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.
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The Centers for Disease Control and Prevention (CDC) is in process of developing a new code for the COVID-19 (coronavirus) that will be released October 1, 2020. In the meantime, the CDC has provided advice on coding the COVID-19 coronavirus.
We’re finally at the #1 most common DRG with recommendations by HIA for 2019. Just to recap, HIA reviewed over 50,000 inpatient records in 2019. Most have probably already guessed what the correct DRG would be with the most recommendations. There are just some diagnoses and DRG’s that will always be a thorn in the side for coders. #1 DRG with the most recommendations during HIA reviews : DRG 871—Septicemia or severe sepsis w/o mechanical ventilation >96 hours with MCC
We’re now at the second most common DRG with recommendations by HIA for 2019. Just to recap, HIA reviewed over 50,000 inpatient records in 2019. We are counting down to # 1. #2 DRG with the most recommendations during HIA reviews: DRG 872—Septicemia or severe sepsis w/o mechanical ventilation >96 hours w/o MCC.
In 2019, HIA reviewed over 50,000 inpatient records. Wow! That is a lot of records. Even with this large number of records, the DRG’s with recommendations are still the ones that coders typically see during audits. #3 DRG 190—Chronic obstructive pulmonary disease with MCC.
In 2019, HIA reviewed over 50,000 inpatient records. Wow! That is a lot of records. Even with this large number of records, the DRG’s with recommendations are still the ones that coders typically see during audits. #4 is DRG 193—Simple pneumonia & pleurisy with MCC.
In 2019, HIA reviewed over 50,000 inpatient records. Wow! That is a lot of records. Even with this large number of records, the DRG’s with recommendations are still the ones that coders typically see during audits. #5 DRG with the most recommendations during HIA reviews : DRG 853—Infectious & Parasitic diseases with O.R. procedure with MCC
In 2019, we reviewed over 50,000 diagnosis codes from many different specialties for our Professional Fee clients. For the final part of this 3-part series, we will look at R00-R99 – Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified.
The Circulatory chapter is one that is identified every year as having a large number of coding changes. Many of these changes are related to documentation providing more specificity and, in some cases, less specificity than the codes reported. Below we will discuss some of the areas of opportunity in this chapter.
In 2019, we reviewed over 50,000 diagnosis codes from many different specialties for our Professional Fee clients. Here are the top three ICD-10-CM chapters where HIA identified coding opportunities: Z00-Z99 – Factors influencing health status and contact with health services; I00-I99 – Circulatory system and; R00-R99 – Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified.
This is Part 5 of a five part series on the new 2020 CPT codes. For the remaining areas we will just briefly summarize the section. Due to the intricate nature of these sections in CPT, it is recommended that the coder read the entire section notes associated with the new codes.
This is Part 4 of a five part series on the new 2020 CPT codes. In this series we will explore the CPT changes for FY 2020 and include examples to help the coder understand the new codes. There is 3 new digestive system codes with 1 deletion and 2 revised; 1 revised urinary system codes with new category III codes; 6 new with 20 deleted nervous system codes with 3 revisions; 2 new eye codes with 3 revisions; and finally a new category III auditory code.
This is Part 3 of a five part series on the new 2020 CPT codes. In this series we will explore the CPT changes for FY2019 and include examples to help the coder understand the new codes. There are 11 new cardiovascular CPT codes added with 8 deletions and 2 revisions.
This is Part 2 of a five part series on the new 2020 CPT codes. In this series we will explore the CPT changes for FY2020 and include some examples to help the coder understand the new codes. There are 11 new musculoskeletal CPT codes added with 1 deletion and 0 revisions.
This is Part 1 of a five part series on the new 2020 CPT codes. In this series we will explore the CPT changes for FY2020 and include examples to help the coder understand the new codes. For 2020 in general, there were 248 new CPT codes added, 71 deleted and 75 revised.
This is Part 6 of a 6-part series focusing on CPT coding of breast procedures. There are many different types of breast reconstruction procedures, each having potential stumbling-blocks for coders. Part 6 focuses on revision of a reconstructed breast.
This is Part 5 of a 6-part series focusing on CPT coding of breast procedures. There are many different types of breast procedures, each having potential stumbling-blocks for coders. This series will address several of the more confusing topics. Part 5 focuses on the coding of different types of autologous tissue breast reconstruction procedures.
Part 4: CPT Breast Education Series | Use of Acellular Dermal Matrix with Breast Implant Reconstruction
This is Part 4 of a 6-part series focusing on CPT coding of reconstructive procedures following mastectomy. There are many different types of breast reconstruction procedures, each having potential stumbling-blocks for coders. Part 4 focuses on the use of acellular dermal matrix with breast implant reconstruction.
Part 3: CPT Breast Education Series | Immediate Versus Delayed Permanent Breast Implant Reconstruction
This is Part 3 of a 6-part series focusing on CPT coding of breast procedures. There are many different types of breast procedures, each having potential stumbling-blocks for coders. This series will address several of the more confusing topics. Part 3 focuses on the difference between immediate and delayed permanent breast implant reconstruction.
This is Part 2 of a 6-part series focusing on CPT coding of breast procedures. There are many different types of breast reconstruction procedures, each having potential stumbling-blocks for coders. This series will address several of the more confusing topics. Part 2 focuses on the use of tissue expanders in breast reconstruction.
With the implementation of ICD-10-PCS the description of codes became much more detailed to describe exactly what is being performed. Cardiac catheterization is one of the descriptions that changed to further detail exactly what is being performed during the procedure.
This is Part 1 of a 6-part series focusing on CPT coding of reconstructive procedures following mastectomy. There are many different types of breast reconstruction procedures, each having potential stumbling-blocks for coders. Part 1 is an overview of the types of breast reconstruction techniques commonly used. Future topics in this series will go into more detail of each technique and the CPT coding implications.
With Christmas fast-approaching, we’re making a list of our favorite holiday movies and checking it twice. And in the spirit of good humor and cheer, we’ve added some ICD-10 codes to these holiday classics. Have a safe, happy, and healthy holiday everyone!
“Lobar” pneumonia references a form of pneumonia that affects a specific lobe or lobes of the lung. This is a bacterial pneumonia and is most commonly community acquired. Antibiotics are almost always necessary to clear this type of pneumonia.
In Parts 1, 2 and 3 we learned about what sepsis is, sequencing of sepsis and what documentation is needed to report severe sepsis. In Part 4, we will look at clinical indicators needed to clinically support the diagnosis of sepsis and determine if a query is indicated.
Severe sepsis occurs when sepsis progresses and signs of organ dysfunction/failure develop. One site stated that approximately 30% of patients with severe sepsis do not survive. Patients may develop one organ dysfunction/failure, multi-system organ failure and/or septic shock.
In Part 2 of our Sepsis Series, we are going to focus on sequencing of sepsis when the diagnosis is clearly documented. Later in the series we will look at what to do when the diagnosis is not clearly documented.
In this series, we will learn what sepsis is or causes of sepsis, how to sequence the diagnosis in ICD-10-CM, what are the clinical indicators for sepsis, is a query necessary before reporting the diagnosis of sepsis, and how to prevent denials on sepsis records.
In the previous three parts of this four part series, we discussed the new ICD-10-CM diagnosis code changes, ICD-10-PCS procedure code changes and FY2020 IPPS changes. In this last Part 4 of the series, we will review the NTAP procedure codes and reimbursement add-on payments for FY2020.
In the previous two parts of this four part series, we discussed the new ICD-10-CM diagnosis code changes and ICD-10-PC procedure code changes. In this session we will review the major IPPS changes for FY2020. On August 2, 2019, CMS published the Final Rule for IPPS (CMS-1716) FY2020 IPPS Final Rule.