1 Sat 0855am Documentation in an Era of ICD10 Meakem · 1 diagnosis code under ICD-9 (726.0) compared to 3 under ICD-10 Open Fracture of Head of Radius 1 code under ICD-9 (813.15)

Documentation in an Era of Change:

The Effect of ICD-10 and RAC

Tim Meakem, M.D., Medical Director

ProVation Medical

• What’s New in 2014

• Review of ICD-10 Transition

• Review of RAC (Recovery Audit Contractor)

• Review of MAC (Medicare Administrative Contractors)

• Reporting Requirements

• Approaching the Problem

• Leveraging Automation

• How to Step Forward (Wisely)

Overview

1

ICD-10 implementation pushed back one year

� Under the “doc fix” bill, ICD-10 implementation has been delayed to no sooner than Oct. 1, 2015

� Organizations will have at least another year, maybe more, to prepare

� Many who recognize that they were not ready for ICD-10 feel fortunate to have this time

� To read the bill in full, visit: http://docs.house.gov/billsthisweek/20140324/BILLS-113hrSGR-sus.pdf

Changes to ICD-10 and RAC in 2014

2

CMS pushes ‘pause’ on additional documentation requests until new RAC (Recovery Audit Contractor) contracts are in place

� Began Feb. 21 for post-payment reviews

� Began Feb. 28 for pre-payment reviews

CMS announces 5 changes to RAC Program

� To be included in the next round of RAC contracts

� Designed to improve transparency

Changes to ICD-10 and RAC in 2014

3

Documentation & ICD-10:

Only the Deadline has Changed

4

Despite being just six months from “go-live”when the delay was announced…

Little progress has been made to improve documentation to reach the level of specificity

required to code accurately in ICD-10

Documentation & ICD-10

5

ICD-10 contains more than 8 times the number of codes than ICD-9

� 69,000 diagnostic codes

� 5 times as many as ICD-9

� 72,000 procedure codes

� 19 times as many as ICD-9


6

The orthopaedic codes section is expanding more than any other section of ICD-10

� Displaced Oblique Fracture of the Shaft of the Right Tibia (ICD-10 code S52.123)

� The appropriate seventh character must be selected from a list of 16 possibilities (versus 5 under ICD-9)

� Adhesive Capsulitis of the Shoulder

� 1 diagnosis code under ICD-9 (726.0) compared to 3 under ICD-10

� Open Fracture of Head of Radius

� 1 code under ICD-9 (813.15) compared to 16 under ICD-10’s displaced of head of unspecified radius (S52.123)


7

Pain management providers can also anticipate substantial changes under ICD-10

� The following expand from 1 code to 9

� Cervical spondylosis without myelopathy (ICD-9 code 721.0)

� Thoracic spondylosis without myelopathy used for thoracic facet joint arthropathy (ICD-9 code 721.2)

� Degenerative disc disease in multiple regions

� Expands from 1 code to 3 in the cervical spine

� Expands from 1 code to 2 in the thoracic spine

� Expands from 1 code to 2 in the lumbosacral spine

� …But no differentiation between disc bulging, disc protrusion, disc extrusion and disc herniation (At least not yet…)


8


9

Spinal stenosis has 1 ICD-9 code—and approximately 30 ICD-10 codes

Documentation & RAC:

A ‘Pause’ in Name Only

10

Medicare Fee-for-Service Recovery Audit Program

� Review claims on a post-payment basis, looking back three years from the date the claim was paid

� This includes:

� Overpayments made to Medicare beneficiaries

� Underpayments made to providers

Documentation & RAC: Post-Payment Audits

11


12

Medicare Fee-for-Service Recovery Audit Program

� $3,667.6 million collected in overpayments in FY 2013

� $6.83 billion collected in overpayments since Oct. 2009

Top issue…insufficient documentation

In 2013, the top issue in 3 of the 4 RAC regions was insufficient documentation to support

services provided


13

The RAC Prepayment Review Demonstration Program

� Medicare RACs review claims submitted on select DRGs before they are paid to ensure that the provider complied with all Medicare payment rules

� Focus is on claims with high rates of improper payment

� Begin with reviews of short inpatient hospital stays

� Additional DRGs will be added at CMS’ discretion

Documentation & RAC: Prepayment Audits

14

Initial focus is on 11 states

Documentation & RAC: Prepayment Audits

15

� 7 with high populations of fraud-and error-prone providers

� 4 with high claims volumes of short inpatient hospital stays

CMS announced ‘pause’ in RAC Program

� In response to industry feedback

� Confident that these changes will result in a more effective andefficient program, including:

� Improved accuracy

� Less provider burden

� More program transparency

� Duration of pause to be announced

Procedures done during the ‘pause’ are still subject to audit once it is lifted

Documentation & RAC

16

CMS including 5 changes in next round of RAC contracts

1. Auditors must wait 30 days to allow for a discussion before sending the claim to the MAC for adjustments

2. Auditors must confirm receipt of a discussion request within three days

3. Auditors must wait until the second level of appeal is exhaustedbefore they receive their contingency fee

4. CMS is establishing revised ADR (additional documentation request) limits that will be diversified across different claim types (e.g. inpatient, outpatient)

5. CMS will require Auditors to adjust the ADR limits in accordance with a provider’s denial rate

Documentation & RAC

17

With updates being made to this program,there is little chance that this ‘pause’ will be

permanent

Documentation & RAC

18

MAC (Medicare Administrative Contractors) Prepayment Reviews

� State MACs can implement prepayment review programs at their discretion to reduce their Comprehensive Error Rate Testing (CERT) error rates

� MACs typically initiate prepayment review of providers they suspect are not properly billing for services

� MACs also are initiating prepayment reviews of new Medicare enrolled providers

Documentation & State MAC Prepayment Audits

19

Other 2014 Impacts

20

Case Mix Index (CMI)

� In an ideal world, a hospital’s CMI would be as high as possible

� Performs high-cost services

� Receives more money per patient

� To calculate CMI:

� Choose a time period (e.g., one month)

� Select all DRGs billed during that period and add Relative Weights (RW)

� Divide by total DRGs

Documentation & Case Mix Index

21

Documentation & Case Mix Index

22

CMS’ ASC Quality Reporting (ASCQR) Program

� Pay-for-reporting, quality data program

� ASCs must report quality data for standardized measures

� Focused on measures that support:

� Improved healthcare outcomes

� Quality

� Safety

� Efficiency

� Patient satisfaction

Increased Reporting Incentives for ASCs

23

Measures for CY 2014 Payment Determination

� ASC-1 Patient Burn

� ASC-2 Patient Fall

� ASC-3 Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant

� ASC-4 Hospital Transfer/Admission

� ASC-5 Prophylactic Intravenous (IV) Antibiotic Timing


24


� All CY 2014 Payment Determinations

� ASC-6 Safe Surgery Checklist Use

� ASC-7 Facility Volume Data on Selected ASC Surgical Procedures


� All CY 2015 Payment Determinations

� ASC-8 Influenza Vaccination Coverage among Healthcare Personnel

Failure to report WILL result in future Medicare payment reductions…


25

In 2014, there is MORE reporting and the components of reporting are BIGGER

Recap

26

Procedure documentation is the basis for:

� Patient Care

� Payment Management

� Medical Liability Defense

� Compliance Specificity

� AUC (Appropriate Use Criteria) Guidelines

� Quality Measurement

� Patient Care Improvements

Recap

27

Person who gets dizzy when standing, has shortness of breath and ankle edema

� You can treat each one individually

� Hydration

� Albuterol puffer

� TED hose

� BUT, it is better to get to the root cause

� If the root cause is CHF, increasing contractility could address all issues

The same principle applies elsewhere, including documentation

A Medical Example: Value of the root cause

28

A Documentation Example

29

Specialties will benefit from leveraging technology to improve clinical documentation

� Ensures a more efficient and effective claims defense

� Accelerates the audit process

� Eliminates data integrity concerns

� Avoids unnecessary financial shortfalls

Counting on further delays…a significant gamble

Bottom line…better clinical documentation leads to payment reliability…

and can make RAC, MAC and ICD-10 a non-issue

Leveraging Automation

30

For surgeons, technology helps in three ways:

1. Ensures that the medical findings specified correspond to the codes that are submitted

� Guides all documentation

� Flags specific data for inclusion

� Process can be updated as regulations change

2. Establishes medical necessity and supports (defends) against anychallenges to the codes submitted

� Captures discreet data elements for each procedure

� Built-in reporting and analytics tools simplify audit preparation

3. Ensures complete, coder-ready documentation

� Improves revenue

Leveraging Automation: Surgeons & Proceduralists

31

Automation allows required data points to be collected directly from procedure notes

� Lessens the need for manual intervention

� Eliminates duplicate data entry

� Enables limited resources to be focused on other core responsibilities

� Increases productivity

� Potentially accelerates patient throughput

When software is interfaced with other systems, more data points are collected without additional resources

Leveraging Automation

32

Deep Medical Content

Stay away from templates

� Do not keep up with quarterly coding or documentation changes

� You are likely to have to maintain them, keep them current

Stay away from coding “pick lists”

� You still have to keep track of all the coding and documentation reqs.

Built around your workflow (not derived from a billing system)

Ensure it is useable for other purposes

� Internal quality assurance

� Registry submission

� Data to use to negotiate with payers

“Best of Breed” approach

� Be wary of start ups, companies for sale, “we can do everything”

What I Look for When Selecting a Technology Partner

33

You have two choices:

1. Get/use an effective system

� Periodically (1-3 yrs) review to ensure it continues to meet your needs

2. Do not get an effective system and you will…

� Be at risk for RAC/MAC audits and coding changes

� Have to keep track of all of the documentation changes

� Have to implement a system to capture the requirements

� Lose all the added benefits (registries, internal quality control, negotiating leverage, interfaces)

Why should we talk about documentation and coding?

34

Net result, without an effective system, you will CONSTANTLY be dealing with these issues

Questions?

35

Documents

1 Sat 0855am Documentation in an Era of ICD10 Meakem · 1 diagnosis code under ICD-9 (726.0) compared to 3 under ICD-10 Open Fracture of Head of Radius 1 code under ICD-9 (813.15)