ICD-10: The Good News

JOEL MOORHEAD, M.D., PHD | TRACEY GOSSEL, M.D. tkg-head-shotSolutions_MayJune2014_Moorehead(1)

The arrival of ICD-10 on October 1, 2015, (note the year; the Senate just voted a one-year delay) presents a wealth of opportunities for forward-looking physicians. Reimbursement for physician services is to some degree a zero-sum game. The federal budget allocates a fairly fixed number of dollars to fund healthcare for all of us. Physicians who are prepared for ICD-10 will almost certainly fare better than those who are not. Here’s how to get there.

Tune-up on CPT Coding

Evaluation and Management (E/M) services and physician charges for procedures will continue to be reimbursed under CPT even after October 1, 2015. If you currently have a coder, ask him or her to give you a crash course in the coding of common diagnoses and procedures in your practice. This is an excellent way to assure that you are being reimbursed appropriately for your services, both now and after ICD-10 begins. From a coding standpoint, you may find your documentation significantly improved.

Help Hospitals Help You

In the past, physician compensation has been separate from hospital compensation for an episode of care. Federal and state payers may be poised to change that. CMS Pub 100-18, Transmittal 505 (February 5, 2014) states that physician and facility services can be considered “related.” If an inpatient claim is denied as not medically necessary, all “related” physician claims could be denied at the same time. Also, bundled payments have been proposed, with a single payment for both facility and physician services. The shared interests of hospitals and physicians will depend increasingly upon detailed documentation.

Detailed physician documentation will become even more critical to accurate coding of hospital admissions under ICD-10, which has a greater number of combination codes than ICD-9. These combination codes can include up to five different elements; for example:

  • S52.531xM  Colle’s fracture right radius, open, Type I or II, with non-union
  • K57.21          Diverticulitis of large intestine with perforation and abscess
                            with bleeding
  • K71.51          Toxic liver disease with chronic active hepatitis and ascites

Detailed physician documentation of all elements of a complex combination code permits coders to assign codes with the highest degree of accuracy and specificity.

Codes with greater specificity are generally assigned higher case weights (CWs). A hospital’s base compensation rate depends on its Case Mix Index (CMI), which is the sum of CWs for all admissions divided by the number of admissions.

Accurate and specific physician documentation allows a hospital to demonstrate to the government the relative Severity of Illness (SOI) of its patients.

ICD-10 Helps Physicians Document Quality Care

Severity-of-illness measures are important to physicians as well. High case weights translate to SOI, telling the government how sick your patients actually are. One inpatient quality measure is the relative Length of Stay (LOS), which is the sum of LOSs for patients admitted/the sum of case weights. This is often reported and compared by individual physicians.

ICD-10 also offers a new data element that may be very useful – the concept of underdosing, as when a patient takes less than the prescribed dose of medication. Think of the seizure patient not taking the prescribed dose of anticonvulsants, or the deep vein thrombosis patient who was noncompliant with Coumadin.

Documenting this can help. Take the example of a Congestive Heart Failure (CHF) patient readmitted within a week of discharge. You could run afoul of a “readmission within a week of discharge for the same diagnosis” quality measure.  However, if the patient quit his meds because he didn’t like the frequent voiding, and you document the patient’s underdosing, an adverse quality event is unlikely to be assigned to you or to the hospital.

There also may be longer-term benefits to this documentation. Some future researcher may access the ICD-10 data on under-dosing and find an alarming incidence of CHF admissions with under-dosing codes. Institutions may respond to this finding by developing low-cost measures to monitor patient adherence to Lasix therapy at home, such as purchasing a bathroom scale for CHF patients and asking them to report their weights daily. With data comes knowledge, and that knowledge can strengthen our power to heal.

Tracey Goessel, M.D., is President of FairCode Associates.

Joel Moorhead, M.D., PhD, is Clinical Director of FairCode Associates.


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