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How to Manage Stage 2 Meaningful Use Requirements


EHR Incentive Stage 2Many medical providers still remain unsure of how to attain and manage meaningful use final rules to fulfill criteria and requirements. As the incentive program--which some claim is more of a disincentive measure--moves to Stage 2 in 2014, prior criteria expands with increased requirements.

Understanding these targets and requirements are imperative for compliance, which should protect practice revenues. Stage 2 objectives involve expanded detailed clinical processes that place more responsibility on the medical community to create additional documentation, possibly added cost and more opportunity for errors. First, eligible professionals (EPs) must realize what is required to address and manage these issues efficiently.

Stage 2 Criteria and Focus

  • More detailed health information exchange (HIE) necessities,
  • Additional e-prescribing and lab result requirements,
  • Ability to transmit patient care summaries via multiple platforms, and
  • Create more detailed data under patient control.

These are the primary targets of Stage 2 meaningful use final rules. These are the general focus of Stage 2, and assume medical providers have fulfilled Stage 1 requirements, applicable during 2011 and 2012. The overriding target of Stage 1 was the electronic capture of patient care and treatment information, ensuring quality control of care and delivering data for public health information purposes.

Satisfying and Managing Stage 2 Objectives

Core Objectives include the following final rules. The primary targets are to improve care quality, patient safety and reporting efficiency. Here is a partial list of primary goals for 2014.

  • Electronic order entry for medications, lab tests and radiology actions,
  • Use of e-prescribing (eRx) systems,
  • Create the ability for patients to view, download and or transmit their health information,
  • Record more detailed clinical summaries,
  • To ensure privacy and security, install improved security protection of health data.
  • Make lab test results available and thorough,
  • Offer patient education resources,
  • Maintain electronic patient lists,
  • Use of secure electronic messaging to peers and patients,
  • Record all medications and reconcile their use,
  • Clearly document all preventative care provided, and
  • Note all immunization treatments.

Stage 2 targets include the following objectives. The primary goals remain to improve care, safety and efficiency for patient diagnosis and treatment, along with improving public health results. The following issues are specific to eligible medical providers.

  • Provide "syndromic surveillance" data,
  • Make "notes" on electronic health records (EHRs),
  • Offer clear imaging results, with appropriate explanations,
  • Digitize family health histories,
  • Report all cases involving cancer, and
  • Electronically report significant specific cases.

Managing these requirements begins with ensuring you follow the meaningful use rules and maintaining documentation that evidences your compliance. The inability to comply and/or prove your adherence to Stage 2 rules will negatively impact your revenue and claims submissions.

As should be obvious, managing Stage 2 requirements involves no "magic bullet." Successfully achieving Stage 2 meaningful use goals do involve achieving the stated objectives, along with the ability to prove you did so.

If you consider these Stage 2 requirements a daunting challenge, as many EPs do, consider outsourcing these requirements to a top third-party, proven medical documentation firm. You will enjoy these advantages, at a minimum.

  • Better protect your current revenue levels or create additional income,
  • Security of knowing that the firm's staff is thoroughly trained in Stage 2 requirements,
  • Receive assurance that meaningful use rules are consistently followed, and
  • Control your costs, while minimizing errors.

Lowering the probabilities of mistakes by overworked and overtaxed busy staff is critical to managing Stage 2 meaningful use requirements. Since most EPs and practice managers are equally busy, it is often unreasonable to expect they can devote the time to guarantee that all rules are followed.

If you choose to comply internally, be sure to create written policies, procedures and checklists for you and your staff to follow to better ensure compliance. Remember, it is ultimately the EP's responsibility to comply with Stage 2 meaningful use rules and objectives.

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Don't Allow New Documentation Rules Translate to Lower Quality Patient Care


New Documentation RulesAccurate patient record documentation requirements hopes to "foster quality and continuity of care." Additionally, medical record standards target improved lines of communication between providers, patients and providers, along with provider to payer communications.

While payers establish their own expectations, all expect accurate evidence-based documentation, preferably electronic. Payers, including Medicare and Medicaid, develop their own checklists, but most requirements include the following items.

Typical Payer Documentation Expectations

Patient medical records should always include the following data.

  • Clear identification of patients on each document component.
  • If kept in "paper" files, legible entries in high contrast ink, preferably black or dark blue, on all documentation to minimize reader error.
  • All recorded entries should be clearly dated and authenticated by the provider.
  • Use accurate codes, supported by equally thorough documentation.
  • Employ on common (standard) medical abbreviations, eliminating misunderstandings in translation or entry.
  • Include every patient "encounter," including phone, fax and electronic messages.
  • Clear recording of problems, medical conditions, medications, allergies, physical exams, immunizations, lab and diagnostic test results, diagnosis factors and treatment plans.

Payers will complete periodic document reviews, to evaluate the accuracy, clarity and thoroughness of submitted provider documentation. Claim delays and/or denials may result if documentation does not achieve, at least minimum payer standards.

Providers and their billing staff are cautioned to pay particular attention to the new coding system, as simple "typos" will typically cause reimbursement delays, at a minimum. Correcting an unjust claim denial because of deficient documentation is more difficult and time consuming than submitting it accurately initially.

Combine Quality Care with Cost Control

Healthcare reform demands delivering quality care, while employing new mandates, including more detailed documentation, seamlessly for maximum patient and provider benefit. Optimizing clinical documentation is a key to maintaining revenues. But, will it affect quality patient care?

The new requirements for "meaningful use" justification, pay-for-performance plans and ICD-10 codes are daunting changes in documentation, but should not result in lower quality care. Providers should find ways to lower and control costs, while maintaining their level of patient care.

Capturing and reporting accurate information has never been more critical to generating revenue, claims submission and patient communications. Medical providers should evaluate the cost management advantages of outsourcing some functions to leading billing, coding and documentation firms, such as M-Scribe Technologies, to remove much of the pressure to improve patient care while also tightly controlling expenses.

Practice staff under additional pressure face major performance challenges. Is it really wise to subject possibly maxed-out personnel to increased pressure of additional, unfamiliar documentation requirements? Probably not.

Similarly, is there any wisdom in medical providers in putting this extra pressure on themselves to lower and control costs, while improving patient care? The answer is easy: No. The bottom line remains the delivery of quality care. The rest of a successful bottom line financial equation will follow.

Increased documentation should not negatively impact quality patient care. Although there is a natural learning curve with any new policies, procedures and requirements, the negative implications can--and must--be minimized. How this goal is reached is typically up to the provider and/or the practice.

However, medical providers will rue the consequences of allowing new documentation necessities to interfere with quality patient care delivery. Even if the immediate concerns are maintaining strong revenue and lowering expenses, delivering quality care will become much more vital in the longer term.

Practitioners delivering consistent, quality care will eventually eliminate the potential negatives in complying with documentation and communication requirements. Just as new coding and digitizing patient medical records is challenging, the future should eliminate these fears, as more providers and practices become comfortable with these realities.

The future health of your patients and practice depends on marrying quality care with cost control and creating clear, accurate documentation. Is this a challenge? Yes. Is it possible? Also, yes.

ICD\u002D10 and Documentation
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Will Pay-for-Performance Techniques Help Control Expenses and Maintain Strong Revenue?


Pay-for-PerformanceThe medical provider community is not enamored with the "pay-for-performance" (P4P) initiatives now dominating the payer landscape. Incentive-laden payment schedules dramatically contrast with classic fee-for-service (FFS) payment systems.

Depending on the components used, P4P systems can take various forms. However, regardless of the elements considered by payers, the medical community continues to favor FFS, as it compensates for the quality of services rendered without evaluation of performance.

Medical professionals have multiple concerns with performance-based measurement systems. Often, the primary questions and issues involve two concerns.

  • Will P4P systems help or hurt controlling expenses?
  • Can I maintain current revenue or increase income with P4P payer techniques, in light of healthcare reform, new ICD-10 coding and documentation requirement increases?

Understanding Pay-for-Performance Logistics

The first requirement is to understand the foundation and goal of P4P systems. The goals of P4P systems is rather straightforward: Define incentive rewards for physicians and other medical providers for improving health care for patients.

The measurement details and standards payers use is much more complex and argumentative. This is the primary area of contention, with no consensus among the medical or payer community as yet. The depth and breadth of performance measurement benchmarks, often stated as the "clinical outcomes" of diagnosis and treatment choices, has generated heavy discussion and, sometimes, strong disagreement.

According to leading research institute, RTI International, many payers use the following factors as the foundation for P4P logistics when designing systems.

  • Clinical outcomes.
  • Clinical process quality.
  • Patient safety.
  • Access to and deliverance of quality care.
  • Patient satisfaction levels.
  • Cost of care efficiency.
  • Adoption of and adherence to an "evidence-based" practice.
  • Proper use of information technology.

This list is not all-inclusive, as some payers use performance standards with more measurement factors. Unfortunately, to date there is little agreement on P4P design details or the projected results.

Expense Control

P4P and evidence-based medical practice almost mandate that physicians cut or, at least, tightly control costs. Since payers often use cost-efficiency as a critical P4P component, practitioners' data may be compared to other providers' efficiency as a measurement tool.

While this incentive standard works "on paper," there is medical community concern how it will impact P4P results in the real world. Depending on the payer benchmarks used, the cost-control requirement will have an impact on most practice ratings.

Even if a P4P system is committed to fair and equitable evaluation, will practice personnel understand the necessary expense limitations placed on physicians and practice managers? Maybe, the best way to exercise expense control is to outsource many functions to a top practice management firm, such as M-Scribe Technologies, to handle billing, coding, documentation, etc. This solution gives practices cost-certain control with managing patient- and service delivery-related expenses.

Revenue Maintenance and/or Improvement

The healthcare reforms, new ICD-10 codes and increased documentation requirements are strong challenges to maintaining or improving practice revenue levels. The medical community's concerns appear to be well-founded.

P4P, although touted as an incentive program, can deliver hidden (or not-so-hidden) penalties to medical providers by reducing, not increasing, revenue. Until a consensus is reached regarding standards and measurement techniques, medical providers will continue to debate the merits and detriments of P4P.

The "learning curve" associated with massive reforms, coding and unfamiliar documentation requirements temporarily could generate revenue challenges that practitioners cannot overcome. Should this occur, providers dedicate all efforts to master these necessities as soon as possible to restore former revenue levels.

Once again, it appears wise for providers and practice managers to consider outsourcing functions to top, proven, professional third-party firms to safeguard revenue. Their staffs have been thoroughly trained in billing, coding and documentation changes needing mastery to keep revenue flowing strongly.

Avoiding claim delays and denials with accurate billing, coding and documentation submission is vital with or without P4P systems. Until the longer term results take place, medical providers probably will continue asking if pay-for-performance techniques will help or hurt cost control and revenue levels? Can you blame them?

ICD\u002D10 and Documentation
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Making Best use of ICD-10 Index and Tabular Lists


ICD 10 Dermatology ClinicsHow can dermatology practices use ICD-10 Index and Tabular Lists to effectively meet conversion challenges?

The ICD-10 Index & Tabular List

The National Center for Health Statistics is the official repository of ICD-10-CM documents. The official source documents are: The ICD-10-CM INDEX TO DISEASES and INJURIES and The ICD-10-CM TABULAR LIST of DISEASES and INJURIES. The disease and injury index shares the same characteristics as most book and document indices. It provides a quick way of referencing code categories. The best way to use the index is to let it guide us as to where to look within the ICD-10-CM tabular list.

The tabular list is comprised of a comprehensive ICD-10 codes listing. Individual chapter breakdowns are typically based on body systems. An example in Dermatology is chapter 12. This is where Diseases of the skin and subcutaneous tissue can be found. This chapter is assigned the letter L, so all codes in this chapter will start with L.

At the beginning of chapter 12 there is an excludes 2 clause including such things as parasitic diseases (A00-B99), metabolic diseases (E00-E90) and viral warts (B07). Notes can provide clarification. Such notes include Includes Notes, Excludes Notes such as Excludes 1 and Excludes 2 and See Notes. The top level heading covering codes L00 to L99 is followed by an excludes 2 note. This Excludes 2 Note clarifies that the listed diagnoses aren’t part of the represented code, and can be made at the same time.

Types of Notes

Excludes1 notes indicate that coding the listed diagnoses together is invalid. Given a patient diagnosis of acquired epidermolysis bullosa (L12.3), it’s invalid for a congenital EB diagnosis to be given at the same time, as congenital and acquired are mutually exclusive. The Excludes1 note guides practitioners to select just one code.

Excludes2 notes indicate that differing codes can co-occur. Diagnoses that aren’t part of the code can be coded at the same time. Acne is in category L70. An Excludes2 note informs the practitioner that acne keloid is not found among L70 diagnoses so it can be listed as well.

See notes indicate places to look for related codes. Poison Ivy is a type of dermatitis. When checking in the Index, you might start at Dermatitis and then under Contact and Allergenic.

See Also notes provide alternative index locations when looking for a code. Looking in the index under papilloma, the index directs you to look under NeoplasmsBenign, or “by site”.

Use Additional Code indicates that an additional code is required. Given a patient with impetigo, (L01), the recommendation to use an additional code identifying the infectious agent (B95-B97) is given.

Code First note urges the practitioner to use an additional code as the first code on the Superbill. Many Code First notes describe variations of a larger disease. In the L14 category of Bullous disorders in diseases classified elsewhere, a patient has a “bullous” subtype of Systemic Lupus Erythematosus(SLE), in which the lupus is causing blisters. The diagnosis associated with SLE (M32.8) is inadequate. Instead, the Code First note suggests using the M32.8 code for SLE, and then adding the L14 code to indicate “bullous changes”.

It’s clear that dermatology practices will make extensive use of ICD-10 Index and Tabular Lists to identify the correct ICD-10 codes for record keeping and claims processing after October 2014. These documents are a primary resource for locating and applying the correct code. Their use will help ensure that comprehensive and accurate medical information is available to help practitioners, patients and researchers.

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Medical Coding and Billing Challenges in 2014


2014 ChallengesMajor changes stemming from the Affordable Care Act promise to make medical coding and billing more difficult in the coming year. Regulations that are effective as of January 1, 2014 require more documentation in order for medical practices to complete the billing process. Understanding these changes is the first step to proper billing. M-Scribe provides medical billing and coding services that allow medical practices to overcome the challenges facing them in 2014.

Diagnosis Codes

The biggest change that will take effect this year is the transition from ICD-9 to ICD-10. The switch means that the number of diagnosis codes will expand from 13,000 to 70,000. A huge increase in the number of codes has the potential to decrease earnings for medical offices and may cause confusion for employees who are not adequately trained on the new codes.

Offices that are not prepared for the change may have difficulty collecting payments. The changes set a strict definition for medically necessary procedures, and claims that use invalid codes that were acceptable under ICD-9 are likely to be denied.

The good news about the change in diagnosis codes is that medical practices have until October 1 to comply. The overhaul is an undertaking that is too labor intensive for most offices, but outsourcing medical billing and coding to M-Scribe lets practices comply with ICD-10 without the commitment of time.

CMS 1500 Form

A new CMS 1500 form will be used in conjunction with the new ICD-10 coding. Documentation must be accompanied with the CMS 1500 form that is now available. Claims made using outdated forms will not be accepted starting April 1.

Current Procedural Terminology

Changes in the CPT are intended to standardized terminology that is used in medical practices across the country. However, significant modifications that require full compliance could put a strain on providers. Providers who use software to complete their medical coding and billing tasks have the option to import the new CPT codes into their existing software packages.

Quality Standards

The quality reporting program managed by the Centers for Medicare & Medicaid Services will be able to levy penalties for noncompliance in 2014. Providers are required to complete checklists that review the quality standards of routine procedures and surgery for patients who are enrolled in Medicare or Medicaid.

Ambulatory surgery centers that failed to comply with G-code reporting standards between October and December 2012 will receive a 2 percent reduction in the reimbursement amount for Medicare claims. This penalty will also be applied to ASCs that fail to comply in the future, so it is essential for providers to be proactive about compliance.

Technological Needs

Changes in patient volume will force medical offices to move to digital medical coding and billing. While most offices have already switched to digital medical coding and billing, approximately 20 percent of hospitals and nearly half of physicians still need to make the change.

Expanded access to insurance is sure to increase patient volume significantly. Medical offices that struggle to manage paperwork will not be able to keep up with the change in volume without the help of computer programs. Outsourcing medical coding and billing is one way to benefit from digital processing without the need to purchase a software package or take the time to train administrative professionals on the changes in medical coding and billing.

Medical coding and billing changes in 2014 pose unique challenges to providers. M-Scribe is available to provide medical coding and billing services to ensure compliance with regulations put into place under the Affordable Care Act.

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The Role of ICD-10 in Improving Business Goals


ICD 10 business GoalsOpposition to ICD-10 is strong from the AMA and other forces, due in part to the excruciating level of detail the new coding system demands. But that same deep level of detail may eventually be realized as a major benefit for advancing the goals of healthcare practices as well as the industry as a whole. Healthcare data mining and data analysis have already been benefiting the healthcare arena, and the deeper level of details ICD-10 promises to produce may increase the benefits even further.

ICD-10 Enhances Data Analysis

A quick review of some of the changes between ICD-9 and ICD-10 pointed out by the Centers for Medicare and Medicaid Services (CMS) make the increased precision immediately evident. The new system increases the number of codes, the numbers of characters in each code and adds more specificity to the coding process. ICD-10 allows for the description of etiology and causation, manifestations and complications, comorbidities, level of functional impairment, detailed anatomical location and other details not available with ICD-9.

CMS notes the switch can benefit healthcare providers by:

  • Accommodating more recently developed diagnoses and procedures
  • Allowing for innovations in treatment
  • Enhancing performance-based payment systems
  • Providing billing that is more accurate, streamlined and efficient

While such benefits can contribute to advancing the goals of a practice, ICD-10 may bring even greater benefits in the way of healthcare data analysis. An article published in the International Journal of Engineering Research and Applications points out the numerous benefits healthcare data mining can bring to the industry, and those benefits can be multiplied with the implementation of ICD-10.

Evaluation of Treatment

Healthcare data analysis can be a useful tool for determining the effectiveness of specific treatments. By comparing and contrasting the symptoms, causes and courses of treatment, healthcare data mining may play a role in discerning the most successful medication doses, therapies or other treatment modalities.

Management of Healthcare

Healthcare data mining software or applications could help identify and keep track of high-risk patients and chronic diseases. Analytical tools could help healthcare providers develop effective interventions, resulting in a reduced need for hospitalization and fewer overall claims.

Closely tracking specific conditions or ailments could also alert providers of a potential outbreak of infections, whether within the hospital parameters or throughout the community or nation as a whole. In addition to serving as an early warning sign of bio-terrorism or an epidemic, results from data analysis could assist with predicting the risk and survival analysis for patients with AIDS or others suffering from certain injuries or conditions.

Management of Customer Relations

Customer relations may be improved through healthcare data analysis, particularly for predicting specific usage patterns, preferences and needs of individuals. Such information could be applied to customer relations in various arenas, including physician offices, billing departments, call centers, inpatient and ambulatory care settings.

Additional Uses of Data Mining

The adoption of electronic health records has already allowed medical and healthcare facilities to amass large quantities of pertinent patient data. Such data can be analyzed to determine specific needs of patients based on their medical histories and current status.

Examples include alerting healthcare professionals about patients that may benefit from preventive measures, flu shots or a disease management program. Focusing on predictive analytics, providers may be able to assess the likelihood of a particular patient to adhere to his or her treatment program based on past behaviors and other pertinent factors.

Although ICD-10 continues to battle its opposition in the present, it may serve as a valuable implementation going forward. Not only could it help individual practices of facilities advance their business goals, but it could enhance the entire industry.

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How does Meaningful Use fit into the EHR Incentive Program?


EHR Incentive ProgramThe renovation of the U.S. health care system is the federal government’s attempt to curtail the rising cost of medical services by implementing digital sharing. When evaluating current Medicaid and Medicare practices, researchers felt there was too little incentive to grow into the technological era of electronic health records. Meaningful use is a large part of moving that process forward and improving coordination of care standards through digital recording.

Electronic medical records are not new. In fact, this technology has existed for decades, but the hardware was expensive and the processing complex. A 2008 survey of physicians conducted by DesRoches showed that 83 percent did not use electronic records even with the improved products. Many had the hardware available, but not the time or incentive to use it.

In 2009, President Obama signed an act that would change things. The Health Information Technology for Economic and Clinical Health Act, HITECH Act, implicated meaningful use standards to push the health care industry into a new era – one the focuses on a health information exchange. The goal is to:

  • Improve quality of care
  • Enhance care coordination
  • Engage patients in their own health care
  • Advance public health

Designers of this bill wanted EHR to be more than just something practices were always on the verge of using, so they developed a system of metrics to show meaningful use of the technology. This stair step approach leads to incentive payments for Medicaid and Medicare providers.

Money Talks

The Medicare and Medicaid Electronic Incentive Programs provide payments to eligible professionals and facilities based on their adoption and implementation of EHR technology. The Medicare EHR program pays up to 44,000 dollars in incentives and Medicaid up to 63,750, according to the Centers for Medicare and Medicaid Services. At the heart of this payment system is a series of meaningful use benchmarks that prove providers are utilizing the platform properly.

Meaningful use comes in three stages. At the completion of each stage, the professional receives an incentive payment if they meet the standards. To qualify for the Stage 1 incentive payment, eligible practitioners need to meet 14 core requirements and at least five of the 10 menu-set offerings, explains CMS. Menu-set options include items like:

  • Incorporating lab-test results into EHR
  • Sending reminders to patients regarding preventive or follow-up care
  • Submitting data to immunization registries

Medical facilities must meet 13 core requirements and five objectives.

Stage 2

Stage 2 begins in 2014. Once a practice completes all the necessary requirements for Stage 1, they are eligible to advance to Stage 2 for a second incentive payment. Stage 2 shifts the focus to information exchange and patient involvement. Of the 20 core requirements, practices must show adherence to at least 17 plus three menu objectives. Medical facilities need to meet 16 core requirements and three menu-set objectives.

Stage 3 will not begin before 2016. With Stage 3, practitioners and facilities will see a new set of challenges they must meet in order to get payment. Beyond Stage 3, the incentive system will turn into one of penalties for providers that are not adhering to the EHR system.

Meaningful use is the metric system that qualifies practices and facilities for incentive payments. It is the propelling force in the switch to a digital network that allows cooperation between all the various health care silos. The primary care physician will know what tests the specialist runs, for example. The radiologist will know what medications a patient is allergic to all by utilizing this system. Meaningful use and incentive payments are just the means to that coordinated end.

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Tips for Making a Seamless Transition to ICD-10


ICD 10 TransitionWith the required implementation of ICD-10 on the horizon, many hospitals, medical facilities and private practices are struggling to make the necessary changes to meet the new standards. While the changes from ICD-9 to ICD-10 may seem varied and complex, the transition need not be a worrisome struggle. It can instead be a rather seamless transition with a few practice management suggestions to help meet the Oct. 1 implementation deadline.

Awareness of Coding Changes

Being aware of two major coding changes can be the first step in effectively implementing them. The federal Medicaid website reports they are:

  • Expansion of code set: Code sets in ICD-10 consist of seven positions, with each position supporting alphanumeric characters. ICD-9 had only five positions, with only the first position open to alphanumeric characters.
  • Increase in number of codes: The number of ICD-10 codes is 68,000 in ICD-10, a substantial increase over the 13,000 codes in ICD-9.

Early Preparation

Although ICD-10 cannot be put into active practice until its official Oct. 1 implementation date, starting the transition as early as possible is crucial step for an effective transition. It gives organizations the opportunity to troubleshoot any issues while ensuring they are not placed on a long vendor waiting list. Vendors specializing in practice management software and electronic health records are likely to be in high demand, which makes early preparation an essential strategy.

Learning the Most Common Codes

Attempting to learn the entire slate of new codes may be impossible as well as unnecessary. Many healthcare professionals may have a handful of codes they consistently use as part of their practice. Making a list of the most common 20 to 25 codes from ICD-9 and then learning the ICD-10 equivalent can be incredibly helpful, especially in the early phases of the transition. Specific hospital or medical facility departments can use the same strategy, focusing on the most common codes needed for effective practice management.

Identifying Gaps in Descriptors

The new coding system demands greater detail in the way of descriptors, and failing to use them could result in the denial of claims. One way to spot check the attention to detail that will be required is to review existing charts and find any gaps that may occur between the new and old coding systems.

Organizations may examine the existing ICD-9 codes used in the charts then match them up with the equivalent ICD-10 codes, taking note of the key words present in the code descriptions. They can analyze the differences by checking how many claims using ICD-9 would be rejected under ICD-10. This can be a vital learning experience for physicians and staff, illustrating the importance of paying acute attention to the additional detail required.

Ascertaining Vendor and Payer Readiness

Even if a hospital, medical facility or private practice has properly prepared itself for the transition, nothing is likely to go smoothly if the facility’s vendors and payers are not equally as prepared. Organizations would do well to inquire about their vendors and payers readiness to embrace the new system. Key inquiries may include:

  • If electronic health record vendors will have revised templates ready
  • The type of testing vendors are undergoing to ensure an efficient transition

One more key fact that may help with transition from ICD-9 to ICD-10 is to remember the overall goal. Regardless of the extra work the ICD-10 transition may be causing in the short-term, the changes were made to ultimately make the billing process more accurate, detailed and reflective of the changes made in the world of medicine over the past 25 years.

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Preparing for ICD-10 testing


ICD 10 TestingPrioritizing ICD-10 testing, with the most critical scenarios taking place first, is advisable as a preferred strategy. Areas of focus include business, clinical and operational functionality. Individual health care payers must each schedule their own end to end testing. Test plans, real medical data and collaboration with partners are all part of the process.

Creating accurate test data for ICD-10 is challenging as this type of data has never before been implemented in full-scale production environment in the U.S. For some indication as to what may happen, we should look north: ICD-10 has been in full production in Canada since 2002. According to AHIMA, Canadian productivity decreased from 4.62 charts per hour just before ICD-10 implementation to 2.5 charts per hour 3 months later, but rebounded to 3.75 charts by 2003 (1 year later). Conversion participants note that both analytical tools and human decision making tools are necessary for success.

ICD-10 implementation will ultimately provide precise diagnoses and treatments, more accurate payments and better tracking of treatment results. Coding mismatches are likely to affect operations for some time: the US Dept of Health and Human Services anticipates an increase in claim errors of 6% to 10%.

Positive Outcomes of Testing

Operational Stability - Accuracy measures such as those for claims payment are maintained at productive levels with new codes.

Clinical equivalency - ICD-9 and equivalent ICD-10 codes define the same characteristics of patient care, and the outcomes meet medical requirements.

Benefit consistency - ICD-9 or ICD-10 code equivalents result in the identical member coverage, with no increase in premiums or co-pays.

Financial consistency - This is the state where benefit payment by the insurer together with recipient copay result in payment coverage.

Real Test Data

Real patient medical data from your practice will provide a solid base for your testing. Using records that reflect the types of cases you treat and submit for reimbursement is the best way to asses the impact of ICD-10 implementation on your practice. Use of test scenarios that match healthcare payers' mappings rather than your practice data is unwise.

Test each of the transaction that will include ICD-10 codes. Transactions and work processes should include claims submission, eligibility and quality reporting.

The AMA provides a fact sheet to meet October 2014 ICD-10 readiness.

Testing Readiness for ICD-10 Overview

Software upgrades are likely to be necessary for your current systems in order for you to be able to send and receive the ICD-10 codes required for reporting and transactions. You must test the systems that send and receive diagnosis codes. Your practice management system is an example. Make certain that the ICD-10 codes are sent from your system, received by the target system, and processed appropriately. HIPAA providers, payers, and clearinghouses are responsible for their own ICD-10 compliance.

The three necessary testing areas to cover are:

  • Sending ICD-10 transactions and reports directly or through a clearinghouse
  • Receiving ICD-10 transactions and reports and processing them in your systems
  • Ensuring payments and cash flow will continue after October 1, 2014

Internal testing is conducted inside a practice. Completing internal testing will allow you to identify and ultimately resolve any internal systems issues related to ICD-10 codes. Testing manual and workflow processes is also important. If your practice works with a billing service, coordinate with them on necessary data collection.

External Testing involves sending and receiving ICD-10 related transactions to your business associates and partners. If the test transactions you’re sending with ICD-10 codes include real patient protected health information (PHI), take care to ensure data privacy. This testing will allow you to identify ICD-10 code issues arising in sending or receiving data. Successful completion of “end-to-end” testing with your partners means that you’re ready to process live transactions.

Overall testing can take 8 to 12 months. Compliance is required for payment as of October 1, 2014.

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ICD-10-CM/PCS and Computer Assisted Coding (CAC)


ICD CACThe ICD-10 October 2014 compliance deadline will soon be here. Managing the transition from ICD-9 to ICD-10 is especially critical for small practices—a successful transition is vital to their success and often their continuing survival. If they weather the change, they’ll be well positioned to realize improved reimbursement models, lowering their costs while improving the quality of their patients’ patient care. Yet the transition is costly, especially for smaller practices, which typically have limited access to sophisticated conversion technologies, experienced conversion specialists and in depth training programs. The use of computer assisted coding is critical to the success of ICD-10 conversion.

What a Computer Assisted Coding System (CAC) Does

  • Scans EHR documents
  • Identifies key terms using NLP (Natural Language Processing) and other technologies
  • Suggests progress (CPT) and diagnostic codes (ICD-9 and ICD-10) that match the terms

What It Doesn’t Do

  • Eliminate the needed for skilled coders

What a Computer-Assisted Coding System Should Produce

  • Increased medical coder efficiency
  • Better medical coding accuracy
  • Quicker medical billing
  • Increased revenue from better itemized bills
  • Identification of clinical documentation gaps

Does CAC Work?

There are many CAC systems vendors offering their services to practices as the ICD-10 deadline looms. But data regarding CAC’s ICD-10 conversion effectiveness is scant. To aid in understanding the usefulness of CAC technology in ICD-10 implementation, the AHIMA Foundation and Cleveland Clinic jointly conducted a research project to examine the impact of CAC technology on data quality, timeliness of processing and the role and impact of coders on the process. Underwritten by CAC vendor 3M Corporation, this pilot program sought to answer two basic questions:

  • Is there a measurable difference between traditional coding and the use of CAC in terms of coding timeliness and accuracy?
  • Will the use of credentialed coders in conjunction with the use of CAC result in improved timeliness and accuracy?

The Findings

1. CAC, with Coder Support, Reduced Coding Time

There was a 22 percent reduction in time per record for CAC supported coding vs. manual coding. The 25 records used were significantly complex, with an average patient stay length of 16 days.

2. CAC, with coder Support, Did Not Reduce Accuracy

Time to code was decreased without lessening quality, as measured by recall and precision for both procedures and diagnoses.

3. CAC Tuning Improves Precision Over Time

Sophisticated CAC systems utilize “tuning” through natural language processing (NLP) to “learn” over time. Six months after the study was implemented, the CAC’s unaided recall rate “improved for coding both diagnoses and procedures.”

The Cleveland study used a NLP CAC system from 3M that’s marketed to hospitals. The envisioned use of coders in such systems is ultimately as editors who oversee the EHR conversion process, rather than perform it. The cost of NLP-based systems is higher than cross-walk option systems, in which ICD-9 codes map to ICD-10 data through a conversion process implemented in an office’s current claims billing system. The crosswalk systems are a short term solution at best: all systems must be ICD-10 compliant by 2015. ICD-10 crosswalk-provided data often fails to provide needed information to medical management pricing and contract applications, are labor intensive and prone to error.

ICD-9 to ICD-10 Transition Outcomes

ICD-10 transition workflow and best practices planning should focus on achieving basic, well-defined outcomes:

  • Clinical equivalency: Use of either the ICD-9 code or its equivalent ICD-10 code defines the same attributes of patient care, medical necessity and treatment outcomes.
  • Benefit neutrality: Use of either the ICD-9 code or its equivalent ICD-10 code produces the same member coverage, without increasing member premium or out-of-pocket expense.
  • Financial integrity: Either set of codes results in the payment of appropriate benefits by the insurer and the appropriate financial contribution by the recipient.
  • Operational stability: Accuracy metrics such as auto-adjudication frequency and claims payments are at equivalent acceptable levels under either the old or new codes.
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