four regional contracts and one for a new region focused solely on auditing DME/HH-H claims nationwide. RACs in Regions 1-4 will conduct post-payment reviews to identify improper payments made in Parts A and B, excluding Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) and Home Health/Hospice (HH-H) providers. The RAC in the newest region, Region 5, will conduct post-payment reviews on DMEPOS and HH-H nationwide.
The map below illustrates the different regions that are covered by these contracts.
For most practices, the best defense against RAC is an effective offense. The best way to verify you are in compliance is to schedule frequent external audits (coding reviews). By doing so, you can uncover any issues and put corrective action in place, so the issue doesn’t continue (and you won’t be forced to pay back the government!).
Cybersecurity attacks are becoming more and more prevalent, particularly in healthcare. It is an alarming trend that has gained a lot of attention in the past decade. HIM professionals need to be aware, now more than ever before, how and where hackers gain access to PHI. Since early 2010, when HHS first started publishing breach information, hacking events have affected a whopping 96 million individuals with over 93 million patient records being hacked in just the first six months of 2015.
|Year Reported to HHS||Number of Hacking Events Reported||Number of Patients Affected by Hacking Events|
Source: US Department of Health and Human Services Office for Civil Rights. “Breach Portal: Notice to the Secretary of HHS Breach of Unsecured Protected Health Information.” June 30, 2015. https://ocrportal.hhs.gov/ocr/breach/breach_report.jsf.
The main takeaway is that HIM professionals must remain vigilant in protecting an organization from internal and external threats. Threats are continually evolving, therefore, solutions to protect information must remain one step ahead. Hackers and cyber-attackers only need to get it right once. Healthcare organizations have to get it right every day. One weak link is all it takes for a hacker to get in.
Recognizing that there is a gap in EHR capabilities and industry needs, the Centers for Medicare and Medicaid Services (CMS) offered to incentivize physician investment in their EHRs. The incentives were designed to lead physicians to use EHRs in ways that not only optimized provider performance but made physicians (and hospitals) “smarter buyers” of the systems themselves. This meant promoting the use of technology in ways that would improve individual care as well as the health of the population. In effect, since healthcare providers were not demanding better EHR systems on their own, Medicare and Medicaid incentivized them to do so with Meaningful Use.
The main EHR features required to fulfill HITECH meaningful use requirements are:
- A core of consistent, structured, clinical content that would be uniform across vendor systems and care settings
- Automated alerts and reminders
- Consistent, robust measurement capabilities
- Data mining capabilities
- Public health reporting
- Interoperability with other systems
What’s Next? A Look Ahead
ICD-11 will be the next hurdle for our industry to panic over and, ultimately, over-prepare for. The new classification system is set to take effect January 2022, but if ICD-10‘s implementation is any indication, this date is just a ballpark timeframe. ICD-11 is promised to be a vast improvement on the previous revisions, considering critical advances in science and medicine, while aligning classification with the latest knowledge of disease treatment and prevention. A significant feature is the improved ease and accuracy of coding requiring less user training than before. It will also have a translation tool to ensure internally consistent translations, including locally used terms. To learn more about ICD-11 view: https://icd.who.int/en/docs/icd11factsheet_en.pdf
Merit-Based Incentive Payment System (MIPS)
Under MIPS, there are 4 performance categories that could affect your future Medicare payments. Each performance category is scored by itself and has a specific weight that is part of the MIPS Final Score. The payment adjustment determined for each MIPS eligible clinician is based on the Final Score. These were the performance category weights for the 2019 MIPS Performance Year:
For 2020, the scoring will remain the same. However, in 2021, the scoring will be 35% Quality, 25% Cost, 25% Promoting Interoperability, and 15% Improvement Activities.
For 2022, the scoring will be 30% Quality, 30% Cost, 25% Promoting Interoperability, and 15% Improvement Activities.
Subscribe to our weekly newsletter
This is Part 1 of a 4 part series on the FY2021 changes to ICD-10 and the IPPS. In this part, we discuss some of the new ICD-10-CM diagnosis changes. Here is the breakdown: 72,616 total ICD-10-CM codes for FY2021; 490 new codes (2020 had 273 new codes); 58 deleted codes (2020 had 21 deleted codes); 47 revised codes (2020 had 30 revised codes)
Acute pulmonary edema is the rapid accumulation of fluid within the tissue and space around the air sacs of the lung (lung interstitium). When this fluid collects in the air sacs in the lungs it is difficult to breathe. Acute pulmonary edema occurs suddenly and is life threatening.
“Client S” is a small, not-for-profit, 40 bed micro-hospital in the Southeast. HIA performed a 65-record review this year for Client S and found an opportunity with 15 of them. 9 had an increased reimbursement with a total of $43,228 found.
The coma scale codes (R40.2-) can be used in conjunction with traumatic brain injury codes, acute cerebrovascular disease or sequelae of cerebrovascular disease codes. These codes are primarily for use by trauma registries, but they may be used in any setting where this information is collected. The coma scale may also be used to assess the status of the central nervous system for other non-trauma conditions, such as monitoring patients in the intensive care unit regardless of medical condition.
In the past, there had been an Excludes1 note at I46.- Cardiac arrest that excluded R57.0, Cardiac shock. HIA had also received a letter from AHA on a case in the past that had stated that only I46.- Cardiac arrest would be coded if both were documented. In addition, the Third Quarter Coding Clinic page 26 had a similar case that asked if both could be coded, and AHA had instructed that only I46.9, cardiac arrest, cause unspecified would be coded if both were documented and that the CDC would be looking at possible revision to the Excludes1 note.
A higher CMI corresponds to increased consumption of resources and increased cost of patient care, resulting in increased reimbursement to the facility from government and private payers, like CMS. We know that documentation directly impacts coding.
Lately we have seen several cases where the endarterectomy was assigned along with the coronary artery bypass (CABG) procedure when being performed on the same vessel to facilitate the CABG. A coronary artery endarterectomy is not always performed during a CABG procedure, so when it is performed it becomes confusing as to whether to code it separately or not.
Assign code Z20.828, “Contact with and (suspected) exposure to other viral communicable diseases” for all patients who are tested for COVID-19 and the results are negative, regardless of symptoms, no symptoms, exposure or not as we are in a pandemic.
The Centers for Medicare & Medicaid Services (CMS) announced new procedure codes for treatments of COVID-19 – effective as of August 1, 2020. Among the new codes are Section X New Technology codes for the introduction or infusion of therapeutics including Remdesivir, Sarilumab, Tocilizumab, transfusion of convalescent plasma, as well as introduction of any other or new therapeutic substances for the treatment of COVID-19.
One common element in many value-based programs is risk adjustment using Hierarchical Condition Categories (HCCs) to create a Risk Adjustment Factor (RAF) score. This method ranks diagnoses into categories that represent conditions with similar cost patterns.
Why are so many AKI records being denied? It’s hard to give one answer for why so many AKI records are being denied lately, but most appear to be due to the multiple sets of criteria available for use in determining if a patient has AKI, as well as physician documentation. As stated in Part 3 of this series, there are three main criteria/classifications used to diagnose AKI.
In previous parts of this series we looked at the definitions of AKI/ARF, causes, coding and sequencing, and the common clinical indicators that patients present with that are diagnosed with this condition. In Part 4, we will look at the documentation that should be present to report the diagnosis without fear of denial, as well as when a query is needed to clarify the diagnosis.
If the facility does a COVID-19 test, and test is negative, do I need a diagnosis code. The answer is yes, you will report a Z-code. The Z-code depends on the record documentation and circumstances of testing. For any patient receiving a COVID-19 test, if negative, there MUST e a Z-code to describe why the test was taken. (Test negative for COVID-19 and MD does not override negative results).
In the first parts of this series we looked at definitions of AKI/ARF, causes, coding and sequencing. In Part 3, we will look at what clinical indicators would possibly be present to support the diagnosis of AKI/ARF.
The FY2021 IPPS Proposed Rule is out and here are some highlights from it regarding ICD-10 Code proposals. We will know if these changes are permanent after the public comment period is over on July 10, 2020 and CMS prepares the Final Rule, usually out by August 1.
As discussed in Part 1 of this series, AKI/ARF is a common diagnosis that coders see daily. In Part 2, we are going to focus on the different types/specificity of AKI/ARF. We’ll learn what they mean, as well as how to code the diagnosis.
This is part 1 in a series focused on coding of acute kidney injury (AKI) and/or acute renal failure (ARF). AKI/ARF is reported often, but is also one of the most common diagnosis found in denials.
With the proliferation of COVID-19 cases, we thought we would put together a quick reference listing of some of the common scenarios that coders have asked about. As with all coding, coders should follow Official Guidelines for Coding and Reporting and the COVD-19 Frequently Asked Questions document by the AHA.
Effective March 1, Medicare will pay physicians for telehealth services at the same rate as in-person visits for all diagnoses, not just services related to COVID-19. This great for providers whose patients are reluctant to visit the office.
The biggest reasons why some hospital systems are moving to single path coding is to eliminate duplicative processes and to optimize productivity. In addition, costs are reduced when only one coder “touches” the record and completes both types of coding.
Effective with 4/1/2020 discharges, ICD-10-CM code U07.0 is used to report vaping -related disorders. ICD-10-CM code U07.0 (vaping related disorder) should be used when documentation supports that the patient has a lung-related disorder from vaping. This code is found in the new ICD-10-CM Chapter 22. U07.0 will be in listed in the ICD-10-CM manual under a new section: Provisional assignment of new disease of uncertain etiology or emergency use.
The US government and public-health officials are urging consumers to utilize telemedicine for remote treatment, fill prescriptions and get medical attention during the new coronavirus pandemic. The goal is to keep people with symptoms at home and to practice social distancing if their condition doesn’t warrant more intensive hospital care.
Coronavirus: Tips for working from home. Companies around the world have told their employees to stay home and work remotely. Whether you’re a new to this concept or a work from home veteran, here’s some tips to staying productive from our #HIAfamily.
This is part two of a three part series in which we address how coders can better interact with Clinical Documentation Improvement (CDI) professionals. In this part, we discuss mismatches and how to best go about resolving them. In part three we will provide a case example of best practice interaction.
This is part one of a three part series in which we address how coders can better interact with Clinical Documentation Integrity (CDI) professionals. Many times these departments are separate and the remote environment makes it difficult to interact efficiently between the two departments. In part one, we will discuss the history and objectives of CDI so the coder has a better understanding of CDI’s role.
One reason that coders should report chronic conditions (including history and status codes) on outpatient records is the HCC’s—Hierarchical Condition Categories. The quick and easy explanation of what HCC’s are is each HCC is mapped to certain ICD-10-CM codes or code ranges. HCC coding is designed to estimate future health care costs for patients.
For Part 5 of this 5-part series, we will look at Chapter 4 within ICD-10-CM—E00-E89—Endocrine, Nutritional, and Metabolic Diseases. There is no possible way to include every guideline or coding reference for this chapter, but here are some of the most common issues.
For Part 4 of this 5-part series, we will look at Chapter 10 within ICD-10-CM—J00-J99—Diseases of the Respiratory System. There is no possible way to include every guideline or coding reference for this chapter, but here are some of the most common issues.
For Part 3 of this 5 part series, we will look at Chapter 9 within ICD-10-CM—I00-I99—Diseases of the Circulatory System. This chapter contains so many of the everyday diagnoses that we code such as hypertension, heart disease and stroke.