Archive for the ‘ARRA’ Category

ICD-10: An Overview Are You Prepared? Part 1

Thursday, August 16th, 2012

The implementation date for ICD-10-CM has been pushed back one year to October 1, 2014, but it doesn’t mean you have a lot of time. If you have not assessed, through a Gap Analysis, the impact of ICD-10 on your organization, you should be planning that event…soon. There is a lot to do.

 Consider organizing an ICD-10 Transition Team. That team should have a project leader.

One of the first tasks of the team is to conduct an overview of ICD-10, identify the differences between ICD-9 and ICD-10, as well as the changes soon to come.

 The ICD-10-CM Manual is available in both a print and an electronic version. It will provide the classification system that identifies diagnoses and injuries. Acute care procedures are not included in ICD-10-CM as they have been provided in a separate classification system called ICD-10 PC, so they are not a focus of home care.

 The Transition Team needs to understand that all entities covered by HIPAA, per the American Recovery and Reinvestment Act (ARRA) who conduct healthcare transactions must comply with ICD- 10 requirements.

 Per CMS, every day it pays 4.4 million claims totaling  $1.5 B. Each month, Medicare receives 19,000 provider enrollment applications. Each year, Medicare pays over $430 B for 45 million beneficiaries. Each year, Medicaid nationally pays 2.5 billion claims for 54 million beneficiaries in 56 states and territories. ICD-10 is expected to assist in cost savings as well impacting fraud and abuse. Because of the specificity of ICD-10, more sophisticated algorithms are designed to hone in on questionable combinations of codes coupled with OASIS answers to spot potential fraud.

 What is the rationale for ICD-10?

 - ICD- 9 is 30 years old and no longer has code space for new diagnoses or new conditions and treatments.

 - ICD-9 is not always precise or unambiguous.

 - US mortality data is being reported in ICD-10

thus making international comparison of mortality and morbidity difficult.

 We need more coding specificity!

- Accountable Care Organizations, Patient Centered Medical Models, Guided Coaches, etc will require more discreet data.

- Benchmarking and quality measurement require more detailed codes

- Reimbursement will require detailed documentation reflected by codes that portray accurate patient conditions

- Increased specificity in data means more robust design of algorithms to predict outcomes and care

- Increased coding detail offers the capability to find previously unrecognized relationships in  

  disease as well as variables

- Increased capability to measure healthcare quality, safety, and efficiency

- Space to accommodate future advances and expansion

- Improved capability to determine disease severity for audit risk and adjustment

 The primary physician or specialist must establish a patient’s diagnosis. A nurse or therapist will document all pertinent diagnoses on the OASIS-C and the Home Health Certification and Plan of Care (Form CMS-485). New or additional diagnoses that the clinician identifies at the assessment must be verified by the physician before the diagnoses may be added to the patient’s medical record. For ICD-10, nothing changes other than greater detail availability via codes.

 At first glance, trying to use the ICD-10-CM Manual may seem overwhelming. In ICD-9-CM, there were approximately 14,000 choices for codes. In ICD-10-CM, there are  approximately 68,000 choices. Codes exist for so many injuries, including W61.11XA biting by a macaw, initial encounter or W61.11XD biting, subsequent encounter or codes for bites by a parrot, a goose, a turkey, or a chicken. All in all nine codes for each animal and there are a total of 312 animals. There are even separate codes for a turtle as one may be “bit by a turtle” or “struck by a turtle.” Humor aside, there are now the precise combination codes to more clearly depict the true presenting picture of the patient and their needs.

 ICD-10 CM may now have 68,000 codes but acute care procedure codes, ICD-10 PC, have increased from 3,000 to 87,000 codes. That is a phenomenal increase, but necessary, given the medical advances these past 30 years. There are expected organizational benefits from ICD-10 including administrative efficiencies, cost containment, capability for more accurate trend and cost analysis, along with improved coding accuracy and productivity.

 CMS believes that the impact on reimbursement expected, includes increased accuracy, fairer reimbursement, improved justification for medical necessity, fewer errors and rejected claims (after the initial learning curve), and reduced opportunities for fraud.

 ICD-10-CM codes may have up to 7 digits and digits 2 and 3 are numeric, digits 4-7 are alpha or numerical. The greater the specificity, the greater the number of characters required.

 A Bit of Humor

 There are so many codes including injuries incurred while sewing, ironing, playing a brass instrument, even while crocheting. There is even a code, V91.07XA, for burns due to water skis on fire. Really, quite the vision and subsequent to…what, one might ask.

 Because of the precise specificity, ICD-10 requires expertise in anatomy and physiology, pathophysiology, and diagnostics. The specificity is far greater than ICD-9 and the need to better understand finite A&P as well as diagnostics is vital. Injuries are grouped by anatomical site rather than type of injury. Another change includes sequelae instead of after effects.

 CMS plans to have a draft grouper ready by April, 2013.

 New features in ICD-10 include combination codes for a large variety of conditions, commonly seen symptoms, and manifestations. An example of a combination code includes:

E13.331 Diabetic Retinopathy with Macular Edema- other specified diabetes Mellitus with moderate non-proliferative diabetic retinopathy with macular edema.

  There are a number of expanded codes for diseases and conditions, such as diabetes, substance abuse, and injuries. Codes for post operative complications have also been expanded with a distinction between intraoperative complications and post procedural disorders.

 There will be an impact on many home health departments. In our next article, let’s discuss what preparation will be needed and the specifics needed for the Gap Analysis.

 Next article: What do we do to prepare for ICD-10: Developing the Gap Analysis

 

 

 

 

 

 

 

 

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The Patient Protection and Affordable Care Act (PPACA) and the Health Care and Reconciliation Act of 2010 are collectively known as the Affordable Care Act along with the American Recovery and Reinvestment Act (ARRA) Part 2

Thursday, June 28th, 2012

The Patient Protection and Affordable Care Act (PPACA) and the Health Care and Reconciliation Act of 2010 are collectively known as the Affordable Care Act along with the American Recovery and Reinvestment Act (ARRA) Part 2

With the last article, we have agreed to look in depth at the above Acts to explore the magnitude of their impact in the health care industry. In the last article we discussed Value Based Programs. In this article, let’s explore the Accountable Care Organization (ACO).

 

The Accountable Care Organization (ACO)

 

CMS has, for years, suggested to healthcare providers across the care continuum that they must refine old and create new methods of providing care. Providers are expected to collaborate and coordinate to minimize the fragmentation in healthcare. They need to work together to improve care delivery, efficiency, and effectiveness. Home health care providers should be aware of the new Chronic Care Management Models that include Accountable Care Organizations (ACOs) (see Select Data ezine, January, 2012 , www.selectdata.com ) .

The Coker Group (2012) defined the ACO as an “integrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targets.”

Let’s look at the Accountable Care Organization

Through collaboration amongst stakeholders, with coordination of expensive chronic care, and with partnership developments, strategic alliances are being encouraged. Is your home health agency ready? What specific programs do you have in operation? Are they evidenced-based? What have been the outcomes? Do you have reliable statistics?

Section 3022 of the Affordable Care Act added another section to the Social Security Act requiring the establishment of a Shared Savings Program intending to “encourage providers of services and supplies (e.g., physicians, hospitals, and others involved in patient care) to create a new type of health care entity, an ACO that agrees to be accountable for improving the health and experience of care for individuals and improving the health of populations while reducing the rate of growth in health care spending” (CMS, Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP).

The Regulations identify that ACO participants may include: Physicians, Nurse Practitioners, Physician Assistants, Clinical Nurse Specialists, Hospitals, and specific medical providers and suppliers. Several safe harbors will grant relief to the ACO from fraud, antitrust, and tax-exemption concerns. The ACO must have at least 5,000 beneficiaries assigned to it.

In October, 2011, CMS finalized new rules under the Affordable Care Act to assist physicians and hospitals and other health care providers to create ACOs through Medicare Shared Saving Programs that are expected to lower health care costs while meeting performance standards on quality of care. The Final Rule requires CMS to “assess the ACO’s quality and financial performance based on a population’s use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark population.”(CMS, Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP).

As stated in the January 2012 Select Data ezine:

“Home health agencies should be paying VERY close attention to the latest requirement for home health found in the Affordable Care Act. The Act encourages development of Accountable Care Organizations (ACOs) and provides for “incentives to enhance quality, improve beneficiary outcomes and increase value of care.” (CMS Q&As Section 1899 of Title XVIII)  The ACO becomes a type of managed care organization that may use fee for service or capitation payment, and is accountable to patients and the third party payor for the quality, appropriateness, and efficiency of the care provided. Because of the Affordable Care Act, CMS was required to have an ACO in place by January, 1, 2012.

There were presently 35 ACOs nationwide by June, 2012, over 50% in California. There are 33 quality measures that an ACO must report on to CMS. These measures are collected by: Patient surveys (7 measures), data calculated using claims (3 measures), determined via EHR (1 measure), and via Group Practice Reporting Option Web Interface (22 measures). These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks.

In track 1, the one sided model, ACOs will have an upside shared savings opportunity with no downside risk, but the shared savings opportunity is less with this model; 50% of the excess savings to a lower cap. Track 2 is a two sided model requiring the ACO to share in 60% of both savings and losses with a cap.

Per CMS, by April 1, 2012, over 1.1 million beneficiaries are receiving care through ACOs which are members of the Shared Savings Program.

Some home health agencies have begun aligning with physician offices, hospitals, rehabilitation facilities, and long term care providers to coordinate care across the health care continuum. Home health agencies are becoming members of hospital teams in both general and specialty areas. Agencies which cannot seem to form the alliances may find themselves with declining referrals in the near future. Home health needs to demonstrate their personalized approach to care so they may be appealing to the PCMH team.

Home health agencies should be encouraging discussions among provider leaders of all levels of the care continuum. Patient ultimate outcomes should be shared by all providers. Establishing those mutual patient outcomes is a primary step in a strategic alliance ACO.

The Shared Savings Program final Rule can be downloaded at http://www.ofr.gov/inspection.asp

Part 3 will focus on the Electronic Health Record (EHR) Incentive Program of the ACA.

 

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The Patient Protection and Affordable Care Act (PPACA) and the Health Care and Reconciliation Act of 2010 are collectively known as the Affordable Care Act along with the American Recovery and Reinvestment Act (ARRA) Part I

Thursday, June 21st, 2012

The Patient Protection and Affordable Care Act (PPACA) and the Health Care and Reconciliation Act of 2010 are collectively known as the Affordable Care Act along with the American Recovery and Reinvestment Act (ARRA) Part 1

Over the next few articles in our June and July ezines, let’s explore these acts and their directives for healthcare. These Acts will “significantly impact and alter healthcare” per HHS and CMS. Knowing more about these Acts assists agencies to prepare for the radical changes coming in healthcare delivery.

The Patient Protection and Affordable Care Act (PPACA) and the Health Care and Reconciliation Act (collectively known as the Affordable Care Act) and the American Recovery and Reinvestment Act (ARRA) have and will continue to have some of the most significant impact on how this nation will care for patients now and in the future, as well as store and access data on those patients. It was enacted in March, 2010 and was devised, per its writers, to move the nation’s health care system from a system based on volume to a system based on quality.

Besides the Home Health Face to Face requirement that has caused distress to the industry, but is forcing physician attestation of home health eligibility and need prior to clinician assessment in the home, there are reimbursement changes coming to all levels of healthcare. By 2015, up to 6% of hospital reimbursement will be at risk if hospitals poorly perform. In the acute care setting, several Value Based Purchasing programs are already underway with declining reimbursement linked to lower performance.

CMS is looking to the Affordable Care Act (ACA) mandated Value Based Programs (VBP) in the home health arena to improve quality by rewarding agencies with better quality outcomes across a comprehensive set of quality measures. Since the program is to be budget neutral, the dollars will come from agencies with poorer performance and poorer outcomes. CMS is looking to link quality and accountability to reimbursement.

In March, 2012, the Secretary of the Department of Health and Human Services submitted the VBP plan to Congress. Besides the required continuous quality improvement using a very detailed comprehensive set of quality measures, there will be payment incentives developed, and one funding proposal submitted by DHHS including payment withholds in home health similar to the acute care setting. That would mean agencies could have withholds and payment adjustments, both in the same year (net adjustment)

• PPACA and ARRA are designed to fundamentally expand access to healthcare for all US residents

 

In doing so, Congress has stated the new delivery models will require rapid engineering of the healthcare delivery system to consistently provide high quality care at an overall lower cost.

 

 

Home health agencies should monitor what the ACA impact is and will be on the acute care setting because, we recognize that for years where hospitals go, it seems, so goes home health.

Note that starting January of this year, and ending December 31, 2016, CMS has initiated another demonstration project. This time it is a process of bundling payments for acute care, post acute care, and physician care. It is believed that bundling this care under the oversight of the hospital will parallel care and reduce costs through reduction of readmissions, improved quality of care, and reduced fragmentation of care. Phase 1 applications were submitted by November, 2011. Applications for the remaining three phases must be submitted by June 28, 2012.

The next three phases will examine:

1. retrospective bundled payments for hospital stays, physicians, and post-acute providers by episodic payment

2. retrospective bundled payment for post acute care when there has been no hospital stay

3. retrospective bundled payment for hospitals and physician when there has been an inpatient stay

It is believed that bundling payments will allow providers to share the benefits of a better efficiency in resource use and streamlined processes. CMS expects that the efficiencies to grow and to protect quality has built in required quality measures.

For more information regarding the Home Health agency VBP plan please visit:

www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/downloads/pdf

For more information regarding the Bundled Payment Program, please visit:

http://innovations.cms.gov/initiatives/Bundled-Payments/index.html

There are so many innovations coming our way. These new demonstrations mandated by the Affordable Care Act are expected to radically change health care delivery. Will you be ready?

Next article: The Accountable Care Organization…35 well underway nationwide. 50% of those are in California. They are expected to expand. Are you ready? Are you really ready?

 

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