Upgrading to Version 5010 involves significant planning and preparation. The Version 5010/4010A electronic standards upgrade deadline was January 1, 2012. However, CMS enacted an enforcement discretion period through June 30, 2012 for all HIPAA-covered entities. It you haven’t upgraded to Version 5010, it is important to begin testing now.

Denise Buenning, MsM, Acting Deputy Director, Office of E-health Standards & Services (OESS) recently took time to answer some of the industry’s top questions on the Version 5010 upgrade.

1. Is the industry up to date with the Version 5010      upgrade and taking steps to prepare for the ICD-10 transition?

Yes, we are hearing that the industry is progressing with Version 5010 implementation. We also continue to see from the Medicare Fee-For-service (FFS) group consistent increases across the board for 5010 transaction volumes and number of 5010 submitters.

We are also hearing that the industry is continuing to take steps to prepare for ICD-10. ICD-10 is a major undertaking for providers, payers, and vendors. It will drive business and systems changes throughout the health care industry, from large national health plans to smaller provider offices, laboratories, hospitals, and more. The updates will go much more smoothly for organizations that plan ahead and prepare now. A successful upgrade to Version 5010 now and transition to ICD-10 later will be vital to transforming our nation’s health care system.

2. What steps should I take if I am behind in the upgrade      to Version 5010?

There are a number of things that HIPAA-covered entities should do now. Communication among plans, providers, clearinghouses, and vendors, as well as other trading partners, is critical. Below outlines three steps providers can take now:

• Reach out to clearinghouses for assistance and/or take       advantage of any free or low cost software that may be available from       payers.
• Check with payers now to see what plans they will have       in place to handle incoming claims, and what interim alternatives are       available.
• Consider contacting financial institutions to       establish lines of credit to get through any possible temporary       interruptions in claims reimbursement as a result of not being Version       5010 compliant.

CMS has developed a fact sheet for health care providers, which discusses the risk mitigation steps in more detail.

3. How is CMS helping the industry prepare?

The Workgroup for Electronic Data Interchange (WEDI) and CMS are holding a webinar on ASCX12 5010 implementation and problem solving on May 23, 2012 from 1:00-2:30 pm ET. Registration is free. These online presentations are designed to gather feedback, track challenges and provide guidance to correcting ASC X12 5010 implementation-related issues.

WEDI and CMS previously held a webinar on ASCX12 5010 implementation, and  a replay of the webinar with the slides presented is located online.
Additionally, the CMS website has official resources to help the industry prepare for Version 5010 and ICD-10. CMS will continue to add new tools and information to the site throughout the course of the transition.

I just returned from an interesting Computer-Assisted Coding (CAC) Summit, with about 265 attendees.  ICD-10 , not surprisingly, seems to be the impetus to look very hard at CAC as many expect to experience a productivity decrease.

I see many benefits to CAC, especially when it can be used concurrently in the inpatient setting – although many are not using it this way, as of now.    However, when it is used concurrently with clinical documentation, it can be of immense help when a clinical documentation specialist and coder, for example, come up with different codes, pointing out the detail in the record that supports the coding.  This can save time and money for all involved.

My only concern is that some may put the cart before the horse – move too quickly to CAC without making sure clinical documentation processes are in place and functioning well.

Without a strong clinical documentation program, the inpatient side won’t benefit from CAC and the data won’t be any better.

My suggestion:  Make sure your clinical documentation improvement is on track and in order.  Then, phase in CAC for outpatient first, then do retrospective inpatient and then move to  full concurrent inpatient.  This makes sure the investment is solid and your automated coding is referencing correct and accurate data.

CMS has addressed – and, seemingly, dismissed – many concerns regarding delayed implementation. For example, those individuals currently in training as ICD-10 coders now will need additional training, at an estimated additional cost of $6,000 per person. More broadly, this is tied to an accepted truism that “if you don’t use it, you lose it.” Consider the education that hospitals and other entities already have provided to their physicians, coders and other staff. Hospital contracts with ICD-10 vendors also will need to be extended, contributing to the 30 percent cost hike.

The proposal to delay ICD-10 implementation is fundamentally costly, and the cost falls squarely on those entities that currently are most compliant with the previously published rule. In other words, the best prepared will suffer the greatest economic damage.

Read more about my proposal for spreading out the burden more equitably.

Well, let me point out that innovative organizations are currently expanding the role of the clinical documentation specialist to function as conduits of information flow, not only between physicians and coders, but also between all members of the clinical team.  Rarely do physicians have the time to read all clinically relevant documentation by dieticians, physical therapists, nursing, and other clinical services rendering care.  That very documentation, however, may contain critical information not only for severity capture but also for continuity and quality of patient care.

To draw an analogy, instrument-rated pilots are grateful for the support provided by air traffic control (those other airplanes “in the clouds” are of significant concern to the pilot).  Similarly, particularly in the electronic medical record environment, documentation specialists provide treating physicians with “situational awareness” regarding clinical issues identified by other providers.

Under emerging ACO models, where physicians and hospitals are subject to substantially greater accountability for quality, cost, and patient satisfaction, awareness of all clinical parameters becomes essential for efficient and effective clinical care. The role of the clinical documentation specialist must further evolve to meet these expanded demands.  This specialist has the capacity to emerge as “integrators of clinical information,” benefitting the clinical team, the ACO and, most importantly, the patient – providing that situational awareness that is so important.

Of these 27 ACOs, 5 are participating in the Advance Payment ACO Model. This Model was established by the CMS Innovation Center to encourage rural and physician-based ACOs to participate in the Shared Savings Program. The Advance Payment ACOs receive advance payments to help cover the costs of establishing the infrastructure needed to coordinate care for the beneficiaries they serve.

The Shared Savings Program ACOs, which will serve an estimated 375,000 beneficiaries in 18 States, brings the total number of organizations participating in Medicare shared savings initiatives to 65. This includes the 32 Pioneer Model ACOs that were announced last December and six Physician Group Practice Transition Demonstration organizations that started in January 2011.

For more information about today’s announcement, view this CMS Fact Sheet

News below:

In a new press release from HHS, Secretary Kathleen Sebelius announced a proposed rule that would delay the compliance date for ICD-10 from October 1, 2013 to October 1, 2014

The ICD-10 compliance date change is part of a proposed rule that would adopt a standard for a unique health plan identifier (HPID), adopt a data element that would serve as an “other entity” identifier (OEID), and add a National Provider Identifier (NPI) requirement. The proposed rule was developed by the Office of E-Health Standards and Services (OESS) as part of its ongoing role, delegated by HHS, to establish standards for electronic health care transactions under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). OESS is part of the Centers for Medicare & Medicaid Services (CMS).

The full release can be found on the CMS Website, and more information about this proposed rule can be found on the proposed rule ICD-10 fact sheet. A segment of the HHS press release is located below.
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The Department of Health and Human Services (HHS) today announced a proposed rule that would establish a unique health plan identifier (HPID). The change would save the health care industry up to $4.6 billion over ten years by enabling greater automation of electronic health care transactions, in turn helping physicians spend less time interacting with health plans — and more time with patients.

The proposed rule was developed by the Office of E-Health Standards and Services (OESS),  as part of its ongoing role, delegated by HHS, to adopt standards for electronic health care transactions under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). OESS is part of the Centers for Medicare & Medicaid Services (CMS).  The proposed rule would implement several administrative simplification provisions of the Affordable Care Act.

The proposed rule also would delay by one year, until Oct. 1, 2014, the date by which covered entities must comply with International Classification of Diseases, 10th Edition diagnosis and procedure codes (ICD-10). Covered entities are defined in HIPAA as (1) health plans, (2) health care clearinghouses, and (3) health care providers who electronically transmit any health information in connection with a transaction for which HHS has adopted a standard .

Some provider groups have expressed serious concerns about their ability to meet the October 1, 2013 compliance date. CMS and HHS believe the change in the compliance date for ICD-10, as proposed in this rule, would give providers and other covered entities more time to prepare and fully test their systems to ensure a smooth and coordinated transition among all industry segments.

With VBP, many healthcare leaders are rethinking their needs when trying to fill a newly created or vacant clinical documentation specialist (CDS) position, which only makes their job harder.  Recruiting and hiring for CDS positions continues to be a challenge for hospitals, but an important one to overcome since a well-placed CDS can make the quality and revenue cycle difference.

If you are charged with leading the clinical documentation improvement (CDI) initiative at your hospital, you already know or will soon realize that the program is only as good as the CDS who is formulating the clarifications and interacting with the medical staff.  

We’re often asked: What do you look for in the CDS applicant?

Many of the same attributes you look for in traditional nursing roles are desired:  teamwork, attention to detail, and high energy level.  But, there a three that are absolutely required for the CDI role: Clinical experience, communication skills, and motivation.

Next Post – More Detail on Finding the Best CDS to Enhance your VBP Program

She looks at the third-largest chapter in ICD-10-CM: Chapter 20, “External Causes of Morbidity,” which also happens to rank it third in terms of having the greatest number of total codes. 

In this article you’ll see the general changes that have occurred and how to anticipate these changes when reporting external causes of morbidity utilizing ICD-10-CM.

Read the full article here.

Let’s face it:   ICD-9 is being replaced because it is 35 years old, terminology and classification of some conditions is outdated and obsolete, such outdated codes produce inaccurate and limited data, ICD-9 lacks specificity (such as laterality), the benefits of the EHR cannot be fully realized without I-10, and comparison of international data is grossly limited without ICD-10.  This is not a nice to have, but a must have.

The AMA’s vote to stop implementation of ICD-10 is likely to fail for a number of reasons.  Insurers, hospitals, and many physicians across the country have already made substantial investments in compliance with the new regulations.  Many coders have already undergone retraining for the new system.  Where were the AMA’s comments back when the rule was published?  To change course now would penalize those entities and individuals committed to compliance with the published rule to the benefit of those who have done nothing.

If one does a count of days from the publication of the final rule until the date of mandatory compliance of October, 2013, one can observe that those impacted by the final rule were given 1,719 days to comply.  To choose a random date, on March 1^st of 2012, 1,140 days will have passed.  A simple calculation shows that 66.3% of the available time to prepare has elapsed.

The societal argument supporting ICD-10 implementation is strong.  The system is necessary to improve the accuracy of severity adjustment, a necessary component of emerging policies supporting payment for quality, not just quantity of medical services provided.  It also improves the quality of diagnostic and procedural information, enabling broad application of claims-based research to improve quality of care. 

The AMA should consider the impact of its policy statement on physicians who may delay training their staff and providing the necessary infrastructure to support the implementation of ICD-10, as they wait to see how Congress will respond.  Will there be a full stop?  I doubt it.  Will CMS come up with some ‘compromise’ like a parallel ICD-9/ICD-10 platform until physicians are ready to opt-in, maybe.

One solution would be to maintain the present 10/01/13 implementation date, but allow “flexible” compliance for physicians, where physician practices could transition during the year.  Would there be an up-side for early implementation?  Possibly.  If one considers the direction the industry is taking with severity adjustment and outcomes measurement, it is likely that those coding in I-10 would receive higher severity (and thus improved profiles).  That would provide an incentive for physicians to become early adaptors.

Regardless of the outcome of current CMS rulemaking, hospitals and healthcare systems should continue to build on their momentum in ICD-10 preparation.  Despite the hard work, many a hospital has seen the benefit from adding the necessary detail required by ICD-10 to improve patient safety and quality care.  Momentum is mass in motion – and very difficult to stop once it gets going.  

VBP is a quality incentive program built on the hospital inpatient quality reporting (IQR) measure and required by the Patient Protection and Affordable Care Act.   Funded by a 1 percent withhold from participating hospitals’ DRG payments, VBP is meant to reward hospitals for better value, patient outcomes and innovations, versus just volume of services.

This October 2012, hospital payment will be linked to quality measures, which is based on the performance period beginning July 1, 2011.  These value-based incentive payments are based on performance, or improvement on a set of clinical and patient experience-of-care quality measures. 

This is the time to review how we look at the patient chart and find areas for improvement.  Traditionally, documentation clarification happens when clinical documentation specialist (CDS) staff seeks clarification when there is evidence of a diagnosis not documented, or where there may be a more specific diagnosis (correct CMS terminology). 

Sticking with a traditional approach to documentation clarification will not be sufficient anymore.  That is because if conflicting documentation exists, reviewing entities are likely to apply coding rules to deny payment.

Consider the following:

• Documentation specialists should concurrently ask the attending physician to clarify apparent or real discrepancies.

And, reviewing entities are now also denying physician diagnoses that appear clinically unsubstantiated.

So consider the following:

• Documentation specialists should concurrently ask for underlying clinical judgment if not evident in the clinical record.

Documentation clarification is just one area where you can build a strong clinicial documentation program.  There are several opportunities to strengthen your program and come out ahead with VBP and other CMS initiatives.

For example, do you focus your clinicial documentation improvement on only one area?  If so, consider making the CDS a true part of the clinical team, responsible for reviewing the chart and working with case management and quality teams when patient safety indicators and core measures are triggered.

Do you tend to focus only on your case mix index?   Case mix index is, to be sure, an important indicator of program success, but consider clinicial documentation improvement impact on quality core measures and how the quality of care improvement aligns with correct payment.

If the chart can “tell the story” of the patient’s episode of care in the hospital— truthfully, accurately and concurrently—then we all come out ahead.  Patients get the care they need and deserve, and  hospitals and physicians get the credit they are due in ratings and reimbursement.