ICD-10-CM implementation date is October 1, 2014 Saturday, Sep 1 2012 

The final rule setting the ICD-10-CM implementation date as October 1, 2014 was released by the Centers for Medicare & Medicaid Services (CMS) on August 24, 2012.

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HHS PROPOSES ONE-YEAR DELAY OF ICD-10 COMPLIANCE DATE Monday, Apr 9 2012 

For Immediate Release: Monday, April 09, 2012
Contact: CMS Office of Public Affairs
202-690-6145

HHS PROPOSES ONE-YEAR DELAY OF ICD-10 COMPLIANCE DATE

(CMS-0040-P)

Action

The Department of Health and Human Services (HHS) today announced a proposed rule that would delay, from October 1, 2013 to October 1, 2014, the compliance date for the International Classification of Diseases, 10th Edition diagnosis and   procedure codes (ICD-10).

The ICD-10 compliance date change is part of a proposed rule that would adopt a standard for a unique health plan identifier (HPID), adopt a data element that would serve as an “other entity” identifier (OEID), and add a National Provider Identifier (NPI) requirement.   The proposed rule was developed by the Office of E-Health Standards and Services (OESS) as part of its ongoing role, delegated by HHS, to establish adopt standards for electronic health care transactions under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).   OESS is part of the Centers for Medicare & Medicaid Services (CMS).

Background

On January 16, 2009, HHS published a final rule to adopt ICD-10 as the HIPAA standard code sets to replace the previously adopted ICD–9–codes for diagnosis and procedure codes (see HIPAA Administrative Simplification;  Modifications to Medical Data Code Set Standards to Adopt ICD-10-CM and ICD-10-PCS,  74 FR 3328). The compliance date set by the final rule was October 1, 2013.

Implementation of ICD-10 will accommodate new procedures and diagnoses unaccounted for in the ICD-9 code set and allow for greater specificity of diagnosis-related groups and preventive services.  This transition will lead to improved accuracy in reimbursement for medical services, fraud detection, and historical claims and diagnoses analysis for the health care system.  Many researchers have published articles on the far-reaching positive effects of ICD-10 on quality issues, including use of specific reasons for patient non-compliance and detailed procedure information by degree of difficulty, among other benefits.

Some provider groups have expressed serious concerns about their ability to meet the October 1, 2013 compliance date.   Their concerns about the ICD-10 compliance date are based, in part, on implementation issues they have experienced meeting HHS’ compliance deadline for the Associated Standard Committee’s (ASC) X12 Version 5010 standards (Version 5010) for electronic health care transactions.  Compliance with Version 5010 is necessary prior to implementation of ICD-10.

All covered entities must transition to ICD-10 at the same time to ensure a smooth transition to the updated medical data code sets.   Failure of any one industry segment to achieve compliance with ICD-10 would negatively impact all other industry segments and result in rejected claims and provider payment delays.   HHS believes the change in the compliance date for ICD-10, as proposed in this rule, would give providers and other covered entities more time to prepare and fully test their systems to ensure a smooth and coordinated transition among all industry segments.

Provisions of the proposed rule announced today

HHS is proposing to change the ICD-10 compliance date to October 1, 2014.

As stated, the ICD-10 compliance date change is part of a proposed rule that would adopt a standard for a unique health plan identifier (HPID), adopt a data element that would serve as an “other entity” identifier (OEID), and add a National Provider Identifier (NPI) requirement.

Standards compliance date

HHS proposes that covered entities must be in compliance with ICD-10 on October 1, 2014.

The proposed rule, CMS-0040-P, may be viewed at www.ofr.gov/inspection.aspx.

A news release on the proposed rule may be viewed at http://www.hhs.gov/news.

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Congress approves measure averting 27 percent physician cut through 2012 Friday, Feb 17 2012 

Special Edition: SGR Update

Congress approves measure averting 27 percent physician cut through 2012

A House-Senate Conference Committee tasked with identifying a compromise to avoid the pending 27.4 percent Medicare physician payment cut reached a 10-month deal that would maintain current physician payment rates through the end of the year. The measure was approved this afternoon by both the House and Senate. The measure now goes to President Obama for his signature. The President is expected to sign the bill.

HHS announces intent to delay ICD-10 compliance date Friday, Feb 17 2012 

News Release
FOR IMMEDIATE RELEASE
February 16, 2012

Contact: CMS Public Affairs
(202) 690-6145

HHS announces intent to delay ICD-10 compliance date
As part of President Obama’s commitment to reducing regulatory burden, Health and Human Services Secretary Kathleen G. Sebelius today announced that HHS will initiate a process to postpone the date by which certain health care entities have to comply with International Classification of Diseases, 10th Edition diagnosis and procedure codes (ICD-10).

The final rule adopting ICD-10 as a standard was published in January 2009 and set a compliance date of October 1, 2013 – a delay of two years from the compliance date initially specified in the 2008 proposed rule. HHS will announce a new compliance date moving forward.

“ICD-10 codes are important to many positive improvements in our health care system,” said HHS Secretary Kathleen Sebelius. “We have heard from many in the provider community who have concerns about the administrative burdens they face in the years ahead. We are committing to work with the provider community to reexamine the pace at which HHS and the nation implement these important improvements to our health care system.”

ICD-10 codes provide more robust and specific data that will help improve patient care and enable the exchange of our health care data with that of the rest of the world that has long been using ICD-10. Entities covered under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) will be required to use the ICD-10 diagnostic and procedure codes.

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BLOG REVIEW: “Are Doctors Infected With The Stockholm Syndrome?” Saturday, May 2 2009 

A companion blog for The Yale Journal for Humanities in Medicine (http://yjhm.yale.edu)

Tuesday, February 17, 2009

Are Doctors Infected With The Stockholm Syndrome?

Medicare is a great social institution. It saves millions of people from financial destitution.

But many doctors feel unfairly treated by Medicare’s payment schedules. For the past two years Medicare has threatened to cut physician reimbursement by 10% in 2008 and by 20% in 2009. After an outcry from physicians, the cuts were eliminated and physicians were given increases of .5% and 1% respectively. Many physicians were relieved to see that the cuts were reduced and some groups including the AMA actually thanked the Medicare Payment Advisory Committee (MedPAC) for being so understanding.

But rather than thank Medicare for the tiny increases which some consider an insult, it would have been better if medicine’s leadership had preserved physicians’ honor and dignity by rejecting them outright.

This pattern of being threatened then given a small reprieve followed by thanking the oppressors bears great similarity to the so-called Stockholm Syndrome which Webster’s New World College Dictionary defines as a psychological state in which hostages sympathize or even become friendly with their captors.

When threatened by severe price cuts that seriously jeopardize their livelihoods doctors may not be kidnapped or locked in closets but they are hostages none the less. And thanking those who oppress them for being so understanding makes them victims of the Stockholm Syndrome.

Clearly, to go from a 20% cut to a 1% increase represents quite a difference in any physician’s income. But still, groveling before Medicare and thanking it for a puny 1% increase is wrong. This weak showing is sure to encourage private insurers to use the same strategy. By threatening to drop doctors from their lists for failure to conform to their standards for quality and cost-efficiency, private insurers will have another tool to control doctors. This control will become acute once electronic medical records are in place and every treatment, test, and consultation ordered by physicians will become instantaneously available to health insurers to see who conforms to their protocols and who doesn’t.

Far better for the future of medicine if its leadership had rejected Medicare’s 1% increase and dedicated the savings to lowering patients’ premiums.

Ed Volpintesta MD

_______________________________________________________________________________

My comment:

This is very true!  I think that this was premeditated by Medicare.  They knew physicians would not accept a small increase of 0.5% or 1%, so how do you get the health care industry to accept it?  Threaten a huge decrease in reimbursement and then come back at the 11th hour with the intended puny increase and act like you are doing physicians a favor…Medicare is a “hero”!  It’s crazy, but it has worked for years now.

Physicians are too busy to fight it because they have to see more and more patients to make ends meet.  So, the insurance companies, including Medicare, keep reimbursements low and physicians have to work harder, see more patients in an hour, and focus on documenting the notes to achieve adequate payment.  Now, we are seeing P4P…Pay for Performance…to get any further increases in reimbursement.  Sounds great right?  Is it really an increase?  I don’t think so.  To improve performance, the physician must reduce the number of patients seen and document more performance measures, which means their reimbursements will go down because they are not seeing as many patients as they did.  So, the increase will bring them up a bit IF they can prove that their performance measures are having a positive effect.  Sounds to me like the physician is working differently to receive the same amount of pay.

We are also looking at reimbursement incentives to implement Electronic Medical Records; however, this typically has made the physician slower and decreases the amount of patients that they can see in a day.  How is that effective for the bottom line?  The cost of EMR is extremely expensive.  In my practice of seven physicians, we are looking at over $100,000 to purchase an EMR.  How do we pay for it if we are seeing fewer patients each day?

Unfortunately, the government and insurance companies are developing regulations and policies without input or direct knowledge of how things actually work in a private practice.  In addition, there is no consistency between health plans, so it takes more employees to appeal denials and keep up with all the specific reimbursement policies.

Physicians in private practice are getting the life sucked out of them.  Insurance companies have created patient antagonism toward their physicians.  Society is pointing fingers at the cost of health care and implying that is the fault of the provider of services.  If that is the case, why do physicians make $100,000 to $300,000 a year, while insurance company executives make near a million or considerably more per year?  Why do the insurance premiums continually increase for both the patient and the employer, while the provider of service sees either flat or decreasing reimbursements?  Yet, insurance companies post health profits each quarter.
Charlene  Burgett, M.S.

High-Risk Screening Paps for Medicare Monday, Apr 27 2009 

Q0091 is for “obtaining the screening Pap”.  If you are doing a woman’s annual “high-risk” pap, you can use this code to obtain it.   If it were a diagnostic pap, this code would not apply.  And, if the physician is NOT doing the pelvic exam (G0101) annually for a high-risk patient, he is throwing money out the window, IMHO.

Medicare allows for a pelvic exam and screening pap every two years; however, if the patient is “high-risk” they are allowed to get a screening pap every 12 months. High-Risk Factors are:

Cervical Cancer High Risk Factors

* Early onset of sexual activity (under 16 years of age)
* Multiple sexual partners (five or more in a lifetime)
* Sexual partners who have multiple sexual partners
* History of a sexually transmitted disease (including HIV infection)
* Fewer than three negative Pap tests within the previous seven years

Vaginal Cancer High Risk Factors

* DES – exposed daughters of women who received DES during pregnancy
* Women (under age 65) who have not had a Pap test in 5 years or more.

High Risk Diagnosis Code= V15.89

When to Use an Advanced Beneficiary Notice (ABN) Thursday, Apr 23 2009 

The use of the ABN is required by Medicare to alert patients when a service will not be paid by Medicare and to allow the patient to choose to pay for the service or to refuse the service. If we do not have a signed ABN from the patient and Medicare denies the service, we have to write off the charge and cannot request the patient to pay for it. The only exception is for statutorily excluded services (those that Medicare never covers like cosmetic surgery and complete physicals for example). In this case, we can still bill the patient for the non-covered service regardless of having a signed ABN. It is, however, a good idea to have the ABN signed for non-covered services so the patient still is aware that they are responsible and we have proof that they knew. Typically, the patient will call our office when they receive our bill and state that “they were never told”, “they weren’t aware”, or a similar complaint. With a signed ABN, we have proof that we have their informed consent to provide the service and their agreement to be financially responsible for the service. In the past, Medicare had a “Notice of Exclusion of Medicare Benefits” (NEMB) that we could provide to the patient (no signature required) to alert them of Medicare’s non-covered services. The ABN has replaced the NEMB.

The typical reasons that Medicare will not cover certain services and that would be applicable to our office are:

  1. Statutorily Excluded service/procedure (non-covered service)
  2. Frequency Limitations
  3. Not Medically Necessary

Statutorily Excluded items are services that Medicare will never cover, such as (not a complete list):

  • Complete physicals (excluding Welcome to Medicare Screenings, with caveats)
  • Most immunizations (Hepatitis A, Td)
  • DME supplies (splints, personal comfort items)
  • Cosmetic surgery

For these items, it is a good idea (not a requirement) to complete the ABN and have the patient check the appropriate box under options and sign the ABN. For the sake of our billing department, I strongly encourage the use of ABN’s for statutorily excluded items.

Frequency Limitations are for services that have a specific time frame between services. For example, for normal pap smears Medicare allows one every 24 months. If the patient wants one every 12 months for their piece of mind, Medicare will pay for year one and the patient will pay for year two and that pattern continues. The ABN needs to be on file for the year that the patient is responsible for paying. If the patient fits Medicare’s guidelines for “high risk” they are allowed to have the pap every 12 months and no ABN is required.

Services that are not considered Medically Necessary are those that do not have a covered diagnosis code based on Local Coverage Determinations. One example is for excision of a lesion. If the lesion is being removed because the patient just doesn’t like how it looks, that is considered cosmetic surgery. If the lesion is showing some changes (i.e. bleeding, growing, changing color, etc), then it is considered medically necessary because it potentially can be malignant. The removal needs to have diagnosis coding to substantiate the medical necessity and Medicare has Local Coverage Determinations that lists all the codes/coding combinations that Medicare will approve for payment.

A rule of thumb in trying to discern the necessity of ABN’s is to discern whether or not Medicare ever will cover the service and if there may be some times that the service isn’t covered. The times the service isn’t covered, an ABN is required. To illustrate this point, I will use two examples:

·EKG’s are covered for certain cardiac and respiratory conditions. The only time an EKG is covered for preventive screening is during the patient’s first year enrolled in the Medicare program and when being doing during the Welcome to Medicare screening. After that time, Medicare will never cover an EKG for preventive screening. To notify the patient of this and to show that the patient agrees to be financially responsible for the EKG, an ABN will need to be completed.

·Another example is for the Tetanus immunization. Medicare will cover tetanus when medically necessary; basically if the patient has cut themselves and the tetanus is provided due to that injury. If the tetanus is provided to the patient because it has been ten years since the last tetanus and the tetanus is not in response to a recent injury, then it will be non-covered because it is not “medically necessary” and the ABN will need to be on file.

ABN’s need to be completely in entirety. The “Options” box can only be completed by the patient and it states that “We cannot choose a box for you”. That would appear to be coercion.  A “blanket” ABN, one that is signed by the patient for all services provided within a certain time period, is not acceptable and is illegal.

In addition, there is a small area to provide additional information that can be used by either the patient or the provider’s office. This could be anything pertinent to the information that the ABN covers. The bottom of the form is where the patient signs and dates. We keep the original ABN in the chart behind the progress note for that day. We MUST provide a copy of the signed ABN to the patient.

The current ABN form with instructions can be found at:

http://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN.html

If a procedure is denied by Medicare and the physician does not have a signed ABN prior to the service being rendered, the service can not be billed to the patient and will need to be written off the physician’s books.  Sometimes a patient may refuse to sign the ABN, if this is the case it is appropriate for the physician to document the refusal and sign, along with having a witness sign.  Medicare will accept this and the patient can be billed for the service if denied by Medicare.

There are some additional billing requirements in the form of modifiers.  The modifiers are applied to the service that the ABN was utilized:

GA:  The ABN is signed, but the service may not be covered.

GY:  A “statutorily excluded” service.

GZ:  The service is expected to be denied as not reasonable or necessary.  This is typically used when there is a secondary payer that requires the Medicare denial before they pay benefits.

The use of the ABN is often misunderstood; however, it is the only way a patient can be informed about their financial responsibility prior to agreeing to a service being rendered.  This is an issue that the OIG has reportedly been interested in investigating for fraud and abuse.