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HHS proposes one-year delay of ICD-10-CM/PCS
by Andrea Kraynak, CPC
HHS released a proposed rule today announcing a one-year delay of the implementation of ICD-10-CM/PCS. If finalized, ICD-10 would become effective October 1, 2014.
“Many provider groups have expressed serious concerns about their ability to meet the Oct. 1, 2013, compliance date. The proposed change in the compliance date for ICD-10 would give providers and other covered entities more time to prepare and fully test their systems to ensure a smooth and coordinated transition to these new code sets,” according to an April 9 press release.
“This is what I expected,” says Shannon McCall, RHIA, CCS, CCS-P, CPC, CEMC, CPC-I, CCDS, director of HIM and coding at HCPro, Inc., in Danvers, Mass. “But I am happy to hear that they didn’t seem to consider bypassing ICD-10 and going right to ICD-11. This goes to show that they do see the value in the system.”
She believes this delay will give providers the necessary time to implement and handle the costs associated with the change. “And now that we know the deadline, there is no excuse,” she says. “At this point, we have a date in sight again and we shouldn’t waste away the time that we have. We were given the extra time; use it wisely.”
The proposed rule, “Administrative Simplification: Adoption of a Standard for a Unique Health Plan
Identifier; Addition to the National Provider Identifier Requirements; and a Change to the Compliance Date for ICD-10-CM and ICD-10-PCS Medical Data Code Sets” also proposes the adoption of a unique health plan identifier under HIPAA. That proposal would implement several administrative simplification provisions of the Affordable Care Act and save an estimated $4.6 billion over 10 years for healthcare plans and providers. The proposed rule also includes the adoption of a data element that would serve as an “other entity” identifier (OEID), as well as add a National Provider Identifier (NPI) requirement.
The proposed rule explains that three main issues emerged in recent months regarding the previous October 1, 2013 compliance date, leading HHS to reconsider the deadline:
- The transition to Version 5010 did not go as effectively as expected
- Providers were concerned about a lack of resources due to competing statutory initiatives
- Several surveys and polls showed a lack of readiness for the transition
“While we considered a number of alternatives for the delay…we believe a 1-year delay would provide sufficient time for small providers and small hospitals to become ICD-10 compliant and would be the least financially burdensome to those who had planned to be compliant on October 1, 2013,” the proposed rule states, estimating that a one-year delay would add an estimated 10%-30% to the total cost of implementation for those entities that have already spent or budgeted for the transition.
Those in the healthcare industry offered mixed reactions to the proposed length of the delay.
“It is disheartening and encouraging in many respects. Disheartening for the facilities and practices who spent the money to prepare for the October 1, 2013 deadline but encouraging for those same people to be ahead of the game now as to breathe a little easier,” says James S. Kennedy, MD, CCS, managing director of FTI Consulting in Brentwood, Tenn.
“The best way to prepare for ICD-10 implementation continues [to be] to first practice ICD-9-CM correctly and then negotiate the differences in ICD-10” Kennedy says. This [proposal could] give us another year to get our infrastructure together and fill in the documentation and coding gaps so facilities can be ready to adapt to ICD-10.”
Meanwhile Cheryl Ericson, MS, RN, clinical documentation improvement education director for HCPro Inc, points out, “This gives everyone an opportunity to slow down, take a deep breath.”
“Most organizations should maintain their current course of progress so that coders become fluent in ICD-10. This just gives everyone extra time for improvement and gives us greater opportunities to recognize weaknesses in documentation,” she says.
She notes that the 2013 compliance deadline was going to be tight for most organizations, but the delay will give everyone time to consider dual coding prior to implementation. “Take this as a blessing in disguise. Train your staff members and get them comfortable so that when the transition does come, it won’t be as stressful,” Ericson says.
Rose T. Dunn, MBA, RHIA, CPA, FACHE, chief operating officer of First Class Solutions, Inc. in Maryland Heights, Mo., and former president, board member, and interim CEO of AHIMA, is disappointed that CMS is delaying a full year and would have preferred only a six-month postponement. “I’d continue to encourage providers to prepare for ICD-10 at a calmer pace and take advantage of spreading the cost of implementation over another year,” she says.
To comment on the proposed rule, visit www.regulations.gov. Comments are due within 30 days of publication in the Federal Register. The rule is due to publish in the April 17 edition of the Federal Register.
Editor’s note: For more information, view the related Fact Sheet. A display copy of the proposed rule is available online. The original announcement of a potential delay came earlier this year in a February 16 press release.
ER docs: We’re caught in the middle
Emergency room doctors see themselves in a health reform vise, squeezed on one side by administrators and payers who think they should work faster and better, and on the other by new penalty and billing rules they are only starting to understand.
That’s what many said during the annual meeting of the American College of Emergency Physicians being held in San Francisco being held this week, which drew a record attendance of more than 6,000. Their concerns are prompting them to “redesign” what they do and how they work to improve both their value and their image.
Emergency room doctors need to “consider stepping out of our perceived comfort zone and perception of only providing acute care,” said ACEP’s new president David Seaberg, MD, professor and dean of the University of College of Medicine in Chattanooga, during his opening remarks.
With this redesign, he said, emergency room doctors should drive “an additional team of health providers, physicians, mid-levels, nurses, techs, case managers, and social workers” who would provide preventive care, immunizations, healthcare screenings, promote wellness through education on diet, exercise and other lifestyle choices.
“We can use our access to patients as a vehicle to enhance emergency medicine’s value by serving as a conduit to integrated medical care, saving cost to the system and promoting quality care that keeps patients well,” Seaberg said.
Emergency department doctors also should “enhance our observation units to further reduce readmissions and potentially avoid admissions, and develop better disease management and palliative care protocols,” Seaberg said.
Hans House, MD, associate professor of the Department of Emergency Medicine at the University of Iowa Hospitals & Clinics, said that his emergency department, as opposed to the hospital, has already started to hire nurse managers and other care coordinators to visit patients and make calls to assure they and their families are getting appropriate care.
“We’re pleased, because it’s very well-received,” he said.
One keynote speaker, Richard Wolfe MD, chief of emergency medicine at Beth Israel Deaconess Medical Center in Boston, said emergency room physicians can do more to be effective gatekeepers to keep patients out of the hospital if they don’t need to be there.
“What is the most expensive thing we do?” He asked “It’s that we admit patients to the hospital.”
“If we can be effective gatekeepers, we can play an absolutely critical role (in reducing costs), but we need to start thinking about how we find other safe places to deliver care,” he said. “And I would argue that if we build home care networks… (and make sure there are) checks with primary care physicians the next day, a much better social infrastructure, and use of nursing facilities for those patients we admit a little bit for medical problems but a lot because we don’t think they’re safe at home, we can have a very huge impact at that point.”
“The next three years of healthcare reform will likely affect the next 30 years of our practice. It will touch all aspects of what we do: how we work, how we are paid, and how we interact with our patients. In short, it will redefine the specialty of emergency medicine.”
IPPS final rule confirms HRRP provisions
Approximately 60 pages of the 1,500-page Inpatient Prospective Payment System (IPPS) final rule focused on confirming the framework of the Hospital Readmissions Reduction Program (HRRP).
In addition to finalizing many provisions of the IPPS proposed rule, CMS also has given providers a glimpse of potential future HRRP readmission measures. For the first two years of the program (FY 2013 and 2014), CMS will review readmission rates for acute myocardial infarction (AMI), heart failure, and pneumonia. These conditions are among seven that account for almost 12% of potentially preventable readmissions, according to MedPAC’s 2007 “Report to Congress”.
CMS plans to add more conditions in FY 2015 and will consider the other four conditions identified in the MedPAC report:
- Chronic obstructive pulmonary disease,
- Coronary artery bypass graft surgery,
- Percutaneous transluminal coronary angioplasty, and
- Other vascular procedures.
One commenter warned CMS that use of only three conditions in the FY 2013 HRRP will create opportunities for gaming the system. For example, hospitals may change coding practices to avoid reporting patients with AMI, heart failure, or pneumonia. CMS said it would “monitor trends in admissions and readmissions to ensure there no systematic shift in patients’ primary discharge diagnoses codes occurs as a result of implementation of the Hospital Readmissions Reduction Program.”
Multiple readmissions
CMS also clarified that it will not count multiple readmissions. For example, a patient is discharged with AMI, readmitted five days later, discharged three days later, and then readmitted a second time five days later. CMS will consider this one readmission. The final rule states:
The readmissions measures are designed to measure whether a patient experienced at least one readmission within 30 days of an initial (or “index”) discharge as a single binary (yes/no) event, rather than counting the number of readmissions experienced within 30 days of discharge as a separate readmissions. For any given patient, only the first readmission they have will be counted for the Hospital Readmissions Reduction Program. In addition, only one readmission during the 30 days following the discharge from the initial hospitalization will count as a readmission for purposes of calculating the ratios set forth in section 1886(q) of the Act. For any given patient, none of the subsequent readmissions they experience within 30 days after discharge would be counted as a new “index” admission (that is, an admission evaluated in the measure for a subsequent readmission). Any eligible admission after the 30-day time period will be considered a new index admission.
Unrelated readmissions
Commenters also asked CMS to consider excluding readmissions for certain patients with the following conditions:
- Cancer
- Trauma, burns
- End-stage renal disease
- Psychiatric disorders
- Substance abuse
- Rehabilitation
CMS said it intends to explore whether to exclude other readmissions from the HRRP, but that it could not do so now. FY 2013 measures require National Quality Forum (NQF) endorsement, and the NQF-endorsed measures do not exclude such readmissions.
Payment adjustment
CMS will address further details of the HRRP in next year’s IPPS final rule. The adjustment CMS will use to reduce payment is a key element that is missing..The final rule states:
Although we did not propose specific policies regarding the payment adjustment under the Hospital Readmissions Reduction Program in the FY 2012 IPPS/LTCH PPS proposed rule, we believe that it is still important to set forth the general framework of the Hospital Readmissions Reduction Program, including the payment adjustment provisions, in order for the public to understand how the measures discussed and finalized in this rulemaking will affect certain hospital payments beginning in FY 2013.
Senators ask for a new ACO proposed rule
Seven U.S. senators believe the Accountable Care Organization (ACO) proposed rule will not only cost more than estimated but will not accomplish the program’s goals. They want CMS to try again.
CMS published the ACO proposed rule in the April 7 issue of the Federal Register. The ACO program allows groups of providers to work together to manage and coordinate care for Medicare beneficiaries through an ACO, according to CMS. An ACO may receive payments for shared savings if it meets certain quality performance standards.
Senators Tom Coburn (R-OK), Jon Kyl (R-AZ), Mike Crapo (R-ID), Mike Enzi (R-WY), John Cornyn (R-TX), Pat Roberts (R-KS), and Richard Burr (R-NC) wrote a letter to CMS asking the agency to scrap the current proposed rule and write a new one. The Senators say they have heard concerns from several leading healthcare institutions that believe the proposed rule will fail to accomplish the ACO program’s purpose. The senators also cite an American Hospital Association report which says implementing the ACO program will cost 10 times more than the proposed rule estimates.
The Senators acknowledge that the ACO concept is a worthwhile goal, stating “An ACO model that can increase provider coordination and patient accountability would be a step in the right direction.” However, they believe “this proposed rule misses the target.”
Salary survey results suggest that the economy is on the rebound
The results of the 2011 Case Management Monthly salary survey are in and I am in the process of analyzing the results. We received more than 700 responses from RN case managers (51%), social work (SW) case managers (10%), case management directors (23%), and case management managers/supervisors (16%) from all over the country.
One of the first things I noticed when looking at the figures is that more than half of the respondents (70%) indicated that they received a raise in the last 12 months. That number is up 8% from last year’s results, which could suggest that the struggling economy is on the mend. Of those who received a raise, 42% received a 2% pay increase, 33% received a 3% increase, and 12% received an increase of 1% or less.
A majority of the respondents (70%) also work more than 40 hours a week (see graph below). The most common work week for all case management department employees appears to be between 41 and 50 hours a week. The majority of case management directors (65%), case management supervisors/managers (61%), SW case managers (58%), and RN case managers (51%) responded that they typically work those hours. Interestingly, of the respondents who received raises, 72% work more than 40 hours in a typical week.
Although most case management department employees work more than the typical 40 hour work week, 71% of respondents indicated that they do not receive overtime pay. One of the respondents wrote, “If we work extra they have a set rate, which is unfortunately the same hourly rate I currently make due to my longevity.”
Keep an eye out for part one of the salary survey results in the May issue of Case Management Monthly. Not a subscriber? Head over to the HCMarketplace and sign up today!
Medicaid RACs are coming…someday
CMS has instructed Medicaid agencies to develop Medicaid recovery audit contractor (RAC) programs; however, the implementation date remains unknown.
CMS sent an October 2010 letter to state Medicaid directors, requiring state agencies to submit their plans for RAC implementation or request an exemption. CMS also said in the letter that it expects the Medicaid RAC programs to be fully implemented by April 1, 2011. However, a February bulletin has suspended that deadline indefinitely.
The bulletin states that the April 1 deadline did not give state agencies enough time to address operational issues to ensure compliance with provisions of the final rule, which is yet to be published. CMS plans to issue the final rule later this year and will indicate the new implementation deadline at that time.
In the meantime, you can find out which states have submitted their Medicaid State Plan amendment (SPA) to CMS, at the CMS website. SPAs address the essential elements of the state’s RAC program. To date, all U.S. states and territories have submitted SPAs.
Last chance to participate in the 2011 Case Management Monthly salary survey
We need your help. Please help us better understand your position by completing the 2011 Case Management Monthly Salary Survey. The survey results will be included in an upcoming issue of Case Management Monthly.
The link below will take you to the survey’s Web site; simply click on the link to answer the survey questions online. If the click-through does not work, please cut and paste the URL into the address bar of your browser.
This survey will close on Friday March 4.
Here’s the link to the survey:
http://www.zoomerang.com/Survey/WEB22BSWADRZ5S/
Thank you for your time and assistance.
Associate editor
bamirault@hcpro.com
CMS announces electronic data submission tool for providers
Editor’s note: The following post originally appeared on the Revenue Cycle Institute website.
As it currently stands, providers respond to documentation requests from review contractors such as recovery audit contractors (RACs) and Medicare administrative contractors (MACs) via mail or fax. As evidenced in the past, providers have had a number of problems with this form of coordination. Announced this week, however, is a new option that allows certain providers to make electronic data submissions.
CMS is referring to the new option as “esMD,” (electronic submission of medical documentation.) Phase one of esMD will begin in April 2011. During this phase, according to CMS, certain review contractors will continue to send medical documentation requests via paper mail and providers will have the option to electronically send medical documentation back to the contractor.
Phase two of the initiative—which CMS is hoping to implement in 2012—will entail review contractors electronically sending documentation requests to providers when their claims are selected for review. As of now, the following review contractors are planning to participate in the esMD pilot beginning in April 2011:
- The RACs for regions A, B and D (DCS Healthcare, CGI Technologies and Solutions, Inc, and HealthDataInsights, respectively)
- The MACs for jurisdictions 1, 3, 4, 5, 9, 10, 12, 13 and 14
- The comprehensive error rate testing (CERT) contractor
- The program error rate measurement (PERM) contractor
In addition, CMS anticipates the following review contractors may be participating in the esMD pilot beginning on or before December 2011:
- The RAC for Region C (Connolly Healthcare)
- The MACs for jurisdictions 2, 6, 7, 8, 11
- The durable medical equipment (DME) MACs for jurisdictions A, B, C and D
In order to participate in the pilot of the esMD program, providers will need to use a “gateway” for information exchange. The Nationwide Health Information Network (NHIN) is a set of standards, protocols, legal agreements and specifications that a consortium of health information organizations have agreed are necessary for secure and private exchange of health information over the Internet, according to CMS. The Nationwide Health Information Network Exchange is designed to “connect a diverse set of federal agencies and private organizations to securely exchange health information,” and CMS intends to use it during the esMD pilot.
One crucial piece to transitioning to electronic submission is the selection of a gateway, which are necessary in order take part in the esMD pilot, according to Debbie Mackaman, RHIA, CHCO, regulatory specialist for HCPro, Inc.
“Providers will need to obtain access to a CONNECT-compatible gateway,” she says. “While hospitals may choose to build their own gateway, CMS anticipates that contracting with a health information handler (HIH) that offers esMD gateway services will be the most popular choice.”
While this new development aims to help streamline internal processes, providers should consider a number of factors, Mackaman says.
“First, providers should do a cost-benefit analysis of using esMD versus mailing paper or CDs,” she says. “Facilities already have to absorb the expenses of the existing process since the current copy reimbursement rate of $0.12 per page does not cover the broad range of costs involved with processing even one request.”
Healthcare providers may also want to consider waiting until CMS works out many of the initial bugs and process changes once the phase one option goes live, she adds.
For more details visit the esMD web site at http://www.cms.gov/ESMD.
Additionally, CMS published three frequently asked questions regarding esMD.
CMS issues proposed rule requiring providers to give additional beneficiaries QIO contact info
Medicare-certified providers, including hospitals, home health agencies and others, may soon be required to provide contact information for the local Quality Improvement Organization (QIO) to outpatients and state surveyors.
The February 2 issue of the Federal Register contained a proposed rule that would require select Medicare-certified providers and suppliers to provide Medicare beneficiaries written notice about their right to contact a QIO with quality concerns. Currently, only hospitals inpatients receive QIO contact information, but the proposed rule would extend the requirement to hospital outpatients.
The proposed rule would also require hospitals inform all patients, including Medicare beneficiaries, about State agency contact information.
This proposed rule comes just weeks after CMS issued a proposed rule that would implement a hospital value-based purchasing program, which takes into account patient satisfaction scores. Proving patients with information about how to express quality concerns could be another way for CMS to capture quality across the continuum.
Impact on hospital case managers
In order to meet the proposed change, Sandra McCune, BSN, RN, utilization management specialist at Lakeland HealthCare in St. Joseph, MI, suggests adding the QIO contact information to existing forms, such as the consent for admission and consent for treatment forms. There is no proposed specific form that providers must use, unlike the Important Message from Medicare.
“A copy of the consent form is already maintained in the patient’s record, so that should satisfy the requirement to document that the info was given,” McCune says.
The proposed rule also states that the same contact information must be given at discharge and/or the end of care. McCune suggests adding the QIO contact information to the discharge and post care instructions.
CMS is accepting comments on the proposed rule. To submit a comment, view the instructions in the Federal Register.
Case management salary survey
We need your help. Please help us better understand your position by completing the 2011 Case Management Monthly Salary Survey. The survey results will be included in an upcoming issue of Case Management Monthly.
The link below will take you to the survey’s Web site; simply click on the link to answer the survey questions online. If the click-through does not work, please cut and paste the URL into the address bar of your browser.
Here’s the link to the survey:
http://www.zoomerang.com/Survey/WEB22BSWADRZ5S/
