2014

Coding and Legislative Alert:
ICD-10, MU Stage II and
other Coding Concerns
Louis McIntyre, MD
Orthopedics Today
Hawaii January 2014
Presenter Disclosure
Information
Louis F. McIntyre, MD
Disclosure Information
The following relationships exist:
Stock Options: Tornier Medical
Speaker Fees: Depuy-Mitek
Research Grant: Depuy-Mitek
Board Member: AANA, AIM, FairHealth PAB
Editorial Board: Orthopedics Today
Member Coding, Coverage and Reimbursement
Committee of AAOS
Issues
ICD-10:
„ ACA:
„ MU Stage II:
„ RVUs TKA, THA:
„
October 1, 2014
January 1, 2014
January 1, 2014
January 1, 2014
Contrasting 9-CM & 10-CM
ICD9-CM
„
„
„
~14,000
~ 4,000
Dx Codes
„
„
„
„
Dxs: Vols 1&2
Procs: Vol 3
ICD10-CM & PCS
„
„
„
„
3-5 digits max
Only numeric
No placeholder
Specificity
„
„
Dx Codes
„
„
„
„
Dxs: ICD10-CM
~68,000
Procs: ICD10-PCS ~87,000
3-7 digits max
Alphanumeric
“x” serves as placeholder at 5th
(and 6th) positions
Specificity
No laterality
Injuries grouped by type of
injury
„
Only open vs closed
fracture
„
„
„
Laterality
Injuries grouped by anatomical
site
Gustilo open fracture type
Expanded combination codes
ICD-10:
The 7 character field
„
„
„
7 digits for higher specificity
Alphanumeric Codes
„ Character 1 is always Alpha
„ Character 2 is always Numeric
„ Character 3-7 can be either Alpha or
Numeric
Decimal after the 1st three characters
The 7th Character
A Initial encounter active treatment.
Surgery, ER, New physician
„ D Subsequent treatment during
healing or recovery
„ S Sequela complications or
conditions that arise from condition
„
The 7 character field
S83.211A Bucket Handle Tear Medial Meniscus Right Knee
Initial Encounter
ICD-10
How is it Organized?
The Index An alphabetical list of
terms and corresponding codes
„ The Tabular List A sequential list of
codes divided into chapters based
on body system or condition
„
Chapters of interest to
Orthopaedics
„
„
„
„
Chapter 6 - Diseases of the nervous
system
Chapter 13 – Diseases of the
musculoskeletal system and connective
tissue
Chapter 17 - Congenital
Malformations, Deformations and
Chromosomal Abnormalities
Chapter 19 - Injury, Poisoning and
Certain Other Consequences of External
Causes
Other chapters of interest
„
„
„
„
„
„
„
„
Chapter 20 External causes of
morbidity
This includes all kinds of things:
V00-X58 Accidents
V00-V99 Transport accidents
V00-V09 Pedestrian injured in transport
accident
V95-V97 Air and space transport accidents
X30-X39 Exposure to forces of nature
And many, many more….
How to find an ICD-10 code?
25 year old football player injures right
knee. Is seen in your office with an MRI
that shows bucket handle tear medial
meniscus
How to find an ICD-10 code?
„
Go to INDEX and
look up condition
How to find an ICD-10 code?
„
Go to
corresponding
TABULAR
CHAPTER to
recommended
category
How to find an ICD-10 code?
„
Add 7th Character
„ A Initial Encounter
S83.211A
How to Find an ICD-10 Code?
Helpful Resources
„
ICD-10 Complete
Official Code Set
from AMA
Cost Impact of ICD-10
Implementation
Nachimson Advisors LLC 2008 ICD-10
Implementation
„ $83,290 3-man practice
„ $2.7 million 100 physician practice!!
„ ½ from increased cost/time of
documentation
„ ¼ from cash flow disruption
„ Small Practice $1500-2000 for
training
Cost Impact of ICD-10
Implementation
Canadian Experience 2001-2003
10% Productivity Decline
„ Lasted an average of 6 months
Training, slower processing time,
increased inquiries from coders
and billing inquiries from payers
„
ICD-10: How to Minimize the
Trauma of the Transition
ICD-10: How to Minimize the
Trauma of the Transition
AMA 2012
„ Organize the implementation effort
„ Analyze the impact
„ Contact systems vendors
„ Budget for costs
„ Contact trading partners
„ Implement system/software upgrades
ICD-10: How to Minimize the
Trauma of the Transition
AMA 2012
„ Conduct internal testing
„ Update internal processes
„ Conduct staff training
„ Conduct external testing of
transactions wit ICD-10 codes
„ Implement (Up to 22 months!!)
„ Monitor (3-6 months!)
ICD-10 Action Plan
Run ICD-9 Frequency Report of top
25 OFFICE codes
„ Pull OP notes for the top 10
PROCEDURES and evaluate for ability
to code ICD-10
„ By end of first quarter goal is to code
in both systems
„ Check with vendors for resources and
support
„
ICD-10 Action Plan
Check with clearinghouse for
resources
„ Estimate cost of transition
„ Check with top ten payers for their
ICD-10 status and medical necessity
guidelines-check websites
„ Plan test by April-May to see if
system is working well enough to
generate payments
„
ICD-10 Action Plan
Use Code-X
„ Consider reserving cash, establishing
LOC for cash flow problems
„
ICD-10: How to Minimize the
Trauma of the Transition
Get
„ Get
„ Get
„ Get
„
Educated!
a Plan!
Codex!
your vendor onboard!
More Information
„
AAOS:
www.aaos.org/prac-man
„
CDC:
www.cdc.gov/nchs/icd.htm
www.cdc.gov/nchs/data/icd9/10cmguidelines2011_FINAL.pdf
„
CMS:
www.cms.hhs.gov/ICD10
Final Rule Stuff
„
Final Rule is publication outlines rules
for reimbursement for CMS and
Medicare
Final Rule:
RVU Value TJA
2013
„
„
„
THA 21.79 wRVU
TKA 23.25 wRVU
Uni 16.38 wRVU
2014
„
„
„
THA 20.72 wRVU (5%)
TKA 20.72 wRVU (11%)
Uni 17.48 wRVU (6.7%)
Regulatory Issues
„
„
“CMS considers the shoulder joint to be
one anatomic structure. An NCCI
procedure to procedure edit code pair
consisting of two codes describing two
shoulder point procedures should never be
bypassed with an NCCI associated modifier
when performed on the ipsilateral shoulder
joint.”
English: can’t report two shoulder CPT
codes for the same procedure in the same
shoulder
Final Rule:
Bundled Shoulder Codes
Column 1
„
„
„
„
„
29807
29807
29821
29827
29828
(SLAP)
(SLAP)
(Synovect)
(ARCR)
(ABTeno)
Column 2 (1 Edit)
„
„
„
„
„
29822
29823
29823
29823
29823
(Limited DB)
(Ext DB)
(Ext DB)
(Ext DB)
(Ext DB)
Meaningful Use Stage II
Thanks to Ranjan Sachdev MD.MBA,CHC
Meaningful Use – Stages
Stage 1 – Began in 2011
„ Stage 2 – Originally scheduled for
2013 but delayed till 2014
„ Stage 3 – Planned for 2015 but likely
to be delayed
„ Criteria for Stage 3 to be determined
„
40
Stage 1 EP’s must meet …
„
Meaningful Use Objectives
„
25 objectives in total
„
„
„
15 “core set”
„ EP must report on all measures
10 “menu set”
„ EP must meet at least 5 and may defer up to 5
Clinical Quality Measures
„
„
„
3 “core” measures OR
3 “alternate core” measures
PLUS 3 additional measures from a
set of 38
41
What if outside the scope of
practice?
They can exclude a specific meaningful
use objective if outside scope of practice
„ Excluded objective can count the same as
if it was met!!
„ For example, if 3 of the 10 menu set
measures do not apply, provider has to
meet only 2 out of the 7 that apply.
„
42
Clinical Quality Measures
(CQM) Reporting
2011 – Submit data to CMS by attestation
„ 2012 – Submit data to CMS electronically
„ Reporting on 3 core measures
„
„
„
If denominator of core measure is zero, report
results for up to 3 alternate core measures
Report on 3 additional measures
(from set of 38)
43
Meaningful Use Stage 2
Final rule has significant changes from
originally proposed MU stage 2 rules
„ Require 17 core measures, 3 of 6 menu
items.
„ Many of menu items moved to core and
new menu items have been added
„
44
MU Stage 2 Versus 1
Core Measures
Measure
Stage 1
Stage 2
8
Implement Clinical
Decision Support
Implement 1 rule
Implement 5 clinical decision
support interventions related
to 4 or more clinical quality
measures
9
Provide patients with an More than 50% who
electronic copy of health request it are
information
provided electronic
copy within 3 days
10 Protect
P t t electronic
l t i h
health
lth
information
C d t security
Conduct
it risk
i k
analysis, implement
updates and correct
identified deficiencies
1.More than 50% who are
provided online access to their
health information.
2. More than 5% view,
download or transmit to
party
third p
arty
y
C d t security
Conduct
it risk
i k analysis,
l i
implement updates and
correct identified deficiencies.
Also address
encryption/security of data at
rest.
47
MU Stage 2 Versus 1
Core Measures
Measure
Stage 1
Stage 2
11
Incorporate lab results as
structured data
> 40%
> 55%
12
1
2
Send
S
end
d patient
patiient reminders
remiind
ders for
for
preventive/follow up care
>2
20%
0% were
sent
appropriate
reminder . Is a
menu measure
Becomes
B
ecomes core
measure. Use EHR
to identify and
provide reminders
to > 10% of
patients with 2 or
more visits in last 2
years
13
1
3
Use
U
se certi
certified
ified
d EHR
EHR technology
tech
hnollogy to
identify and provide patient
specific education resources
>1
10%
0% are
provided
patient specific
education
materials
>1
10%
0% are provi
provided
ided
d
patient specific
education materials
48
MU Stage 2 Versus 1
Core Measures
Measure
Stage 1
Stage 2
14
Perform medication
reconciliation when patient
received from another setting
of care
> 50%
> 50%
15
Provide summary of care
record when patient
transitioned to another setting
of care
> 50%
Menu measure
> 50%
Moves to core set
16
Capability to submit electronic
data to immunization registries
or immunization information
systems
Perform at least 1 test
of EHR capacity to
submit data to
immunization registries
Successful ongoing
submission of data to
immunization registry or
immunization
information system
17
1
7
NEW
N
EW
>5
>5%
5% pat
patients
tientts sentt
secure messaging using
messaging function of
certified EHR technology
49
4
9
Clinical Quality measures
(CQMs)
„
„
6 domains
National Quality Strategy priorities for health care
quality improvement. These domains include:
„
„
„
„
„
„
„
Patient and Family Engagement
Patient Safety
Care Coordination
Population and Public Health
Efficient Use of Healthcare Resources
Clinical Processes/Effectiveness
Need 9 CQMs from 3 domains
Page 50
Caution…
For meaningful use stage 2 you can
only submit measures that EHR is
certified to submit.
„ If EHR is not certified to submit a
specific measure, submission of that
measure will not count towards
achieving meaningful use numbers
„
Page 51
Compliance Issues
„
„
„
„
„
Significant risks - attestation inaccurate
Expect increased audits and checks
Expect recoveries with fines and penalties
under False Claims Act
If false data submitted, all claims after that
may be considered False Claims
Advice - Must incorporate compliance in
EHR implementation and Meaningful Use
attestation
52
Stage II MU
Have to attested to Stage I first
„ Begin reporting 2014
„ Need only report for three months
„ Last month to report for 2014: Feb
2015
„
Questions?
Contact
Louis F McIntyre M.D
[email protected]
@LouisMcintyreMD
Thank You!!