In less than a week from this posting, on October 1, 2015, ICD-10 diagnosis codes will debut. OrthoBuzz already reported on the 12-month leniency policy announced by the Centers for Medicare and Medicaid Services (CMS). In addition, during the home-stretch to the ICD-10 launch, CMS has published an online series of “cheat sheets” to help providers select at least the first few correct digits for the new codes. The guidance is primarily for family practitioners, but there are sections for back and neck pain and joint and limb pain that orthopaedists might find useful.
Keep in mind that private insurers are not obliged to follow CMS’s leniency lead in this area, although according to a Medscape.com article, Aetna, Humana, and Anthem have announced that they will. UnitedHealthcare is reportedly still mulling the issue, and Medicaid policies regarding how precise ICD-10 codes need to be will vary from state to state.
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The Centers for Medicare and Medicaid Services (CMS) announced this week that it will not deny claims from providers during the first 12 months of ICD-10 implementation based on a lack of code specificity, “as long as the physician/practitioner use[s] a valid code from the right family.” Similarly, CMS will not penalize physicians whose coding lacks ICD-10 specificity when reporting to the Physician Quality Reporting System, Meaningful Use, or Value Based Modifier programs, as long as the submitted code comes from the “correct family.”
In making this joint announcement with the AMA, CMS also said it will establish a “communication and collaboration center,” which will house an ombudsman “to help receive and triage physician and provider issues.” As “ICD-Day” (October 1, 2015) looms, CMS is encouraging small-practice providers to avail themselves of the readiness tools at the “Road to 10” website, which includes a separate section for orthopaedists.
With the clock ticking toward an October 1, 2015 compliance deadline for ICD-10, Tennessee Rep. Diane Black recently introduced a bill, HR 2247, that would require a transition period for the changeover from ICD-9 codes. Rep. Black’s bill would not stall the October 1 compliance date, but it would require the U.S. Department of Health and Human Services (HHS) to provide transparent end-to-end testing of the new system to certify that it’s fully functional. According to the legislation, during the testing period and for 18 months following HHS certification, the Centers for Medicare and Medicaid Services (CMS) would be prohibited from denying claims “due solely to the use of an unspecified or inaccurate code.” Essentially, that means CMS would have to accept, process, and pay claims that are submitted with either ICD-9 or ICD-10 codes.
Two weeks prior to the filing of Rep. Black’s legislation, Texas Rep. Ted Poe introduced HR 2126, which would simply prohibit HHS from replacing ICD-9 until the Comptroller General completes a study “to identify steps that can be taken to mitigate the disruption on health care providers resulting from a replacement of ICD-9.” Both pieces of legislation have been referred to the House Committee on Energy and Commerce and the House Committee on Ways and Means.
In a recent survey by MedData Group, 65% of 254 physicians spanning all subspecialties and practice sizes said they expect electronic health records (EHRs) to have the greatest practice impact among all medical technologies in 2015. Among orthopaedists, 78% ranked EHRs as being the most influential practice technology. Diagnostic technologies ranked a distant second among physicians, but twice as many as last year considered this area of technology to be significant. The survey found that overall practice-management priorities in 2015 will focus on two areas: successful implementation of ICD-10 and better quality care for patients.
According to Medscape (login required), a dozen changes coming in 2015 could affect physician income and practice workflows. Here’s the list:
- Rise of High-Deductible Health Plans – According to the Kaiser Family Foundation, 18% of insured patients have at least a $2,000 deductible. Higher deductibles often mean more paperwork for practices, the need to provide cost estimates in advance, and increasing involvement with collection agencies.
- Declining Malpractice Premiums– For three benchmark specialties, ob/gyns, internists, and general surgeons, malpractice insurance premiums decreased by 13% since 2008. Some experts attribute the declines to tort reforms that were enacted many years ago, but most expect that premiums, which have proven to be cyclical, will start rising again.
- ICD-10 Really Coming– Many experts are saying the Oct. 1, 2015 deadline for the new ICD-10 coding system is for real this time, after repeated implementation delays. Although ICD-10 is supposed to cut down on errors and speed reimbursement, many physicians are skeptical that the technology will work.
- ACOs Enter a Crucial Year – 2015 marks the end of the 3- year shared-savings Medicare ACO contract, which shielded ACOs from losing money. Those that stay in the program will face financial penalties if they don’t hit certain targets. The Centers for Medicare & Medicaid Services (CMS) said that only one quarter existing Medicare ACOs received a shared-savings bonus.
- Concerns about Telemedicine– More patients may start using web- and phone-based physician services in 2015. The three largest telemedicine companies more than doubled their volume from 2011 to 2013 and continue to grow. Telemedicine does seem to be siphoning some patients from traditional practices, but the main concern is the quality of telemedicine-based diagnoses and treatments.
- Competition from Retail Clinics– Visits to walk-in, retail clinics skyrocketed by 400% from 2007 to 2009. Consultant Thomas Charland advises doctors to forge reciprocal referral relationships with retail clinics, rather than fighting them.
- PCPs to Lose Enhanced Medicaid Payments – At the beginning of 2015, Medicaid reimbursements for PCPs will fall back to their pre-“enhanced” levels, which average 40% below Medicare. Unless Congress extends the funding, some PCPs may be forced to reconsider how many Medicaid patients their practices can afford to take.
- Meaningful Use: Carrot Becomes Stick – In 2015, penalties for not entering the Medicare Meaningful Use program begin, starting at 1% of Medicare payments and moving to 3% in 2017. A survey by Medscape shows that 3 out of 4 doctors who have an EHR are attesting to Meaningful Use.
- Penalties Start under PQRS– In 2015. The Physician Quality Reporting System turns from voluntary to penalty-eligible. The penalty for not reporting quality data is 1.5% in 2015 and rises to 2% in 2016.
- New Physician-Payment Websites– Open Payment and Medicare payment websites report payments made to doctors either from Medicare or from drug and device manufacturers. Both websites have had technical glitches and have posted inaccurate information.
- Medicare Will Pay for Chronic Care Outreach –Medicare will pay physicians in 2015 for managing patients with two or more chronic conditions by phone or email. Doctors will receive $40.39 per patient per month for providing a minimum of 20 minutes of care. To qualify, doctors need to have an EHR system and be able to exchange patient information with other caregivers.
- New CPT Modifiers for Greater Specificity – Starting in January, instead of the catch-all, amorphous modifier 59, CMS will implement four new subset modifiers – XE, XS, XP and XU. The intention is to increase efficiency of payments to doctors.
By a vote of 64 to 35, the US Senate approved a one-year “patch” of the current SGR-based Medicare payment formula, rather than entirely replacing the flawed system. President Obama signed the bill, which provides a 0.5% increase in physician Medicare reimbursements for the rest of 2014.
It’s the 17th such temporary stopgap Congress has passed over the last 11 years, and it came despite staunch opposition to another short-term “doc fix” by many physician groups, including the AMA and the AAOS. When the House passed the same measure a week earlier, AAOS president Frederick Azar, MD, said he was “profoundly disappointed.”
There was a last-ditch but unsuccessful effort by Senate Finance Committee chairman Ron Wyden (D-Oregon) to get his colleagues to vote on a permanent repeal of the SGR formula. Had Congress not acted at all, a 24% cut in Medicare reimbursements would have taken effect April 1, 2014. Previous patch votes have been accompanied by congressional promises to use the reprieve to hammer out a bipartisan deal to pay for a permanent SGR repeal. That has never happened, and few are optimistic that it will happen this year.
As physicians are swallowing the bitter pill of another SGR patch, some are relieved with another stipulation in the bill: a one-year delay in the implementation of the ICD-10 code set until at least Oct. 1, 2015. The AMA recently estimated that implementing the new, more complex code set could cost small practices up to $225,000, and last July the AAOS supported a bill to stop the transition to ICD-10 so physicians could develop an appropriate alternative. Another provision in the new bill gives the secretary of Health and Human Services permission to address “misvalued codes” used in the Medicare physician fee schedule.
According to Thomas Barber, MD, chair of the AAOS Council on Advocacy, “The delay in ICD-10 implementation may provide temporary relief for some, but the importance of a permanent SGR policy together with the harmful misvalued codes provision in this patch greatly outweigh any benefits.”
Read a summary of the bill’s provisions here: http://www.massmed.org/Advocacy/Key-Issues/Medicare/Summary–Protecting-Medicare-Access-Act-of-2014/#.UzrNkqJ0lyI
The medical landscape is always changing. With the Affordable Care Act, implementation of ICD-10, and penalties for not participating in the Physician Quality Reporting System (PQRS), practices have a lot of challenges ahead.
To help meet those challenges, orthopaedic surgeon Thomas C. Barber, chair of the AAOS Council on Advocacy, recommends that practices consider expanding ancillary services such as MRI or physical therapy. He also advises that practices should bill for all services rendered and use marketing and enhanced relationships with referring physicians to solidify their business. Finally, astutely observe the trends in your local health care community, such as ACO formation and changes in surgeon/hospital relationships. Barber says that understanding your practice’s economics and local environment will help you see opportunities for merging or collaborating with other practices.
Oct. 1, 2014 is the deadline for ICD-10 conversion. However, according to a survey from the Workgroup for electronic data interchange, 8 out of 10 practices have not begun testing and only half have begun the initial steps of impact assessment. Some attribute these delays to their IT vendors not being ready; 40% of vendors said their products won’t be ready before 2014. There has been discussion about The Centers for Medicare and Medicaid Services (CMS) possibly delaying the deadline again or an “enforcement-free” period of 6 months, but CMS has resisted that idea.
On a more positive ICD-10 note, Sutter Health of California is planning on going live this May, a result of its 3-year planning efforts. The May launch will give Sutter doctors a five-month test period before the deadline. Danielle Reno, Sutter’s ICD-10 program director said, “We won’t be submitting claims to payers in ICD-10, but we will turn it on, and physicians will be able to use it.” Another company testing its ICD-10 plans is North Carolina Healthcare Information & Communications Alliance (NCHICA). Holt Anderson, executive director at NCHICA, ran a test pilot with some of the best coders, and there were still significant concerns about accuracy. Using “dual coders” who coded in both ICD-9 and ICD-10, only 55% of the transition scenarios were accurate in the first wave of testing.