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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Practices have not seen many revisions to the Evaluation and Management (E/M) office / outpatient visit guidelines in three decades – until now. As of January 1, there are new E/M coding guidelines. We’ll get to those in a bit, but first let’s look at why they changed.
Pseudoseizures are a form of non-epileptic seizure. These are difficult to diagnose and oftentimes extremely difficult for the patient to comprehend. The term “pseudoseizures” is an older term that is still used today to describe psychogenic nonepileptic seizures (PNES).
With the implementation of ICD-10-CM came different codes and coding rules for many diagnoses. One of these is the coding of bowel obstruction when the patient presents for this condition that is caused by another condition.
This is Part 5 of a five part series on the new 2021 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 2021 CPT codes. In this series we will explore the CPT changes in the urinary, nervous, ocular and auditory systems. There are 2 new urinary/male reproductive system codes with no revisions or deletions; 3 new female reproductive codes with 2 deletions, 0 new with 4 deleted nervous system codes with 5 revisions; 5 new eye category III codes; and finally a 2 new auditory codes with one deletion.
This is Part 3 of a five part series on the new 2021 CPT codes. In this series we will explore the cardiovascular system CPT changes. There are 5 new cardiovascular CPT codes added with 0 deletions and 4 revisions.
This is Part 2 of a five part series on the new 2021 CPT codes. In this series we will explore the CPT changes for FY2021 and include some examples to help the coder understand the new codes. There are 0 new musculoskeletal CPT codes added with 0 deletions and 2 major revisions along with an extensive update to arthroscopic loose body removal requirements. For the respiratory system, there were 2 new codes, one code deletion and no revisions.
This is Part 1 of a five part series on the new 2021 CPT codes. In this series we will explore the CPT changes for FY2021 and include examples to help the coder understand the new codes. For 2021 in general, there were 199 new CPT codes added, 54 deleted and 69 revised.
In January, new CPT codes were released. There were 248 new CPT codes added, 71 deleted and 75 revised. Most of the surgery section changes were in the musculoskeletal and cardiovascular subsections. These included procedures such as skin grafting, breast biopsies, deep drug delivery systems, tricuspid valve repairs, aortic grafts and repair of iliac artery.
We have seen many updates and changes to COVID-19 (SARS-CoV-2) since the pandemic started. On January 1, 2021 we will see even more changes as outlined in this post. Also the CMS MS-DRG grouper will be updated to version 38.1 to accommodate the changes.
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 FY2021 IPPS changes. In this last Part 4 of the series, we will review the NTAP procedure codes and reimbursement add-on payments for FY2021.
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 FY2021.
This is Part 2 of a 4 part series on the FY2021 ICD-10 Code and IPPS changes. In this part, the ICD-10-PCS procedure codes are presented. For FY2021 ICD-10-PCS there are 78,115 total codes (FY2020 total was 77,571); 556 new codes (734 new last year in FY2020)…
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.
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.