Tag: coding

Revenue Cycle Management

Clear up EOB Confusion

Remember: An EOB is not a bill.

Working in the healthcare field, you know that acronyms are a part of your daily life. From the Health Insurance Portability and Accountability Act (HIPAA); to local coverage determinations (LCDs); to relative value units (RVUs) — as a coder, you are constantly bombarded by acronyms.

It’s common for one such acronym, explanation of benefits (EOB), to cause confusion among patients. Read on to learn more about EOBs, as well as remittance advice (RA).

Delve Into How EOBs Work

Insurance companies send EOBs to patients two to three weeks after their initial appointment.

“EOBs are insurers way of explaining their reimbursement, based on the CPT® codes and ICD-10 codes submitted,” says Catherine Brink, BS, CMM, CPC, president of Healthcare Resource Management in Spring Lake, New Jersey. “EOBs usually list the service provided was approved or not approved, the amount a provider charged, the amount approved by the insurer, the amount paid by the insurer, the amount you may be billed, then a code that indicates how the claim was paid, denied, or partially paid based on the patient’s policy. This is explained in detail on the EOB.”

Don’t miss: Although patients often mistake an EOB for a bill, an EOB is not a bill.

“Most patients do not understand EOBs or the definition of the acronym ‘explanation of benefits,’ which means what the insurer will pay based on your particular policy,” Brink says.

Check out this example from Brink: A participating provider charges $200 for a service. Medicare’s approved amount for this service is $160. Medicare pays 80 percent of $160-$128. The 20 percent difference, $32, is the patient’s responsibility to pay. If the patient has a Medigap insurance plan, then that $32 is usually paid by insurer depending on the insurance plan. The $40 difference from what the par provider charged and the Medicare approved amount must be written off by the par provider since it is part of the par contract with Medicare. Biller and coders must understand this and adjudicate the remittance advise, which is sent to the provider, correctly.

Note: An EOB is sent to the patient and an RA is sent to the provider. The patient needs to understand the EOB since he is responsible for the 20 percent.

Helpful tip: When asked how practices can help ease the confusion patients often have about EOBs, Brink says practices should explain to patients what the EOB will tell them and try to help them interpret it.

Practices could let their patients bring in EOBs and explain them. Practices could post this on their websites as a helpful service they provide, Brink adds.

Some practices offer education classes for patients to teach them about EOBs, and the patients like these classes, Brink says. “I see this in bigger practices who have the personnel to do this, for instance, education sessions, such as breakfast seminars.”

Practices Should Utilize RAs to Ensure Maximum Reimbursement

While an EOB is sent to the patient, a RA is sent to the provider who billed the service, according to Melanie Witt, RN, MA, an independent coding expert based in Guadalupita, New Mexico.

“Both types of statements provide an explanation of benefits, however,” Witt says. “The content of the RA and the EOB is nearly identical with the exception of a few minor items.”

Both RAs and EOBs contain the following information, according to Witt:

  • Information regarding the patient
  • The service provider
  • Any adjustments made to the claim
  • The type of procedure performed
  • The date the procedure was performed
  • The cost of the procedure
  • An explanation if the payment was denied

“Additional information regarding the patient’s benefits is often included as well, including the particulars of the plan, such as co-payments and deductibles,” Witt adds.

The major difference between RAs and EOBs is that an EOB contains a disclaimer stating the EOB is not a bill, according to Witt.

Example: For example, at the top of an EOB for Cigna, you will find the statement: “THIS IS NOT A BILL. Your health care professional may bill you directly for any amount you owe.”

Practices should utilize their RAs to streamline their processes.

“All billing staff should spend time studying the reasons cited for adjustments or denials from the RA they received,” Witt says. “Each RA message should be tracked to ensure that any patterns of inappropriate adjustments (incorrect use of a modifier, bundling issue, reduction for secondary procedure, etc.) or denials (code not covered, code bundled, demographics incorrect, not medically necessary, etc.) are addressed to ensure maximum reimbursement.”

Billers should also use RAs to compare what was paid to the published fee schedule from the insurer, Witt adds.

-originally posted from TCI Supercoder June 26, 2018

Revenue Cycle Management

4 Common Myths on Reporting Heart Failure Dx Codes

ICD-10 can be tricky to master with the sheer number of diagnoses to choose from, sequencing rules, and special notes. However, you don’t have to sacrifice precious dollars in your cardiology practice.

Bust these four myths to streamline your heart failure claims.

Male anatomy of human organs in x-ray view

Myth 1: Acute and Chronic Heart Failure Develop at Same Rate

Truth: Acute heart failure develops suddenly, and the symptoms are initially severe. On the other hand, chronic heart failure usually develops slowly, over time.

“Patients with chronic heart failure have a previous history of heart failure and are on long-term management such as medications to control the heart failure,” says Carol Hodge, CPC, CDEO, CCC, CEMCcertified medical coder of St. Joseph’s Cardiology in Savannah, Georgia explains. “Chronic heart failure is an established form of heart failure that can be controlled, but not cured.”

Coding solution: If the physician documents acute diastolic congestive heart failure, you would report I50.31 (Acute diastolic (congestive) heart failure). However, if the physician documents chronic diastolic (congestive) heart failure, you would report I50.32 (Chronic diastolic (congestive) heart failure).

Myth 2: ADHF Doesn’t Involve Worsening of Heart Failure Symptoms

Truth: Acute on chronic heart failure (ADHF) is the sudden symptomatic worsening of heart failure (established known heart failure), says Julie-Leah J. Harding, CPC, CPMA, CEMC, CCC, CRC, CPEDC, RMC, PCA, CCP, SCP-ED, CDIS, AHIMA-approved ICD-10 trainer and ambassador and director of revenue operations-cardiovascular surgery at Boston Children’s Hospital in Boston, Massachusetts.

ADHF typically includes dyspnea with physical activity and or lying flat, the patient may have gasping for breath while walking, lower extremity swelling, fatigue, pulmonary edema (chest congestion), palpitations, loss of appetite, weight loss, low urine output, confusion and memory issues, according to Harding.

When chronic heart failure becomes uncontrolled, it is referred to as acute on chronic, and symptoms such as increased shortness of breath and pedal edema, may occur, according to Hodge.

“The worsening of these symptoms on top of the chronic condition is referred to as ‘acute on chronic,’” Hodge explains. “Once the acute phase isresolved, it is returned to being referred to as ‘chronic.’”

Coding solution: The physician documents acute on chronic right heart failure. You should report I50.813.

Myth 3: Specificity Not Important in Heart Failure Documentation

Truth: When it comes to heart failure documentation, specificity is vital. As Harding emphasizes, “You can offer any magnitude of ICD-10 codes, but if it is not documented, you cannot report them.”

“The most common mistake I see in reporting heart failure is that documentation only supports heart failure, unspecified,” Hodge says. “Providers need to be educated to document whether the heart failure is systolic, diastolic or combined. And, is it right or left heart failure? “

Harding talks about her experience from the congenital heart disease perspective.

“In the congenital heart disease world, most of our patients have a form or element of heart failure, according to Harding. “Our struggle, and it is common in the acquired world as well, is the lack of specificity in provider/clinician documentation.”

We seldom receive “acute,” “chronic,” or “acute on chronic” written in the patient record, Harding adds. We often query the providers for clarification.

Myth 4: You Can Ignore “Code First” Notes

Truth: You should also pay close attention to “code first” notes in ICD-10.

For example, a “code first” note under category I50- (Heart failure) tells you to sequence heart failure due to hypertensive heart and chronic kidney disease.

A common error she sees is coders not using the combination codes or the hypertensive with heart disease codes, according to Hodge.

“These codes should be used to indicate hypertensive heart disease followed by the code for the type of heart failure,” Hodge adds. “Kidney disease very often occurs with hypertension and congestive heart failure, and those guidelines should be followed to correctly sequence those codes.”

Coding solution: The physician documents that the patient has hypertensive heart and chronic kidney disease with acute systolic (congestive) heart failure and with stage 5 chronic kidney disease. You would report the codes in the following order: I13.2 (Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease); I50.21 (Acute systolic (congestive) heart failure); N18.5 (Chronic kidney disease, stage 5).

-originally posted on TCI supercoder, June 26, 2018

New Patient Image
MDSuitemedical billingMedical Billing and CodingMedisoft

What Makes A New Patient “New”?

A patient makes an appointment at your clinic and “has never been seen before”, you bill a new patient visit only to have the payer reject the claim, stating, “New patient qualifications have not been met”.

So, what went wrong?  Not all Evaluation and Management (E/M) codes fall under the new (versus established) categories.  For example, if the patient presents through the Emergency Department, the patient is always new, and the provider is always expected to get the patient’s history to diagnose a problem.  However, in the office setting, the patient sees their primary provider routinely.  The provider knows- or can quickly access- the patient’s history to manage their chronic conditions, as well as make decisions on recent problems.

The definition of a new patient in the CPT code book is: “one who has not received any professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.”  In addition to this definition, CMS adds “an interpretation of a diagnostic test, reading an X-ray or EKG etc., in the absence of an E/M service or other face to face service with the patient does not affect the designation of a new patient.”[i]

Three key components that make up a new patient are:

  1. Professional Service (not modifier 26)– If the provider has never seen the patient face to face, a new patient code should be billed.
  2. Three-year rule- the general rule to determine if a patient is “new” is to check to see if that patient has been seen in the past three years. Check your dates on this-if the patient was seen the last time in May of 2015 and its March of 2018, it hasn’t been three years, according to the payer.
  3. Different specialty/subspecialty within the same group is possibly the most confusing. For Medicare patients, use the NPI registry to see what specialty the physician’s taxonomy is registered under.  The credentialing process is of upmost importance in ensuring no denials happen due to improper credentialing.

What happens when doctors switch practices?

If a doctor changes practices and takes his patients with him, the provider cannot bill for the patient as a new patient based on the “new” tax ID.  The tax ID doesn’t matter because the provider has already seen these patients and has established a history.  Just because the patient is being seen in a new facility, that patient is still seeing the same provider.

What happens when a provider sends the patient to mid-level provider?

When an MD or DO sends a patient to a mid-level provider (Nurse Practitioner or Physicians Assistant) and the visit is not an incident-to, the mid-level provider could bill a new patient code if they are a different specialty with different taxonomy codes.  An example would be a family practitioner and the mid-level sees hematology patients.  Since the specialty is different, the mid-level could bill as a new patient visit.  However, if the mid-level is also considered family practice, then a new patient visit code could not be used.

Of course, in billing there are always exceptions to the rules.

For example:

  • For some Medicaid plans, obstetric providers need to bill an initial prenatal visit with a new patient code, even if they have seen the patient for years prior to the patient’s pregnancy. Make sure you check your own local rules and Medicaid plans if you are billing obstetrics.
  • Hospitalists and Internal Medicine providers are the same specialty according to Medicare, even though each has a different taxonomy code.

If a new patient claim is denied, look to the medical record to see if the patient has been seen in the past three years by your group.  If so, check to see if the patient was seen by the same provider or a provider of the same specialty by checking the NPI registry website.  It’s always helpful to know how the provider is registered with the payer denying the claim.  If in researching all of this, there isn’t any substantiating evidence to support the denial, appeal the claim.

 

[i] Medicare Claims processing manual, chapter 12-Physican/Nonphysician Practitioners (30.6.7)

electronic patient recordICD-10MACRAmedical billingMedical Billing and Coding

New PT CPT Codes for 2017

pt-with-patient

CPT® 2017 has a few expanded codes for physical therapy evaluations and follow-up exams.  These codes are in effect for dates of service starting January 1, 2017.

97001 to be replaced by three codes in 2017:

These new codes will add more specificity and details regarding the scope of the evaluation and states that it involves clinical decision-making of low/moderate/high complexity. The evaluation includes history to identify any factors that impact the plan of care; using standardized tests and measures to assess body structures and functions that may limit activity or restrict participation; and evaluation of the patient’s current status on presentation. The evaluation typically includes face-to-face time with the patient and/or family.

97161 Physical therapy evaluation: low complexity, requiring these components: A history with no personal factors and/or comorbidities that impact the plan of care; An examination of body system(s) using standardized tests and measures addressing 1-2 elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; A clinical presentation with stable and/or uncomplicated characteristics; and Clinical decision making of low complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 20 minutes are spent face-to-face with the patient and/or family.
97162 Physical therapy evaluation: moderate complexity, requiring these components: A history of present problem with 1-2 personal factors and/or comorbidities that impact the plan of care; An examination of body systems using standardized tests and measures in addressing a total of 3 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; An evolving clinical presentation with changing characteristics; and Clinical decision making of moderate complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 30 minutes are spent face-to-face with the patient and/or family.
97163 Physical therapy evaluation: high complexity, requiring these components: A history of present problem with 3 or more personal factors and/or comorbidities that impact the plan of care; An examination of body systems using standardized tests and measures addressing a total of 4 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; A clinical presentation with unstable and unpredictable characteristics; and Clinical decision making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 45 minutes are spent face-to-face with the patient and/or family.

CPT® 2017 adds 97164 to replace 97002 (Physical therapy re-evaluation).

The new code adds more specificity and details regarding the scope of the evaluation, which includes history review and standardized tests (criteria established and agreed upon by a group of experts) and measures to assess body structure and function; a revised plan of care using standardized instrument and measurable functional outcome assessment tool; and typically involves 20 minutes of face-to-face time with patient and/or family.

Consider these to be the equivalent of E&M codes (99000) for Physical Therapy.  You should now consider these elements when coding for services:

  • Patient’s history
  • Examination results
  • Clinical decision-making
  • Development of the care plan

The level of the PT evaluation performed depends on the clinical decision-making and the patient’s severity, according to CPT® instruction. For reporting, PTs must demonstrate review of these body regions and body systems:

  • Defined body regions such as the head, neck, back, lower extremities, upper extremities, and trunk
  • Musculoskeletal systems, which include gross symmetry, range of motion, strength, height, and weight
  • Neuromuscular systems, which includes gross coordinated movement and motor function
  • Cardiovascular and pulmonary systems, which include heart and respiratory rates, blood pressure, and edema
  • Integumentary system, which means assessing the pliability, scar formation, color, and integrity of the skin

One other thing-make sure to sequence these codes before your modality CPT codes (those starting at 97010).

OT and AT have similar changes.  Look for those in a future post.

References:
CPT® 2017 Professional Edition, American Medical Association, pages 664-668
Federal Register, Vol. 81, No. 136, Pat. 46162, July 15, 2016, “Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other revisions to Part B for CY 2017; Medicare Advantage Pricing Data Release: Medicare Advantage and Part D Medicare Advantage Provider Network Requirements’; Expansion of Medicare Diabetes Prevention Program Model”
AAPC Healthcare Business Monthly, November 2016

 

ICD-10Medical Billing and CodingMedisoft

It’s the holiday season….time to spread the Flu!

santa-hat

With all the weather changes we have experienced in the south over the past few months, getting the flu has been the last thing on anyone’s mind.  80 degree temps here in Kentucky in November is unheard of!  We’ve all been taking advantage of getting out in the fresh air (flu?  what flu?).

Well, now we are experiencing our first “Arctic Blast” and my first trip to Kroger this week resulted in witnessing probably the most embarrassing thing we as parents experience….projectile vomiting from a child in the grocery store.  Okay, maybe not the most embarrassing thing in the world but one that certainly had me running for the hand sanitizer and masks (no-I didn’t stick around to help).

And yes, remembering that in fact, the flu season is upon us.

Guidelines for Billing Influenza Vaccines

Medicare pays for one seasonal influenza virus vaccination per influenza season (12 months do not have to pass). Annual Part B deductible and coinsurance amounts do not apply for the influenza virus and the pneumococcal vaccinations. All physicians, non-physician practitioners, and suppliers who administer these vaccinations must take assignment on the claim for the vaccine.

Medicare will pay both administration fees when a beneficiary receives both the seasonal influenza virus and the pneumococcal vaccines on the same day. Report ICD-10-CM diagnosis code Z23 Encounter for immunization when an individual receives both vaccines, but report separate administration codes for the seasonal influenza virus (G0008) and pneumococcal (G0009) vaccines.

Medicare Payment Allowances for this flu season (8/1/2016-7/31/2017)

CPT® Code Payment Allowance
90630 Influenza split virus vaccine, quadrivalent (IIV4), preservative free, for intradermal use $20.343
90653 Influenza virus vaccine, inactivated, subunit, adjuvanted, for intramuscular use $37.383
90654 Influenza virus vaccine, split virus, preservative-free, for intradermal use Pending
90655 Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.25 mL dosage, for intramuscular use Pending
90656 Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.5 mL dosage, for intramuscular use $17.717
90657 Influenza virus vaccine, trivalent (IIV3), split virus, when administered to children 6–35 months of age, for intramuscular use Pending
90661 Influenza virus vaccine, trivalent (ccIIV3), derived from cell cultures, subunit, preservative and antibiotic free, 0.5 mL dosage, for intramuscular use Pending
90662 Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use $42.722
90672 Influenza virus vaccine, quadrivalent, live (LAIV4), for intranasal use $26.876
90673 Influenza virus vaccine, trivalent (RIV3), derived from recombinant DNA (RIV3), hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use $40.613
90674 Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, preservative and antibiotic free, 0.5 mL dosage, for intramuscular use

*NOTE-Claims for this code must be held until 1/1/17

$22.936
90685 Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.25 mL dosage, for intramuscular use $26.268
90686 Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.5 mL dosage, for intramuscular use $19.032
90687 Influenza virus vaccine, quadrivalent (IIV4), split virus, when administered to children 6–35 months of age, for intramuscular use $9.403
90688 Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.25 mL dosage, for intramuscular use $17.835

 

HCPCS Level II Code Payment Allowance
Q2035 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Afluria) $16.284
Q2036 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Flulaval) $16.284
Q2037 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluvirin) Pending
Q2038 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluzone) Pending
Q2039 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (not otherwise specified) Flu Vaccine Adult – Not Otherwise Classified: Payment allowance is to be determined by the local claims processing contractor.

The payment allowance for some codes is still pending. Check the CMS website periodically for updates.

Resources:

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/VaccinesPricing.html

https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Provider-Partnership-Email-Archive-Items/2016-12-08-eNews.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=descending#_Toc468862699

 

 

Integrated Cloud Based Solutions

Other changes for 2014

sunriselogo2009With all the chatter going on with ICD-10, I thought it appropriate to write something that doesn’t revolve around ICD-10.  There are changes in Meaningful Use stage 1, and new criteria for Stage 2 Meaningful Use, Clinical Quality Measures and PQRS.  Happy reading!

If you have attested for at least 2 years for stage 1 meaningful use, then stage 2 is next on the docket for your practice. If you have attested once for stage 1 then all those things you attested to before now will change this year. Stage 1 requirements change in 2014 as well as Stage 2 Meaningful Use objectives for those of you who have successfully completed two years of Stage 1.

 Let’s first tackle those changes in 2014 to Stage one Meaningful Use:
1. Electronic Health Record (EHR) software systems have to re-certify their product to meet new regulations for 2014. Right now your current EHR has undergone the certification process for 2014 and will be available early spring of 2014.
2. For those of you that plan on doing stage 1 in 2014, certain “core” and “menu” objectives have been removed/combined and you can no longer count measure exclusions toward meeting menu objectives. You will have to meet 5 of the 9 menu items and 13 (as opposed to 15 in previous years) core objectives.
3. Clinical Quality Measure reporting will change as well. You will have to report on 9 and those 9 need to cover at least 3 of the 6 National Quality Strategy Domains. I’ve explained more later on.
4. Reporting is done in one calendar quarter, as opposed to 90 consecutive days previously (for example, April 1 2014- June 30, 2014). Rules for Medicaid incentive have not changed for 2014 so you can report for any continuous 90 days under Medicaid.
5. This is the last year you are eligible to begin to get incentive payments. If you are planning to start your first year this year you can still earn as much as $24,000 in incentives. AND your meaningful use performance in 2014 will be the basis for 2016 payment adjustments.
6. CPOE Denominator changes-now required (you will not be able to exclude from this measure).
7. Vital sign age limit is 3 years and older (changed from 2 years and older) for blood pressure and no age limit on height and weight. Since BP is separate, you can exclude from the BP measure.
8. The old stage 1 requirement for providing patients with an electronic copy of their health information upon request will be changed in 2014 to “Provide patients the ability to view online, download and transmit their health information within 4 business days of the information being available to the EP”.
9. The old stage 1 requirement for providing patients timely electronic access to their health information within 4 business days will be changed in 2014 to “More than 50 percent of all unique patients seen by the EP during the EHR reporting period are provided timely (within 4 business days after the information is available to the EP) online access to their health information subject to the EP’s discretion to withhold certain information”.

Moving on to what is next with Stage 2 Meaningful Use.

Stage 2 retains the same basic structure as Stage 1; however, all those Menu items in stage 1 become CORE items for Stage 2 with higher thresholds that you must achieve. There are also some new Stage 2 core and menu objectives.

STAGE 1

STAGE 2

 

13 Core Objectives 17 Core Objectives
5 of 10 Menu Objectives + 3 of 6 Menu Objectives
18 total objectives 20 total objectives

+CQM’S

=STAGE 2 MEANINGFUL USE

What are the requirements?
17 Core Objectives – These are objectives that everyone who participates in Stage 2 must meet. Some of the core objectives have exclusions, but many do not.
3 of 6 Menu Objectives – You only have to report on 3 out of the 6 available menu objectives for Stage 2. You can choose objectives that make sense for your workflow or practice. Again, some of these objectives have exclusions.

The following is a list of the Stage 2 Meaningful Use 17 Core Objectives
1. Use computerized provider order entry (CPOE) for medication, laboratory and radiology orders
2. Generate and transmit permissible prescriptions electronically (eRx)
3. Record demographic information
4. Record and chart changes in vital signs
5. Record smoking status for patients 13 years old or older
6. Use clinical decision support to improve performance on high-priority health conditions
7. Provide patients the ability to view online, download and transmit their health information
8. Provide clinical summaries for patients for each office visit
9. Protect electronic health information created or maintained by Certified EHR Technology
10. Incorporate clinical lab-test results into Certified EHR Technology
11. Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach
12. Use clinically relevant information to identify patients who should receive reminders for preventive/follow-up care
13. Use certified EHR technology to identify patient-specific education resources
14. Perform medication reconciliation
15. Provide summary of care record for each transition of care or referral
16. Submit electronic data to immunization registries
17. Use secure electronic messaging to communicate with patients on relevant health information
In addition to the 17 core objectives, there are 6 Menu Objectives (and remember, you’ll only have to do 3 of the 6).
1. Submit electronic syndromic surveillance data to public health agencies ($-for the additional interface)
2. Record electronic notes in patient records
3. Imaging results accessible through CEHRT
4. Record patient family health history
5. Report cancer cases to a public health central cancer registry
6. Report specific cases to a specialized registry
Important Note: While there are exclusions provided for some of these menu objectives, you cannot select a menu objective and claim the exclusion if there are other menu objectives that you could report on instead.

Changes to Clinical Quality Measures
Beginning in 2014, the reporting of clinical quality measures (CQMs) will change for all providers.
You have the option of submitting three months of CQM data online through the CMS Registration & Attestation System. This will be the same website you go to for attestation now.
You also have the option to submit a full year of data electronically using the QRDA format to receive credit for the EHR Incentive Program and the Physician Quality Reporting System.
Please note that your attestation for the Medicare EHR Incentive Program is not complete until you submit clinical quality measure data, so your EHR incentive payment will be held until your electronic submission is processed.
If you are a provider using Medicaid, you must submit your clinical quality measurement data to your State Medicaid Agency.
How to Select CQM’s in 2014
Beginning in 2014, eligible professionals must select and report on 9 of a possible list of 64 approved CQMs for the EHR Incentive Programs.
There is also a new requirement in 2014 that the quality measures selected must cover at least 3 of the 6 available National Quality Strategy (NQS) domains, which represent the Department of Health and Human Services’ NQS priorities for health care quality improvement. The 6 domains are:
• Patient and Family Engagement
• Patient Safety
• Care Coordination
• Population and Public Health
• Efficient Use of Health Care Resources
• Clinical Processes/Effectiveness
In short there are a lot of changes this year in addition to ICD-10 implementation.

Stay tuned….

Sunrise Services, LLC

 

Integrated Cloud Based Solutions

ICD-10 Walking Through the Workflow

With less than a year to go until the ICD-10 code set implementation deadline, physician practices should be pursuing a comprehensive plan designed to ensure a smooth coding transition with minimal cash flow disruption.

A key step in any ICD-10-CM transition strategy is to conduct a detailed assessment of existing workflows and processes to determine which elements will require modification, according to Bess Ann Bredemeyer, a consulting director with McKesson Business Performance Services (BPS).

By identifying each point in the claims lifecycle that ICD-10- CM will touch, appropriate adjustments can be made and simulations conducted to test the new processes against real-world conditions.

“The best way to proceed with an assessment is to begin at the patient encounter and then move through to the claim drop and denial management,” Bredemeyer said. “That way you won’t miss anything.”

Clinical Documentation  Whether the clinical documentation is sent directly to a coder or to data entry personnel, it is also important to ensure that any changes in National Coverage Determinations (NCDs) and payer’s Local Carrier Determinations (LCDs) are incorporated and reflected in the claim. A good approach includes:

  • Identifying the top 50 most utilized diagnoses codes
  • Evaluating where additional documentation will be required
  • Mapping out modifications to support appropriate reimbursement
  • Updating charge tickets, super-bills and other revenue cycle tools

This is a Test  With all the elements theoretically in place, it is critical to begin testing your new workflow to determine if it can handle ICD-10-CM. Code audits can assess both clinical documentation and coding to determine whether the claims should come through clean or not. A real-world testing process may also reveal previously unknown problems that would otherwise remain hidden until the ICD-10 go-live.

Don’t Be Denied  Because of the complexity of ICD-10-CM and the sheer magnitude of the change, it’s reasonable to assume that even the best-laid plans may encounter some unexpected problems. For that reason, it makes sense to be prepared for a rise in denials. For physician practices, that means ensuring that staffing is adequate to manage an increase in volume, and that problems will be quickly identified and remediated.

“There is no denying that the transition to the new code set will require planning and resources to mitigate the burden of change,” Bredemeyer said. “That’s why you should get started now on developing a workflow analysis impact assessment that will help you develop a detailed ICD-10 timeline and budget.”

Article Resource:

ReveNEWS, Industry Spotlight, “Walking Through the Workflow- An Important First Step,” November 2013 edition located on the McKesson ReveNEWS website

 medisoft