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The calendar may say the ICD-10 transition is long gone, but practices still will likely feel its repercussions in 2017 in terms of payer requests, denials and the new code set’s influence on value-based care. Looking to next year, practices should start being proactive with these coding opportunities now to consider how the following five factors will impact documenting, coding and billing for care
The calendar may say the ICD-10 transition is long gone, but practices still will likely feel its repercussions in 2017 in terms of payer requests, denials and the new code set’s influence on value-based care. Looking to next year, practices should start being proactive with these coding opportunities now to consider how the following five factors will impact documenting, coding and billing for care...
While accuracy has always been essential, its importance is unparalleled now due to two dynamics: the increased specificity of ICD-10, and the quality improvement requirements of value-based care models. Both of these things are compelling providers to document more detailed information, which certainly adds to already significant workloads and that have been estimated to add 1 to 2 hours per work day.
Rather than trying to save time (and creating a billing compliance risk) by using a cut-and-paste documentation approach, a better strategy is to enable physicians to quickly capture discrete data in the electronic health record using the software’s advanced documentation functionality while offering the flexibility to add unstructured notes when necessary.
Perhaps the best indicator that a practice is documenting, coding and billing accurately is its claim denial rate. If physicians are seeing denial rates grow from their pre-ICD-10 baselines they should conduct a careful assessment of how their care teams are capturing data and how coders and billers are accessing that data and billing for services.
Although denial rates may have stabilized since the ICD-10 transition, do not be surprised if they escalate again as payers now have close to a year of ICD-10 data and begin to develop more aggressive medical necessity models. The Centers for Medicare and Medicaid Services (CMS), for example, has dropped its earlier grace period on unspecified ICD-10 codes.
It’s critical that practices understand the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)-and more specifically, the Merit-Based Incentive Payment System (MIPS). According to the Deloitte Center for Health Solutions 2016 Survey of US Physicians, 50% of physicians say they have never heard of MACRA. This makes it vital for all practices, even those with few Medicare patients, to pay attention to the impact this bellwether legislation has on documentation, coding and reimbursement.
In effect, MACRA/MIPS is CMS’ consolidation of the Physician Quality Reporting System, Meaningful Use and the Value-Based Modifier programs. Quality measures comprise about half of a physician’s MIPS point score, which makes it imperative for practices to accurately capture and code information related to quality-of-care indicators. Practices should task their revenue cycle staff with understanding MACRA/MIPS and setting practice policy. The MACRA/MIPS leader can gather instructional information about the program from physician-specialty trade organizations to educate the practice and implement processes to help fulfill its requirements.
ICD-10, MACRA/MIPS and value-based care models in general require practices to take a more sophisticated approach to revenue cycle management than ever before. Elevating staff expertise to a higher level of coding and billing knowledge is necessary, but doesn’t need to be tackled alone. Practices that outsource their coding and billing can develop strong partnerships with their vendors. Those with internal coding and billing functions can turn to specialty societies for training.
Engaging an experienced and knowledgeable partner to assess documentation and coding practices can also help optimize revenue cycle processes. So many changes are occurring rapidly today that little seems to get easier for providers actually trying to care for patients. By engaging everyone and working together as a team, practices can drive improvements in coding, the revenue cycle and patient care.
In everything from data capture to patient care, all responsibilities can no longer fall solely on physicians’ shoulders. Implementing workflows that allow clinical support staff to understand and share documentation duties, for example, can alleviate some of the burden from physicians. (For example, perhaps nursing staff members can document the mammograms or HbA1c tests needed for value-based payment programs.)
By proactively preparing for these coding enhancement opportunities, physicians and other members of the care team will have an easy transition come 2017. On top of this, practices as a whole will see an improvement in not just patient care, but in the fiscal health of their practice.
About the authors:
Nancy Gagliano, MD, is chief medical officer and Randy Jones, DHA, is senior vice president for management consulting services for Culbert Healthcare Solutions