Because the Centers for Medicare and Medicaid Services (CMS) has yet to issue the so-called “modification rule” for the electronic health record (EHR) Meaningful Use program for 2015, the AMA is calling on the agency to create an automatic hardship exemption for physicians who did not have the opportunity to report successfully this year.
In April, CMS proposed modifications to stages 1 & 2 of the program that reduced the reporting period from a full calendar year to 90 days. Stakeholders believed this was necessary since many physicians could not update systems, change products, or accommodate Internet outages or other disruptions under a 365-day reporting program.
“The AMA welcomed and supported the proposed changes, but it’s now Oct. 1 and CMS has left physicians without any guidance or assurances that they will be capable of meeting program requirements before the end of the year,” said AMA President Steven J. Stack, M.D. “The AMA has regularly stressed that CMS must finalize Meaningful Use modifications well ahead of Oct. 1 to provide the time that physicians need to plan for and accommodate these changes, yet CMS has continued to delay finalizing this rule. As a result, many physicians who were counting on this flexibility will be subject to financial penalties under the rules currently in place. The AMA is asking CMS to create an automatic hardship exemption as soon as possible so that physicians are not penalized for regulatory delays that are outside their control.”
Previous AMA efforts to shape the Meaningful Use program can be found at AMA Wire. For additional information visit BreaktheRedTape.org, or join the discussion on Twitter using #FixEHR.
Doctors, hospitals and insurers are bracing for possible disruptions on Oct. 1 when the U.S. health-care system switches to a massive new set of codes for describing illnesses and injuries.
Under the new system, cardiologists will have not one but 845 codes for angioplasty. Dermatologists will need to specify which of eight kinds of acne a patient has. Gastroenterologists who don’t know what’s causing a patient’s stomachache will be asked to specify where the pain is and what other symptoms are present—gas? eructation (belching)?—since there is a separate code for each.
In all, the number of diagnostic codes doctors must use to get paid is expanding from 14,000 to 70,000 in the latest version of the International Classification of Diseases, or ICD-10. A separate set of ICD-10 procedure codes for hospitals is also expanding, from 4,000 to 72,000.
Hospitals and physician practices have spent billions of dollars on training programs, boot camps, apps, flashcards and practice drills to prepare for the conversion, which has been postponed three times since the original date in 2011.
Some coding experts warn that claims denials could double as providers and payers get used to the new, more specific codes.
Others are more sanguine. “We’re hoping it will be like Y2K,” when the switch to 2000 dates was expected to crash computers world-wide, says Robert Wergin, president of the American Academy of Family Physicians. “Everybody will worry, and the claims will go through fine.”
The real upshot won’t be apparent immediately. “Any problems that crop up will be far more evident on Oct. 15 than Oct. 1, because it takes that long to process claims,” says William Rogers, an emergency physician who is the Center for Medicare and Medicaid Service’s ombudsman for ICD-10 conversion.
ICD codes are an international system for recording diseases, injuries and other conditions set by the World Health Organization; federal agencies developed the far more elaborate version for the U.S. To get paid, doctors submit such diagnosis codes along with separate procedure codes that describe the service performed. Private and government insurers scrutinize the ICD codes to judge whether the service was medically necessary.
The new coding system is needed, many health-care experts say, because modern medicine has outgrown the old one, adopted in the U.S. in 1979. The ICD-9 doesn’t differentiate between Type 1 and Type 2 diabetes, for example, or distinguish Ebola from “other diseases spread by viruses.”
ICD-10 will help researchers better identify public-health problems, manage diseases and evaluate outcomes, proponents say. Over time, it will create a much more detailed body of data about patients’ health—conveying a wealth of information in a single seven-digit code—and pave the way for changes in reimbursement as the nation moves toward value-based payment plans.
“A clinician whose practice is filled with diabetic patients with multiple complications ought to get paid more for keeping them healthy than a clinician treating mostly cheerleaders,” says Dr. Rogers. “ICD-10 will give us the precision to do that.”
The multitude of codes for external causes of injuries have gotten most of the attention to date. Hurt in a prison swimming pool? That’s Y92.146. Crushed by a human stampede while resting or sleeping? That’s W52.04. But insurers and Medicare officials say that, in most cases, they won’t require doctors to include such external-cause information for billing, although it is useful for research purposes.
Clinicians will need to document enough detail about patients’ conditions to support the new codes, including what side of the body is affected, how severe the problem is and whether it has occurred before.
ICD-10 also offers different codes for ailments depending on myriad circumstances, such as whether respiratory diseases are due to tobacco use and whether obesity is due to consuming excess calories or some other reason. In many cases, doctors readily know such information; in other cases, it could require more discussion and longer visits.
Medicare officials say they won’t deny claims solely for lack of specificity for the first 12 months, as long as providers supply the correct general category of illness. But that doesn’t apply to hospital procedure codes, and most commercial insurers aren’t offering such a grace period.
To what extent insurers will require doctors to use the most specific codes, or use them to adjust reimbursement rates, isn’t clear. “In the first few months, the goal is simply to get the ICD-10 codes into the system and make sure providers are using them,” says Clare Krusing, a spokeswoman for the America’s Health Insurance Plans.
Cost estimates for the ICD-conversion vary widely. Dueling studies have estimated the cost from less than $10,000 to more than $225,000 for small practices. Some large hospitals systems say they have spent millions on training and other preparations.
“This affects literally every single system in a hospital, except maybe the cafeteria,” says Ed Hock, managing director of revenue cycle solutions for the Advisory Board Co., a consulting firm that has warned its hospital clients to expect their accounts-receivable days to increase by three to five, on average. “That can mean millions of dollars in cash flow.”
ICD-10 codes will affect Medicare payments for some conditions because the added specificity moves them to a different severity tier, which changes how they are reimbursed. For example, in ICD-9, there is only one code for hepatic encephalopathy, a severe brain disorder that can occur with liver failure, which is considered a major complication. ICD-10 asks whether the patient is in a coma and if not, the condition is downgraded to a regular complication and the hospital is paid, on average, $2,800 less, according to an analysis by the Advisory Board.
But ICD-10 does give providers and health plans a chance to increase payments by recording patients’ conditions in more detail. In Medicare Advantage and other plans that receive per-member, per-month fees to provide care, payments are adjusted to reflect the severity of patient illnesses, so the more secondary diagnoses providers record, the more they may be paid.
“Hospitals leave millions of dollars on the table today through incomplete documentation or coding errors,” says Mr. Hock. “There’s a revenue opportunity in doing this right.”
Some patients will be affected, too. Those getting regular tests or infusions at outpatient centers will need to bring new orders bearing ICD-10 codes starting Oct. 1, says Kevin Lenahan, chief financial officer at Atlantic Health Systems, which owns five hospitals in New Jersey.
Atlantic plans to have personnel armed with ICD-10 code books stationed at every registration desk that day. “We won’t turn patients away. We’ll either call their doctor, covert the code for them or, in the worst case, we’ll put the bills on hold until we get the right information,” says Mr. Lenahan.
Insurers will have to work with both ICD-9 and ICD-10 codes for months or years until all the claims for tests, treatments and doctor visits before Oct. 1 are cleared. “If someone had a service in August that doesn’t get billed until December, that will still have an ICD-9 code,” says Debra Cotter, director of ICD-10 implementation for Pittsburgh-based Highmark Inc. Insurers generally give patients two years to submit out-of-network claims. “If someone has stashed a bill in a shoebox, it might be a year or more before they realize they’re owed some money,” Ms. Cotter says.
Even the threat of a government shutdown will not stop the Oct. 1 switch to ICD-10, the Centers for Medicare & Medicaid Services says.
“In the event of a shutdown we will continue – and I want to be clear on this — to pay claims,” CMS Principal Deputy Administrator Patrick H. Conway, MD, told media during a telephone conference call on Thursday.
“We will continue to implement the ICD-10 transition. We do planning at any time when there’s the potential of a government shutdown [and] we will continue to pay claims. We will continue to be operational and we will make the transition to ICD-10.”
William Rogers, MD, CMS’s ICD-10 ombudsman, added that “the MACs will still be operating. They’ll still be accepting claims and claims will still be paid, and we are sure of that.”
If government is kept operational by a continuing resolution, Conway says nothing would change.
“We would continue to process claims, the MACs would continue to pay claims and we would execute the ICD-10 transition,” he says. “In terms of staffing we have the flexibility to ensure that core operations are operational and in effect and we say our payment systems are a core piece of the Medicare system that will continue to be fully operational.”
This is not CMS’s first experience with a government shutdown, so Rogers says they aren’t starting from scratch.
“We do think service around core customer service and provider service functions are critical, so we would prioritize those, whether it be ICD-10 or other areas,” he says. “Our goal is to have a smooth transition to ICD-10 both from a payment perspective and from the service around that payment.”
Rogers says it’s not clear if his office of the ombudsman would be considered a vital service during a government shutdown.
“We just don’t know,” he says. “It really is the different legal issues that have to be considered about what emergency operations and what aren’t. So, honestly we don’t know at this point. People who aren’t in this room are deciding what we can do and can’t do in case of a shutdown in terms of staffing here at CMS.”
On other issues related to ICD-10, Conway says it will take “a couple weeks before we have a full picture” of the transition.
“First off, very few providers file a claim on the day of the office visit, lab, or surgery. Most provider batch their claims and submit them every few days,” he says. “Generally speaking Medicare claims take a couple of days to process and can take approximately two weeks. The Medicaid claims can take up to 30 days to be submitted and processed. For this reason we expect to have more detailed information after a full billing cycle is complete.”
“We recognize that this is a significant transition and we have set up processes and operations to monitor the transition in real time assess our systems and investigate and address issues as they come in through the ICD-10 coordination centers.”
Conway says that providers having problems with claims submissions should first contact their billing vendor or clearinghouse. If problems persist, they can contact their Medicare administrative contractor, or the ICD-10 ombudsman at CMS.
Although physicians’ associations have expressed dread at the looming transition, Rogers says he believes the switch to ICD-10 will be relatively smooth.
“Most smaller practices just use a Superbill,” he says. “It requires an expansion of the number of diagnoses on the Superbill but they can easily crosswalk their ICD-9-based Superbill to an ICD-10 Superbill. Once they’ve done that it’s business as usual in the office. I expect that small practices should have little or no expense involved.”
Here’s a bit of good news for Medicare, the popular government program that’s turning 50 this week. Older Americans on Medicare are spending less time in the hospital; they’re living longer; and the cost of a typical hospital stay has actually come down over the past 15 years, according to a study in the Journal of the American Medical Association.
Doctors, hospitals and government administrators have put a lot of effort into making Medicare more efficient in the past 15 years. Dr. Harlan Krumholz and colleagues at Yale University took on a study to see whether that effort has paid off.
“The results were rather remarkable,” says Krumholz, a cardiologist and leading health care researcher. “We found jaw-dropping improvements in almost every area that we looked at.”
The researchers looked at the experience of 60 million older Americans covered by traditional Medicare between 1999 and 2013. They found that mortality rates dropped steadily during that time, and people were much less likely to end up in the hospital.
“If the rates had stayed the same in 2013 as they had been in 1999, we would have seen almost 3.5 million more hospitalizations in 2013,” Krumholz says.
“People who were being hospitalized were having much better outcomes after the hospitalization,” he says. “They had a much better chance of survival.”
And the average cost of a hospital stay dropped too, he says, from $3,290 to $2,801 in inflation-adjusted dollars over the 15-year period for patients in the traditional Medicare program. (Researchers couldn’t quantify the experience in Medicare Advantage, the managed-care alternative to Medicare).
Krumholz attributes the improvement to a wide variety of measures designed to boost patients’ health, from prevention programs to advances in medical care. He says some of the savings also came about because medical care shifted from hospitals to less expensive outpatient clinics.
“They’re pointing out a very good thing in the medical system,” says economist Craig Garthwaite at the Kellogg School of Management at Northwestern University. He says the recession, which helped slow rising health care costs overall, apparently played a minor role in this story of Medicare.
Costs really are being contained, Garthwaite says. One other reason that’s happening is that the federal government is reimbursing hospitals and doctors less for treating Medicare patients.
“That’s an easy way to get control of medical spending in Medicare,” Garthwaite says, but “it’s just not something we can do in the private market, and we have to worry about how sustainable it is for the Medicare program overall.”
With the post-World War II baby boom now reaching retirement age, more and more people are turning 65 and becoming eligible for Medicare. That growth continues to drive up the overall cost of the program, even as that average cost per illness or hospitalization comes down. And as older Americans live longer lives, they use Medicare for more years than previous generations did.
Medicare is still running a bit of a deficit, but the situation is improving. The program’s trustees say its trust fund will be solvent through 2030. Some adjustments would be needed to keep the program in good financial health beyond that date.
Garthwaite says other recent trends could make matters worse, with one especially worrisome example being sharply rising drug prices.
“Some of these [new cancer] products are providing only a few months of life for several hundred thousand dollars,” he says. And the system doesn’t do a good job of making difficult judgments in situations like that.
Joseph Antos, an economist in health policy at the American Enterprise Institute, agrees that the good news from the Yale study doesn’t assure a rosy future. He’s concerned about the financial health of Medicare if, for example, an effective drug for Alzheimer’s disease is developed.
“I would argue that if anybody came up with an effective treatment for Alzheimer’s today, that treatment would be hailed as a major breakthrough and we wouldn’t be looking at the cost,” Antos says.
And that would almost certainly break the pattern that’s been documented over the past 15 years, where improving health has actually helped drive down the cost of medical care.
Medicare reimbursement information systems recently began comparing two distinct codes on home health agency claims before the claims are paid.
The rule change comes after an extended period of upgrading information systems and testing with the industry. The IT systems are comparing the Health Insurance Prospective Payment System code (HIPPS) on a claim to the HIPPS coded generated by a corresponding Outcomes and Assessment Information Set, known as OASIS.
According to the Centers for Medicare and Medicaid Services, “OASIS is a group of data elements that represent core terms of a comprehensive assessment for an adult home care patient and form the basis for measuring patient outcomes for purposes of outcome-based quality improvement.” The goal of developing OASIS was to measure patient outcomes and support outcome monitoring, clinical assessment, care planning and internal agency activities.
“If the HIPPS code from the OASIS assessment differs, Medicare will use the OASIS-calculated code for payment,” according to available guidance. “At this time, if no corresponding OASIS assessment is found, the claim will process normally.”
Many home health agencies create software to integrate necessary data entry and grouping functions in their information systems to support the new policy. Agencies without such software or unhappy with a current product can get free grouping software from Medicare.
Kidney-care providers could see their Medicare payments reduced by up to 2% in the next few years if they do not score high enough on quality measures.
The CMS on Friday proposed updates to policies and payments for end-stage renal disease, which would affect payments to more than 6,000 U.S. kidney dialysis facilities.
In recent years, the agency has focused on efforts to drive high-quality care, such as disease prevention, chronic disease management, improving outcomes and promoting efficiency.
The ESRD proposal released last week is part of that broader push. It would change how dialysis facilities are reimbursed by linking a portion of their payments directly to quality scores. It would also eventually add new metrics to the ESRD Quality Improvement Program.
There are currently 11 measures to evaluate end-stage renal disease care through the quality program. They include eight clinical measures, such as: how many patients receive the best vein access method (arteriovenous fistula) versus the least recommended (catheter), how well toxins are being filtered from the blood during dialysis; infection rates; and how well hypercalcemia is controlled. They also include three reporting measures, including patient experience, anemia and bone mineral metabolism management.
The CMS assigns a score for each measure, and those scores are later combined to create a “total performance score”—which ranges from zero to 10- for each facility. Centers that do not meet the minimum score established by a benchmark determination would be financially penalized up to 2% of its Medicare reimbursement.
It is estimated that the treatment of end-stage renal disease costs Medicare $34 billion in 2011, about 6% of all Medicare spending. Hemodialysis for end-stage renal disease costs the program about $88,000 annually per patient.
The CMS plans to add quality-of-life measures, such as pain and depression management and readmission rates in 2018. By 2019, two new measures will be adopted: one looking at seasonal flu vaccination, and ultrafiltration rates, a process for removing excess water and sodium from the body of kidney-failure patients.
Although studies have suggested that higher ultrafiltration rates in hemodialysis patients are associated with a greater risk of all-cause and cardiovascular deaths, nephrologist Dr. Alan Kliger, chief quality officer for Yale New Haven Health System, cautions against the premature use of the ultrafiltration metric.
Higher amounts of life-threatening fluids accumulate between treatments for patients who eat or drink more than recommended, and they would need ultrafiltration. “That doesn’t necessarily mean that higher filtration causes more deaths,” Kliger said. “They may be dying not because we are ultrafiltering them more but because they have physiologies that make them more dangerous patients.”
That particular measure has not been endorsed by the National Quality Forum, a nonprofit that reviews and endorses quality improvement metrics. In a draft report issued in June, the NQF’s Renal Standing Committee declined to recommend the metric the CMS plans to adopt and instead recommended a different one for ultrafiltration.
Dr. Frank Maddux, chief medical officer of Fresenius Medical Care, one of the two largest U.S. dialysis providers, expressed similar concerns about CMS’ use of measures that are either not endorsed or are being considered for removal by NQF.
He also raised questions about measures for standardized transfusion and hospitalizations, which he said appear to rely on baseline performance data submitted in 2013 for the 2018 payment year.
“It strikes me that those measures are not very mature,” he said. That’s a major concern since a 2% reduction is a “substantial issue all providers take seriously.”
However, even imperfect measures can work if they are valid, reliable and feasible in the evolution of the systems to capture data, Maddux said. “They become points of concentration for the organizations that are providing care.”
But, he added, “If that concentration is not aligned with the state of the science, then we aren’t spending our time on those things that are most important.”
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