Post ICD-10: Implementation
Post ICD-10 Implementation Strategies
On October 1, 2015, we entered into a new phase of our careers with the implementation of ICD-10. This occurrence provided the perfect impetus for the retooling of every carrier’s policies, reprogramming of edits in their software and increased scrutiny through audits. This is the ideal time to familiarize yourself with updates in the coding and documentation requirements for all carriers, including federal programs and private payers, as well standards of care regulated by the Illinois Medical Disciplinary Board.
Since the implementation of ICD-10, the interpretation of code usage and policies pertaining to billing procedures are becoming evident with each carrier. The increased description and specificity of ICD-10 have fueled program policies that are shifting toward quality care, rather than the number of services provided. The data accrued from the claim form will generate statistical analysis and a means for insurance carriers to control the reported “out of control” costs of health care.
While some still debate where to list the subluxation complex, now referred to in the diagnosis list as the “somatic and segmental dysfunction,” advanced payment model changes are being implemented throughout the health care profession. Payment for quality and cost-effective care is replacing the fee for service model of reimbursement. Under the Patient Protection Affordable Care Act (PPACA), Medicare has instituted differential payment, known as the Value-Based Modifier (VM), to physicians. Hospital and group practices have already experienced the implementation of this new model.
In 2017, the VM will be assigned to each provider in solo practice and groups of two or more eligible providers. The new paradigm shift will move toward rewarding providers with increased reimbursement for quality of care, decreased complications and decreased reoccurrences. Reimbursement in the past monetarily rewarded those who performed more services. This gave no incentive to control health care costs. Data provided with the increased specificity of the ICD-10 coding system will yield methods to measure a health care provider’s performance. Since the PPACA mandates that every man, woman, and child have insurance, and essential health benefits include chiropractic care, the days of a “cash” practice are seemingly shrinking.
On January 1, 2019, we are scheduled to begin the Merit Incentive Payment System (MIPS) payment adjustment system under Medicare. Under MIPS, the Secretary must develop a methodology to assess eligible provider’s performance and determine a performance score. The score will then be used to apply a payment adjustment factor for 2019 onward. The MIPS score will dove-tail onto the value-based modifier, which initially was partially calculated by each provider’s participation in the PQRS and the EHR Meaningful Use programs.
One may ask, what does this have to do with ICD-10? Unlike our European counterparts, utilization guidelines in the United States insurance system are largely based on the diagnosis codes, documentation to support the diagnosis and medical necessity for care. ICD-10 greatly expanded the number of possible codes from 17,000 to 70,000 codes. This was primarily due to the increased specificity of codes. Medicare has also put in place mechanisms to report complicating factors. A complicating or comorbidity factor is determined by data gained from the examination and the past history. The complicating factor acts as a multiplier to calculate additional amounts of allowable treatments.
Therefore, it is incumbent for the provider to properly diagnose the patient to the highest degree of specificity and include complicating factors, which will document the medical necessity of care. This will ultimately lead to quality care in an effective manner that is consistent with evidence-based care. Merely picking a code from a list is not as easy, nor a good practice, without proper justification of the condition. If the patient legitimately has a complex condition with complicating factors, the doctor who is able to document these factors will thus be reimbursed more consistently. That is why I believe that a diagnosis of lumbalgia or cervicalgia should rarely be used. What is the true diagnosis? This will impact not only each provider but ultimately our profession as well.
As we embrace the New Year with ICD-10 codes, each doctor will have to learn the coding system in a more in-depth manner. Like learning a new language, this will then yield a more accurate diagnosis, which will be utilized for reimbursement, data collection and changes in the coverage for needed chiropractic care for our patients. Now is the time to advance our level of understanding of the diagnosis codes to better influence chiropractic care in the future.
Dr. Fucinari and the ICS will be presenting several classes in the coming months to aid the doctor and staff in the implementation of ICD-10 and Medicare guidelines. For an updated schedule of classes and locations, go to www.ILchiro.org or www.AskMario.com. Dr. Fucinari is a Certified Medical Compliance Specialist and a Certified Insurance Consultant. Dr. Fucinari is the author of several books and other resources, including, ICD-10 Coding of the Top 100 Conditions for the Chiropractic Office, available at www.Askmario.com For further information on compliance audits, books or record reviews, please contact Dr. Fucinari at Doc@Askmario.com