More from June 2015 - Vol. 34 No. 05
ICD-10 is a few months away. Here’s what you can do to prepare
Uncertainty related to implementation was one of the main reasons many providers postponed preparing for ICD-10. Now that political uncertainty has been all but eliminated, electronic health record (EHR) vendors, clearinghouses, and health plans are all moving forward with preparation for the ICD-10 transition. Otolaryngologists in group or small practices must follow this lead and focus on preparation efforts to ensure that practice revenues will not be interrupted come October 1.
ICD-10 is a few months away, what can I do to prepare?
Communicate with your payers/vendors
One of the most effective things you can do at this point is communicate with all payers and vendors to ensure they are prepared and ask them what you need to do to further prepare. Below is a sample list of questions to ask your payers/vendors to receive ICD-10 information that could be crucial to your practice’s workflow after October 1. (This list is just a sample and is in no way all-encompassing nor should it be interpreted as legal advice):
Does our license with you include ICD-10 regulatory updates on a moving-forward basis after the ICD-10 go-live date of October 1?
Who are the ICD-10 contact people and what is their contact information?
What modifications to my EHR must be made to accommodate ICD-10?
Will there be any additional fees charged as a result of the ICD-10 upgrade?
When will system upgrades for ICD-10 go into effect?
Will there be any additional training provided as a result of the ICD-10 upgrade?
Is there a charge associated with any additional training that is required?
Besides system upgrades, what additional documentation and forms changes (matrices, clickable templates, etc.) will you provide?
When can we see updated policy/edit/prior authorization changes for ICD-10?
Will system upgrades for ICD-10 require additional hardware to support the software modifications?
How will your products and services accommodate both ICD-9 and ICD-10 as we work with claims for services provided both before and after the transition deadline for code sets?
What does testing mean to your organization and when will we be able to test ICD-10 claims/transactions?
What are your post-implementation contingency plans to ensure accurate provider reimbursement? (e.g., Will you grant “advance payments” in the form of paper checks for risk mitigation purposes?)
Improve documentation practices
While you cannot submit actual ICD-10 codes and receive payment until the deadline has arrived, you can submit detailed documentation for your claims as a form of practice in anticipation of the deadline. Several EMR vendors allow ICD-10 coding now, so patient problem lists are being populated with both ICD-9 and corresponding ICD-10 codes. This can help get a practice acquainted with doing the ICD-10 coding, and when the switch is flipped in October, several ICD-10 codes will already be associated with established patients. For a Microsoft Excel list of common ENT ICD-10 codes, visit the Academy website: www.entnet.org/content/icd-10-coding-resources.
There are several factors to focus on when improving the specificity of your documentation. Some examples include (documentation elements will vary by different codes):
Anatomy (e.g., attic, tympanum, mastoid, diffuse cholesteatosis)
Anatomical Location (maxillary, frontal, ethmoidal, sphenoidal, pansinusitis)
Disease Acuity (e.g., acute, subacute, chronic, recurrent)
Localization/Laterality (e.g., right, left, bilateral)
Infectious Agent (e.g., scarlet fever, influenza, measles)
Type (e.g., open, closed)
Episode (e.g., initial encounter, subsequent encounter, sequela)
Manifestations (e.g., serous, mucoid, suppurative, non-suppurative, with/without spontaneous rupture of tympanic membranes)
Circumstances (e.g., exposure to environmental tobacco smoke, history of tobacco use, occupational exposure to environmental tobacco smoke, tobacco dependence)
Below is a sample of incorrect versus correct documentation under ICD-10 requirements:
INCORRECT DOCUMENTATION UNDER ICD-10
CORRECT DOCUMENTATION UNDER ICD-10
A 3-year-old female presents with unilateral otitis media with a ruptured tympanic membrane.
A 3-year-old female presents with acute serous
otitis media (L) ear with spontaneous 60%
central ruptured tympanic membrane.
Patient presents with adenotonsillitis, dyphagia, laryngitis, obesity.
Patient presents with chronic adenotonsillitis with adenotonsillar hypertrophy, oropharyngeal dysphagia, acute obstructive laryngitis, morbid obesity with alveolar hypoventilation.
Patient presents with hearing loss with history of high doses of IV antibiotics.
Patient presents with bilateral hearing loss with a history of high doses of IV gentamicin. Hearing loss secondary to gentamicin.
Assess your claims for mapping risk
Knowing your most frequent patient diagnoses and the optional ICD-10 codes will translate to help you assess which claims may be at risk for errors and their potential impact on revenues. See charts below for a few examples of risk levels.
Low-risk claim with 1:1 translation
Chest pain unspecified
Chest pain, unspecified
Moderate-risk claim with 1:4 to translation
Chronic otitis externa NEC
Unspecified chronic otitis externa, unspecified ear
Unspecified chronic otitis externa, right ear
Unspecified chronic otitis externa, left ear
Unspecified chronic otitis externa, bilateral
Higher risk claim with 1: several translation
Other acute otitis externa
Unspecified acute noninfective otitis externa, right ear
Acquired stenosis of left external ear canal,
Acquired stenosis of external ear canal, unspecified, bilateral
Acquired stenosis of external ear canal, unspecified ear
Other acquired stenosis of right external ear canal
Other acquired stenosis of left external ear canal
Other acquired stenosis of external ear canal, bilateral
Other acquired stenosis of external ear canal
Acute chemical otitis externa, right ear
Acute chemical otitis externa, left ear
Acute chemical otitis externa, bilateral
Acute chemical otitis externa, unspecified ear
Acute contact otitis externa, right ear
Acute contact otitis externa, left ear
Acute contact otitis externa, bilateral
Acute contact otitis externa, unspecified ear
Acute eczematoid otitis externa, right ear
Acute eczematoid otitis externa, left ear
Acute eczematoid otitis externa, bilateral
Acute eczematoid otitis externa, unspecified ear
Acute reactive otitis externa, right ear
Acute reactive otitis externa, left ear
Acute reactive otitis externa, bilateral
Acute reactive otitis externa, unspecified ear
Other noninfective acute otitis externa, right ear
Other noninfective acute otitis externa, left ear
Other noninfective acute otitis externa, bilateral
Other noninfective acute otitis externa, unspecified ear
A longer list of common ENT ICD-9 codes and their relevant ICD-10 crosswalks can be downloaded online at www.entnet.org/ICD-10-Top-200-ENT-Diagnosis-Codes.
If you have not already, you should be testing claims with payers and/or Medicare Administrative Contractors (MACs). The Workgroup for Electronic Data Interchange (WEDI) has published a comprehensive guide on how to test your claims with ICD-10 at www.wedi.org/docs/resources/testing-for-small-providers-white-paper.pdf?sfvrsn=0. Your MAC should already have tested several claims by now. Request that your MAC share any testing results with you and check the CMS website for other published end-to-end testing results. Also remember, the closer you get to the deadline, the higher the likelihood that payer or MAC resources will be occupied by other physicians also trying to test. Test as soon as possible to beat the last-minute rush.
Don’t get denied!
The Academy’s ICD-10 website page has several resources, including a sample ENT ICD-10 Superbill that will assist your planning and preparation efforts. Visit the ICD-10 website for more at www.entnet.org/node/740. Ad Hoc Payment Model Workgroup looks to the future with Alternative Payment Models (APMs)
NUTS AND BOLTS Endocrine surgery bundled payment modelBy Drew M. Locandro, MD, excerpt from ENTConnect Report Our practice is an eight-physician, single-specialty independent practice with six offices in a major metropolitan area. Several years ago, one of our surgeons developed a busy endocrine (thyroid/parathyroid) surgical practice. Patients came from greater and greater distances—even from other countries—and some were willing to pay cash for surgery. Pricing from local hospitals and multispecialty centers required negotiation on a per-case basis that was inconsistent and often did not include anesthesia, pathology, and other fees. Similar to all practices, some patients defer surgery due to cost, especially if they have high-deductible insurance coverage, catastrophic coverage only, or no insurance. In 2011, our practice opened a single-specialty ambulatory surgery center. Want to find out how Dr. Locandro’s cash pricing system works? Interested in other alternative payment model experiences or have one of your own to share? Read more and engage in the conversation at today! Available on ENTConnect: http://entconnect.entnet.org.
The Academy strongly supported the repeal of the SGR formula and the movement toward development of new payment models in the landmark legislation that became law in April 2015. We believe this effort will add to the momentum in the shift from the traditional fee-for-service (FFS) system to value-based care. As part of the Academy’s efforts over the past few years to prepare for this transition, the Ad Hoc Payment Model workgroup was created. Led by co-chairs Robert Lorenz, MD, MBA, and Jane T. Dillon, MD, MBA, and managed by Health Policy staff, this group is comprised of physician leaders from research, quality improvement, 3P, and the Board of Governors. The main goals of this workgroup include reviewing potential opportunities to improve quality of care and decrease cost for otolaryngology-related services and dissemination of information about alternative payment models. To that end, the Ad Hoc Payment Model Workgroup created a new Member awareness campaign to identify and leverage Member alternative payment model (APM) knowledge. Member awareness campaign To assess Member knowledge and participation, the Ad Hoc Payment Model Workgroup partnered with the Board of Governors (BOG) to conduct a survey regarding Members’ experiences in states already involved in a new payment model. The survey revealed an eagerness to learn more about alternative payment models, as well as several Members with leadership roles in these new schemas. These leaders were asked to tell their personal stories to help the membership become more familiar with how APMs are affecting the specialty. In addition, these leaders helped to provide Academy members with an introduction to the risks and benefits of the various payment model structures. These personal experience reports were distributed to the membership at-large via periodic ENTConnect posts detailing otolaryngology APM involvement. (See “Endocrine Surgery Bundled Payment Model” at far right.) Looking toward the future of the healthcare system, the Academy will be well-poised to work with private and public payers with the establishment of an Academy-owned registry. An Academy-owned registry will help to inform alternative payment models, help demonstrate clinical effectiveness, and will allow our Members to report quality measures directly to CMS—all crucial elements in value-based care. Medicare moves to value
NUTS AND BOLTS Meeting of the minds for ongoing dialogueOn May 21, 2015, AAO—HNS/F leaders met with top CMS/CMMI officials who spearheaded the recent launch of the Health Care Payment Learning and Action Network. Academy participants in this critical meeting included Robert Lorenz, MD, MBA, coordinator for Practice Affairs and co-chair of the Ad Hoc Payment Model workgroup; Jane T. Dillon, MD, MBA, coordinator for Socioeconomic Affairs and co-chair of the Ad Hoc Payment Model Workgroup; Lisa E. Ishii, MD, MHS, coordinator for Research and Quality Improvement and Chair for the Registry Task Force, James C. Denneny III, MD, EVP and CEO; Jean Brereton, MBA, senior director, Research, Quality and Health Policy; Jenna Kappel, MPH, MA, director of Health Policy. During the meeting, Academy leaders discussed possible opportunities to partner with CMS in APM development by describing ways that we could improve value, decrease costs, and increase quality. CMS/CMMI was very receptive to several of the ideas and the Academy’s leadership will move forward with collaborative efforts. Stay tuned to the website, HP Update, and upcoming Bulletin articles for updates: www.entnet.org/content/payment-reform.
The Academy applauds the Department of Health and Human Services (HHS) recent efforts to promote the collaboration of partners in the private, public, and non-profit sectors to transform the nation’s health system by emphasizing value over volume. Following the announcement of an aggressive goal to have 30 percent of Medicare payments in alternative payment models by the end of 2016 and 50 percent by the end of 2018, HHS launched the Health Care Payment Learning and Action Network (Network). The Network, overseen by a third party contractor so that CMS is a participant in this effort, but not the main driver, will primarily work to enhance value by analyzing data for current APMs, then use that data to create common core issue approaches and implementation guides. The Academy was extremely pleased to participate in the first working session of the Network and looks forward to learning more about best practices and how best to analyze data and report on new payment models. As part of recent Academy efforts related to informing Members about alternative payment models, the HHS announcement, and the Network, Academy physician payment and quality leaders met with CMS/Centers for Medicare & Medicaid Innovation (CMMI) to continue dialogue with them about the Academy’s ongoing efforts to improve quality and reduce costs, and increasing otolaryngologist-head and neck surgeons opportunities to participate in alternative payment models. Academy leaders have developed a good relationship with Patrick Conway, MD, MSc, Deputy Administrator for Innovation and Quality and CMS Chief Medical Officer, that has led to ongoing open dialogue with him and his CMS team members regarding important quality-related issues impacting our physician members and the patients they treat. The open door policy with Dr. Conway and his team members has allowed for several policies to move forward that benefit otolaryngologist-head and neck surgeons and their patients, including CMS’ adoption of the new Sinusitis and Acute Otitis Externa (AOE) measures groups and CMS’ decision to include coverage of auditory osseointegrated implants (AOIs) as prosthetics. As many specialty societies including otolaryngology are trying to determine how to be included in the healthcare system transformation, this latest meeting was crucial for the Academy to receive feedback from CMS/CMMI about how societies fit in with the HHS goals. Thank you The Ad Hoc Payment Model Workgroup leaders and your AAO-HNS Health Policy staff greatly appreciate the support of our Members, committee volunteers, and other leaders in helping us shape policy in an ever-changing market. As key information, policy changes, and other issues related to alternative payment models that impact the specialty emerge; we will continue to keep Members informed via the Bulletin, HP Update, and the weekly news.