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Obamacare and Private Practice Challenges with regards to ICD-10

January 14, 2014

ICD-10_questions_answered-1It’s an unintended but almost perfect storm: The Affordable Health Care Act requires transition to the new ICD-10 by October 1, 2014, even as providers scramble to convert to Electronic Health Records (EHR) by the required 2015 deadline. Problems are already coming to light as private practices try to simultaneously contend with the overlapping complexities of both challenges.

In its second such report in two months, the Office of the Inspector General for the Health and Human Services Department (OIG), warned that the lack of oversight in EHR conversion was leading to inflated costs and overbilling. The federal government’s $22 billion funding to assist hospitals and private practices in converting to digitized records failed to adequately address issues of waste, fraud and abuse.

The OIG report was especially critical of the practice of “cloning,” in which medical billing codes are cut and pasted from one electronic document to another. “Physicians find [cloning] is one of the only ways they can manage the documentation process,” said the American Health Information Management Association’s Michelle Dougherty. The New York Times noted a recent study in which “emergency room physicians in a community hospital spent 43 percent of their time entering data during a 10-hour shift, compared with only 28 percent directly caring for patients.”

Medicare says it is at last providing guidance to medical billing contractors on preventing the entry of erroneous digital data, and is increasing scrutiny of billing practices, with a focus on cloning.

Many of the billing problems that concern the OIG may stem not from abuse, but from busy medical office staff striving to cope with the new, unfamiliar and far more complex ICD-10 codes and the related new Medicare claim form, The CMS 1500 (version 2/12), amid transition to a digital world.

The ICD-10-CM

The International Classification of Diseases, published by the World Health Organization (WHO) is used worldwide for reimbursement systems, tracking statistic on disease and mortality as well as for health care decision support systems. The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) is replacing the ICD-9-CM as the new standard Medical Data Code Sets. It varies from the ICD-9-CM:

  • Addition of ambulatory and managed care encounters
  • An increase in injury codes
  • Ability to create diagnosis/symptom codes reducing the total number of codes needed
  • Code length now has an additional 2 characters for sub classification

This change increases specificity of coding. Though it’s still possible to assign nonspecific codes, practitioners must use the most specific code. The intent is to improve patient care by providing more meaningful and in-depth patient data. With over 68,000 diagnostic codes, the ICD-10 has many five times as many codes as the ICD-9 and twice as many categories. Amid such a big sea change, it’s not surprising that busy medical office staff and physicians will look for shortcuts to cope with a myriad of new codes even as they try to manage the transition from paper to digital records. Then, of course, there’s the revised claim form to be mastered:

The CMS 1500 (version 2/12)

The new Form CMS 1500 (version 2/12) authorized by the NUCC has been restructured to include both ICD-9 and ICD-10 codes.

As of April 1st, Medicare will only process claims submitted on the revised CMS-1500The NUUC states: “The end product is one standard data set, with complete and unambiguous data definitions, for use in the electronic environment, but applicable to and consistent with evolving paper claim form standards.” During a transition period from January 6 – March 31, 2014, Medicare will process both the old and new CMS forms (versions 08/05 and 02/12, respectively).

The new CMS form supports the updated medical billing data requirements, with space for up to 12 diagnosis codes, a field for indicators differentiating ICD-9 from ICD-10 codes, and an area for provider role qualifiers.

With the best intent if not the best planning, the Affordable Care Act has laid multiple challenges on private practitioners that must be mastered within a short span of time. Some confusion and unintentional error is inevitable. But the end result will be improved specificity of diagnosis and more accurate billing, with a legacy of refined data to help drive patient care.


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