New Video on Roadto10.org

CMS has published a new, post implementation video on their website, Roadto10.org.  Per the announcement:

In this Centers for Medicare & Medicaid Services (CMS) ICD-10 video, Sue Bowman from the American Health Information Management Association (AHIMA) and Nelly Leon-Chisen from the American Hospital Association (AHA) discuss the unique characteristics and features of the ICD-10 coding system. Topics include:

• What is a valid code
• Guidelines for coding and reporting
• Coding process and examples: 7th character, unspecified codes, external cause codes, laterality
• How to submit coding questions
• Resources for coders 

Visit the Medicare Fee-For-Service Provider Resources webpage for a complete list of Medicare Learning Network resources on ICD-10.

CMS ICD-10 Ombudsman and Coordination Center Available

I received the email below from CMS today, and thought I would share it with you.

CMS has established a coordination center and an ombudsman to help providers

 through this difficult transition to ICD-10. These are fantastic resources for providers,

so that they can resolve issues once they've exhausted their attempts to find the right

code for a situation.  It's reprinted below, and we hope you find it helpful.

Because of CMS formatting that I can't change, it does appear a little funny on our site, but the information is so useful, I hope you'll look past that.

News Updates | October 7, 2015

ICD-10 Ombudsman and ICD-10 Coordination Center Here to Support Your Transition Needs It’s important that you know help’s available if you have problems with ICD-10: ICThe ICD-10 Ombudsman, Dr. Bill Rogers, can be your impartial advocate You can contact the ICD-10 Coordination Center ICD-10 Ombudsman Dr. Rogers, a practicing emergency room physician, is known to many of you   already. Since 2002, he has been the Director of the Agency’s Physicians  Regulatory Issues Team, assisting physicians, other practitioners, and medical societies in identifying and simplifying Medicare policies and regulations. His role  as ombudsman will be to be a one-stop shop for you with questions and concerns  and to be your internal advocate inside CMS. ICD-10 Coordination Center The Coordination Center is a dedicated group of Medicare, Medicaid, and    information technology systems experts drawn from across CMS. They have  the full support of the entire CMS staff to address any issues quickly and   completely. First-Line ICD-10 Information and Support For general ICD-10 information, we have many resources on our                CMS ICD-10 website and Road to 10 webpage. Contact the MAC for Medicare claims questions. Your MAC                             is your first line for Medicare claims help. MACs cannot                                     respond to questions about Medicaid or Commercial health plans. If you have a Medicaid claim question contact your State Medicaid Agency. If you have a commercial or private health plan claim question               , please contact your health plan directly. Keep Up to Date on ICD-10 Visit the CMS ICD-10 website and Roadto10.org for the latest news and  resources, including the ICD-10 Quick Start Guide. Sign up for  CMS ICD-10 Email Updates and follow us on Twitter.

Updates!

With the ICD-10 implementation date just around the corner, we at SCAN, and you as our Provider partners are working very hard.  There's so much information to filter through, it sometimes seems impossible to keep up with.

CMS has posted their DRAFT CPT/HCPCS filtering list.  What is on the list is not hugely problematic, but what's missing (Modifiers) is.  As you know, modifiers alter the meaning of the CPT/HCPC codes, and inclusion of some of those modifiers may be important.  Health Plans have until August 21st to comment.  You can rest assured that we're studying the list, and will make comments to CMS in a timely manner.

CMS also posted another important file: The updated CMS-HCC and Rx-HCC files.  As you know, CMS posted a draft file a little over a month ago--they've now taken it down and replaced it.  They are not calling this the final ICD-10 mapping, so we'll be sure to monitor the CMS website and post updates here.

We've posted a number of new Q and As on the Ask-a-coder page.   In addition, we've completely new Helpful Links page.  All of the links are now categorized, making it easier for you to find exactly what you're looking for.

Just as an FYI--when we have special or time sensitive posts to HCCUniversity.com, we usually send out an email blast.  These are sent infrequently, and usually no more often  than once a month.  If you'd like to be added to our growing list of HCCUniversity readers, please send your name and email address to coding@scanhealtplan.com, and we'll be sure to add you.

That's it for today.  As we get closer to ICD-10, we 're sure to hear things from CMS that are of importance to you. We'll pass them along here, on HCCUniversity.com and through our email blasts.


Stacey Hernandez, CCS-P          

Advance Notice of 2016 Medicare Advantage and Part D Rates Released

On Friday, February 20, CMS released the proposed rules for Medicare Advantage Payment for 2016.

Comments to the proposed rule are due to CMS on March 6, 2015.  You can download the proposed rule on the CMS website.

The final rule will be released on April 6, 2015 in accordance with the law, and you'll be able to download it on the Announcements and Documents Page.

For an easy to read summary of the notice, you can download the CMS Press Release.

CMS plans to completely phase in the new CMS-HCC model, with no blend.

In addition, CMS is proposing that they will calculate 2016 MA and Part D risk scores by blending two separate risk scores.  One risk score would be calculated using 2015 diagnoses from the Risk Adjustment Processing System (RAPS) and Fee-For-Service (FFS) data, and another separate risk score would be calculated using 2015 diagnoses from the Encounter Data System (EDS) and FFS.  CMS would then blend these two risk scores, weighting the risk score from RAPS and FFS by 90% and weighting the risk score from EDS and FFS by 10%.  This will make the subission of all encounter data more important than ever before.

CMS has decided not to disallow services performed in the home setting, but health plans still must report services performed in the home.

We suggest you review the CMS documents, and download the final rule, which will likely be released late in the afternoon of April 6, 2015.

Can You Code From a Problem List?

Today we posted a collections of documents from CMS. These documents were Questions and Answers from a series of CMS Risk Adjustment  User Group Calls.  Among the answers is a question we get very frequently--Is it okay to code from a problem list?  To find out, check out the CMS User Group Q and A's on HCC University.

What's New For the rest of 2014 and Beyond?

It seems like Risk Adjustment for Medicare Advantage is ever-evolving.   According to a Final Rule, published by CMS in the Federal Register on May 23, 2014, the one thing we can certainly expect more of is audits.

CMS will be introducing a Recovery Audit Contractor (RAC) for Part C, slated before the end of 2014.  RAC auditors use a combination of methods, including medical record review and automated edits, to identify improper payments.  Currently, there are RAC contractors in Part A, B and D--so the addition of a Part C RAC will mean that all of Medicare is under RAC audits.

We don't yet know what RAC audits for Part C will look like--but if you want to stay ahead of the curve, you should be looking at your data for any anomalies now.  Speaking at an America's Health Insurance Plans conference, Sonja Brown, a health insurance specialist in the Center for Program Integrity in CMS’s Division of Plan Oversight and Accountability,initial areas of review are end-stage renal disease (ESRD), hospice and Medicare as Secondary Payer (MSP).

In addition to the RAC, beginning in 2015, the OIG will be doing their own Risk Adjustment Data Validation Audits (RADV), which we assume will look just like a CMS RADV, but may be more targeted.

This means that with so many audits going on simultaneously, it will be the rare medical group that is not affected.  Medical groups should be doing their own internal chart reviews to determine where more physician education is needed.

We'll continue to keep you up to date on new and changing rules from CMS as we become aware of them.

ICD-10 Webcast for Internal Medicine and Family Practice Posted

This morning, CMS posted a new webcast, aimed at primary care physicians on their Roadto10.org website:  

An AHIMA-certified coder presents training focused on unique ICD-10 clinical documentation needs and hot topics for each medical specialty. The five webinars will follow the same outline and objectives catering to each medical specialty with specific examples.

• Physician Perspective/clinical impact of ICD-10
• Documentation requirements for certain conditions
• Documentation changes and new concepts
• Use of “unspecified” in ICD-10

This webcast features Dr. Maggie Gaglione, a board certified internist and bariatrics specialist, a physician in private practice in Virginia.  Per Dr. Gaglione:

“Comprehensive documentation is key to identifying and assigning the best diagnosis code. By doing our part, and focusing on how we document our patients’ condition we put the foundation in place to drive value based quality and improve the health of populations served.”

You can view this webcast here.

ICD-10 Rural or Urban; It Impacts All Providers (+playlist)

This CMS video discusses the impact of ICD-10 Implementation on all providers.

For physcians and other treating clinicians, one of the most important considerations is documentation.  If you accurately and concisely document a disease, then you have the best chance of you or your coder finding an appropriate ICD-10 (or ICD-9) code.

I hope this video is helpful.

HHS and DOJ Issue Joint Letter on Cloning of Medical Records

On September 24, 2012, Secretary Katherine Sebelius of the Dept. of Health and Human Services, and Eric Holder, Attorney General, of the Department of Justice, issued a joint letter to several health care associations, including the American Hospital Association and Federation of American Hospitals. You can view a copy of the letter on HCC University, on our Tools page.

Although the letter applauds the widespread adoption of EHRs, it notes that there are indications that some providers are using them to clone records and to game the system.  The letter points out that this type of false is not only dangerous to the patient, but also illegal. 

The letter notes that CMS is stepping up its medical record review activities to identify these issues, and that the DOJ, FBI and other law enforcement are monitoring these issues and will take action when warranted.

So--how do CMS, the DOJ and others identify cloned medical records?   Cloned records are often very obvious.  Although they may occur in handwritten records, it is most often found in EMRs with cut and paste and template functionality. 

Although templates are not inherently bad, auto-populating them indiscriminately with information can lead to obviously cloned records. While some things may not change significantly from visit to visit (for example, the bulk of the patient's history may remain the same), a patient's condition is rarely, if ever, static.  A patient's interim history, vital signs, symptoms and treatment are almost never exactly the same. Copying and pasting these components leads to inaccurate medical records.

Another area where cloning becomes obvious is in the assessment.  Often, previously treated or self-limiting diseases remain in the assessment for months or even years.  We've seen charts where a diagnosis of "acute sinusitis" continued on for over a year, with no treatment after the initial date of service where it appeared.

It's important to remember that once one part of the medical record is obviously wrong, and auditor is likely to discount the record in its entirety, since it's impossible to tell what is and isn't accurate.

Clinicians using EMR should use templates wisely, and cut and paste functionality very sparingly.  All information in the chart should accurately reflect the patient's complaints, conditions, and treatments on the current date of service.

California Physician Adoption of EHRs

A recent report by the California HealthCare Foundation, showed that 71% of physicians responding have an EHR in their main practice location.   That's great news, right?  Now for the bad news--only 30% of those physicians can meet 12 Stage 1 Meaningful Use objectives.

The study found that only 37% of the physicians plan to apply for either the Medi-Cal or Medicare incentives.

While the physicians may not meet the requirements (or choose to apply) to receive the $44,000 in incentive money, most physicians are happy with their EHRs --35% of respondents said they were very satisified with their EHR, 38% were somewhat satisfied.  The study found a link between the functionality available in the EHR and physician satisfaction.

The study provides recommendations for outreach to physicians by DHCS to help physicians meet the requirements for the Medi-Cal incentives.

New Specialties Approved for Risk Adjustment

Effective January 2012, the following CMS Physician Specialties are approved for risk adjustment submission:

• 21   Electrophysiology
• 23   Sports Medicine
• C0  Sleep Medicine

CMS has indicated that they will publish a complete specialty listing soon. When the listing is published, we'll post it to the Tools section of HCCUniversity.com

Keeping Up with What's New in Medicare

The Medicare program is massive, and ever changing.  Changes come out several times a year--Part A changes around September, Part B changes in January.  Add that to changes in ICD-9 and CPT, changes in your commercial business--it's all a bit much.

How can you keep up with all these changes? The CMS website is difficult to navigate--and finding things is complicated. 

But, one great place to bookmark and visit frequently is the Medlearn Matters webpage.  This page has educational materials about new Medicare programs and coverage. It's a great way to keep up with what's new in Medicare.  https://www.cms.gov/MLNProducts/

In addition, there's a Medlearns Product Catalog, that allows you to order certain printed matter.  You can view the catalog at https://www.cms.gov/MLNProducts/downloads/MLNCatalog.pdf

You can learn about EHR incentives, the annual wellness exam, and even take online training courses, some of which have CEUs for coders.

Although you won't find everything there--you will find a lot of information about new and changed programs on the Medlearn Home page.

A Very Frequently Asked Question

We frequently are asked about "where CMS says" one thing or another.  First, you have to remember that CMS can't and won't address every possible situation.  By applying common rules and logic, you can usually know what CMS would do in a given situation.  One question we get a lot is:

Our doctors want to know why they can’t just write “250.40 –diabetes with renal manifestations” in the record and code 250.40—and where CMS says they can’t do this.

Our answer to this question is as follows:

CMS doesn’t write the rules for ICD-9 by themselves—and it would be impossible to write a rule for each and every possible situation that can occur.  The Official Coding Guidelines make it clear that a diagnosis must be supported by the medical record, and must affect the care of the patient.

The rules for ICD-9 are written by the four cooperating parties – the American Health Information Management Association, the National Center for Health Statistics, the American Hospital Association, as well as CMS.  All official interpretations not found in the coding guidelines are the responsibility of the American Hospital Association, via Coding Clinic.

A short diagnosis code description (like diabetes with renal manifestations) is just that—a description.  The word “manifestations” is not a diagnosis, it’s a category of conditions, and the physician is required to describe what disease in that category exists.  A physician can no more support an ICD-9 code by writing the description than they can support an E/M code by writing its description. 

Writing “Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family” does not support a 99214, it’s a description of a 99214. Similarly, in order to support a diagnosis, the physician must document what’s wrong with the patient.

So, with diagnosis coding, the physician must document in the medical record what is actually wrong with the patient--not a category of what's wrong with the patient.

Do You Need Free CEUs?

Who doesn't need free CEUs?  Well, there are 12 CEUs available on the CMS website for AAPC members.  You can check them out here at the Medicare Learning Network.

The Medicare Learning Network offers courses on everything from the CMS 1500 form to PQRI and E-Prescribing.

New CMS ICD-10 Implementation Handbooks

CMS has developed  Implementation Handbooks and related templates to help providers and payers in transitioning from ICD-9 to ICD-10.  We'll be posting the handbooks and templates on HCC University, but in the meantime, you can download them from the CMS website at:

ICD-10 Implementation Handbooks

Full Encounter Data Update

The rules for Full Encounter Data are ever evolving.  Today, CMS released the new Encounter Data Quarterly Newsletter.  It seems the rules for Full Encounter Data are ever evolving.  Initially, CMS told Health Plans that they would not be submitting Interim hospital bills.  In this newsletter, CMS has indicated that Interim bills will be submitted. 

In the category of good news, CMS has indicated that if Health Plans don't have the full 9 digit ZIP code, they can use 9999 for the last 4 digits.  Medical groups should submit the correct ZIP code whenever possible, but if it's unavailable, 9999 will pass the CMS edits.

Finally, sometime this month, CMS will release the Encounter Data Companion Guides. 

We'll post the newsletter on HCC University on the Full Encounter Data/ICD-10 page in the next few days.

CMS Full Encounter Updates

CMS is currently holding technical assistance meetings for health plans across the country.  SCAN representatives attended the July session in San Diego the week of July 11.

A lot of issues remain up in the air, but we do know a few things.

• CMS is holding fast on the subject of the 13 month timely filing.  Plans are given an additional month over the 12 month FFS timely filing to account for the submission from provider to plan to CMS.   There is discussion of filing benchmarks and we hope to know more about this after the final session ending the first week of August.
• Plans cannot make material corrections to claims/encounters, this must be done by the provider of service.  For example, diagnosis codes, procedure codes and other fields involved in pricing the claim (e.g., addresses, modifiers) must be corrected by the provider.
• Full 9 digit ZIP codes will be required on claims/encounters.
• CMS has clarified that the only dental claims that will be required are those that are covered by fee-for-service Medicare.  This includes jaw reconstruction after an accident, and examinations (no treatment) prior to kidney transplants and some heart valve implants.  If the services are performed by a hospital based dentist (rare) then the submission must be on the 837 I, and if performed by a dentist in private practice, on the 837P.  No 837D (dental) claims will be accepted by CMS.
• \CMS has no projected date for a draft of the CMS-HCC model with ICD-10 codes.  There was also no update about a move to the new 87 disease CMS-HCC model.

As we learn more from CMS about full encounter data requirements, we'll post it here.

Please let us know if there are any specific issues you'd like to see in this space.  You can leave us a comment, or email us at coding@scanhealthplan.com.

CMS Physician Conference Call for ICD-10 Implementation

Date:  08/03/2011

Time:  1:00 - 3:00 PM  EASTERN TIME

Subject:  ICD-10 Implementation Strategies for Physicians National Provider Call

Target Audience: Medical coders, physician office staff, provider billing staff, health records staff, vendors, educators, system maintainers, laboratories, and all Medicare fee-for-service (FFS) providers

NOTE:  YOU MUST REGISTER IN ADVANCE FOR THIS CALL. SEE BELOW.

The Centers for Medicare & Medicaid Services (CMS) will host a national provider call on "ICD-10 Implementation Strategies for Physicians." Is your office preparing for a smooth transition to ICD-10 on October 1, 2013? CMS subject matter experts will discuss ways that physician offices can prepare for the change to ICD-10 for medical diagnosis and inpatient procedure coding. A question and answer session will follow the presentations.

• The following topics will be discussed:
• ICD-10 requirements and resources overview
• Implementation strategies for physician offices
• Update on coverage conversion activities
• National ICD-10 implementation issues
• Update on bill processing, including claims that span the implementation date
• Update on Home Health Agency Home Health Resource Grouper

How to Register:

  

In order to receive the call-in information, you must register for the call. It is important to note that if you are planning to sit in with a group, only one person needs to register to receive the call-in data. This registration is solely to reserve a phone line, NOT to allow participation.

  

Please note: If you plan to request continuing education credit from your professional organization and if this organization requires proof of registration, you will personally need to register so that you receive a confirmation e-mail.

  

Registration will close at 1:00 p.m. ET on August2, 2011, or when available space has been filled. No exceptions will be made, so please be sure to register prior to this time.

  

To register for the call participants need to go to: http://www.eventsvc.com/palmettogba/080311

Fill in all required data.

Verify that your time zone is displayed correctly in the drop down box.

Click "Register".

You will be taken to the "Thank you for registering" page and will receive a confirmation e-mail shortly thereafter. Note: Please print and save this page, in the event that your server blocks the confirmation e-mails. If you do not receive the confirmation e-mail, please check your spam/junk mail filter as it may have been directed there.

If assistance for hearing impaired services is needed the request must be sent to medicare.ttt@palmettogba.com no later than 3 business days before the event.

On the day of the call, please dial in at least 15 minutes before call start time.

Presentation Materials:

Presentation materials for the August 3 call will be available on http://www.cms.gov/ICD10/Tel10/list.asp#TopOfPage in the "Downloads" section no later than 24 hours before the conference call. Remember to download the presentation materials from the CMS site prior to the teleconference.

  

Continuing Education Credits

 Continuing education credits may be awarded by the American Academy of Professional Coders (AAPC) or the American Health Information Management Association (AHIMA) for participation in CMS National Provider Conference Calls.

  

Continuing Education Information for American Academy of Professional Coders (AAPC)

If you have attended or are planning to attend a CMS National Provider Conference Call, you should be aware that CMS does not provide certificates of attendance for these calls. Instead, the AAPC will accept your e-mailed confirmation and call description as proof of participation. Please retain a copy of your e-mailed confirmation for these calls as the AAPC will request them for any conference call you entered into your CEU Tracker if you are chosen for CEU verification. Members are awarded one (1) CEU per hour of participation.

Continuing Education Information for American Health Information Management Association (AHIMA)

AHIMA credential-holders may claim 1 CEU per 60 minutes of attendance at an educational program. Maintain documentation about the program for verification purposes in the event of an audit. A program does not need to be pre-approved by AHIMA, nor does a CEU certificate need to be provided, in order to claim AHIMA CEU credit. For detailed information about AHIMA's CEU requirements, see the Recertification Guide on AHIMA's web site.

  

Please note: The statements above are standard language provided to CMS by the AAPC and the AHIMA. If you have any questions concerning either statement, please contact the respective organization, not CMS.

New Documents Posted to the HCCUniversity.com

We have posted a number of new documents to the Full Encounter Data/ICD 10 page of HCCUniversity.com.  Scroll down to CMS Encounter Work-Groups and you'll see the documents listed below.

All of the documents are related to the January 2012 implementation of full encounter data, and the CMS workgroups that are ongoing.  Most of the questions are unanswered as of this time, but we hope as new documents become available, CMS will make more decisions.

Capitated and Staff Model Plans Summary Notes

Chart Review Work Group

Encounter Data Newsletter - Quarter 1

Encounter Data Newsletter –Quarter 2

Encounter Data Work Group Summary Notes for Editing and Reporting: Key Findings and Recommendations

Third Party Submitters Work Group

2012 Combined Advance Notice and Call Letter Posted to the CMS Website

The 2012 Advance Notice of Methodological Changes for Calendar Year (CY) 2012 for Medicare Advantage (MA) Capitation Rates, Part C and Part D Payment Policies and 2012 Call Letter has been posted to the CMS website at: 2012 Advance Notice and Call Letter.  


Although we have not had time to analyze the notice in detail, CMS is proposing not to implement the new model that was proposed for Part C for 2012 in order to minimize changes during 2012.

Based on the proposal released on Friday, there will be no changes to the CMS-HCC Model for 2012.  CMS will not implement previously proposed changes (e.g. addition of dementia and morbid obesity) until 2013 at the earliest, unless they change what is in the Advance Notice.  We will know with certainty on April 4, 2011 when the Announcement is published, but at this time, it is extremely unlikely that the model will change in 2012.

We will have more information for you at a later date.