Wednesday, July 31, 2013

Gearing Up for ICD-10

There are thousands of articles out there on getting ready for ICD-10 implementation.  Most of them are very broad in their scope.  One item that sometimes gets short shrift is planning for new superbills in the physician office setting.

Maybe because it seems overwhelming--or maybe because the writers often come from a hospital setting.  In the hospital setting, coding is much different.  The query process means that you can start off with documentation that is of low specificity, and end up with more specificity to improve code selection.  In all but the largest of physician clinic settings, there is no query process.  The documentation is what it is.

So, what advice can we give to the practicing physician, who may be overwhelmed with the large number of codes available?  I think the most important thing for physicians to do is be realistic about their documentation (while taking the opportunity to improve it!), and analyze what they really use in ICD-9 as a starting point.  Your superbill may contain 100 ICD-9 codes, that translate to 2,500 possible ICD-10 codes.  But how many of those ICD-9 codes do you really use and document in your day to day practice? That old clinical saw about horses vs. zebras will serve you in good stead here too.

Use your practice management software to analyze the top 100 codes you use today--not what is on your superbill.  Look at the frequency of use over the course of a year.  If 25 of those codes make up 80% of your ICD-9 volume, turn to the General Equivalence Mappings (GEMs) to help you find crosswalks for those codes.  Allow plenty of space for write in- diagnoses in the beginning--and track those codes.  Take the top 25-50 of your write- in codes, and add them to your superbill.   By the time you have 75 codes on your superbills, MOST specialties will have a superbill that helps you code 80% or more of your daily visits.

Some specialties (orthopedic surgery, for example) will be forced to create much larger superbills, unless they limit their practice to a specific body part.  But the basic premise is the same.  However, because of the specificity of ICD-10, and the few areas of the code book that do not contain a "Not Otherwise Specified" code, you'll be forced to change your documentation style, or be unable to find codes for some conditions.  Remember that anatomy and laterality are key in ICD-10, along with dominance (mostly for neurological conditions).  Your documentation should indicate R vs L, along with whether the patient is R or L hand dominant.  You might have been able to find a code for "R arm fracture" in the past, but now you'll need to document the bone(s) involved, including the area of the bone involved.  This does mean some increase in documentation, but these increases have the potential to improve documentation greatly.  Continuity of care can be improved with these changes, and exchange of important clinical information between specialties.

Whatever approach you plan to take to create superbills in ICD-10, the time to start is now.   Today, there are 426 days until ICD-10 submission is required.  Waiting until then to see what is required is too late.  Starting now will allow you the necessary time to make any changes needed in your documentation, and begin to understand the differences in ICD-10 language and rules.  Take the time now to read the official guidelines (even if you've never read the ICD-9 guidelines!) so you know what the requirements are to choose a code.

Remember to check the Presentation and ICD-10 pages on HCC University for information on ICD-10 coding.  And let us know what types of information you need on ICD-10.

Monday, July 29, 2013

Risk Score Calculator Updated with 2014 Model

The Risk Score Calculator on has been updated with the 2014 CMS-HCC Risk Score Calculator.

The calculator will allow you to calculate risk scores for services on or after 4-1-2013.  The updated calculator shows the components of the 2013 (25%) model and the 2014 (75%) model, and the final blended score.

We hope you find this new tool useful.

Wednesday, July 24, 2013

CMS Rejects of Full Encounter Data Encounters

Even after more than a year, we continue to see a number of CMS rejects of submitted encounters.  These rejects occur in all types of encounters, and for a number of reasons.  One of the most common rejects we see is for the referring physician's NPI.  This happens in a number of types of encounters, but most commonly in DMEPOS encounters.  Let's look at encounters missing a referring physician NPI,  and the various errors we see in them:

1)      Incorrect DOS—most DMEPOS are rentals, or represent a monthly supply.  Almost all of the encounters I saw were for a single date of service, and should be a 30 day  span—e.g. from January 1-30. 

2)      Incorrect # of services—many of the DMEPOS encounters have a # of services “1”—when it should be “30”.

3)      Incorrect place of service—in almost all cases, DMEPOS requires a POS of 12 (sometimes 31 or 32 if that’s the patient’s home).  Many of these encounters have a POS 11 or 99.

4)      Missing modifiers (things like Anesthesia always requires a modifier, some surgeries require a modifier to indicate if they are RT, LT or bilateral –50. Most DMEPOS have modifier requirements as well)

5)      Unlisted E/M (99499).  While this code would be expected for a chart review submission, many of these are WITH another E/M on the same date, which makes no sense--generally only one E/M service is allowed on a given day.

Remember that your encounter data to MA plans should be submitted as you were submitting to your MAC, FI or DMERC--because in effect you are.  We must submit all of your encounters to CMS for processing on the same claims processing systems that the MAC, FI and DMERC use.  So, if the claim or encounter won't pass your Medicare contractor's processing system edits, then it won't pass the encounter data processing system edits either. 

The closer your encounter data submissions are to FFS Medicare, the more likely they are to be processed by CMS.

Monday, July 22, 2013

New Medicare Presentations Posted on CMS Website

CMS has posted a number of new presentations on their website, to help providers with CMS Fee-for-Service (FFS) quality programs.  While these presentations deal with FFS quality programs, the documentation for several of these programs are similar to the documentation required for the HEDIS and Five Star programs in Medicare Advantage.  You can take these programs by following the information below:

The PowerPoint presentations and recordings from past webinars can now be accessed on the Resources page of the eHealth website.

The following webinar resources are available:

We hope this information proves helpful!