Making Sense of Healthcare's Regulatory Alphabet Soup

October 13, 2015
Keith L. Martin

Major developments on ICD-10 and meaningful use are just the latest news out of Washington, D.C., affecting physicians and practices.

It's been a pretty significant two weeks for physicians and medical practices nationwide with the implementation of the ICD-10 coding system and significant rule development on the meaningful use of EHRs.  For physicians and practices who often feel like they are on the Titanic of government regulations, this is just the tip of the proverbial iceberg.

As part of their "Washington Update" at this year's Medical Group Management Association (MGMA) Annual Conference in Nashville, Tenn., on Monday (Oct. 12), Jennifer McLaughlin, a senior government affairs representative for MGMA, and Suzanne Falk, a government affairs representative, also at MGMA, educated attendees on the current status of the sea of regulatory alphabet soup affecting their practice's bottom line.

The duo provided major update and guidance on government regulations, including:

ICD-10
In the 12 days since the rollout of ICD-10 coding system, both McLaughlin and Falk noted that things have been "quiet" at practices, with initial payments carrying the new codes being processed and even paid.

"This has a lot to do with the preparation and due diligence [over the years]," noted McLaughlin.

The next major things to watch, she noted, will be CMS' handling of non-specific ICD-10 codes on claims submitted by practices for Medicare patients. The federal agency announced a one-year grace period for providers, where it will not deny claims carrying such codes if they are from the appropriate "family" of codes for the condition.  McLaughlin said that while this will prevent the "floodgates" of denials from Medicare auditors, it won't stop all ICD-10-related issues with these claims.

Another major thing to watch, McLaughlin noted were the four U.S. state Medicaid plans - in California, Louisiana, Maryland, and Montana - who are not ready for ICD-10 and are actually reverse coding claims from the new code set back to ICD-9. "Our concern here is that this will lead to pending or rejected claims in these states, so we'll be watching that," she noted.

NEXT: Meaningful Use

Meaningful Use
In the days since CMS announced modifications to the Stage 2 rules of meaningful use and finalized the Stage 3 rules, physicians have been coming to grips with what it means for them this year.

From reducing the reporting period to 90 days (vs. a full year) to reducing thresholds for practices to view, download, and transmit patient data, CMS made key changes to the use of EHRs, McLaughlin and Falk said. In addition, there are opportunities for medical practices to apply for hardship exemptions to meeting meaningful use, including if they switch EHR systems or if their EHR system becomes decertified.

Another key piece of last week's announcement regarding the EHR Incentive Programs, McLaughlin noted, was the recognition by CMS that the core objective of "protecting patient health information" -better known as having a HIPAA security risk analysis - has been a major obstacle for those attesting to meaningful use.

"CMS has confirmed, for the first time, that it is this [objective] that is the leading cause of failed meaningful use audits," McLaughlin said. "You do need to have a security risk analysis in place at your practice and there are plenty of resources to get that done."

But the one area where MGMA has issued its displeasure with meaningful use is in the finalization of the Stage 3 rules. MGMA, like other organizations, has pushed for the delay of implementing Stage 3 while physicians digest the Stage 2 rules.

"The entire healthcare community is galvanizing around a delay of meaningful use Stage 3," said McLaughlin. "This came out before the [abolishment of the Medicare Sustainable Growth Rate formula and the Merit-Based Incentive Payment System (MIPS)] … so CMS should really wait until all providers are successful in Stage 2 or have the ability to succeed in Stage 2... then issue changes in Stage 3."

NEXT: PQRS

Physician Quality Reporting System (PQRS)

Before it becomes one of the key components of MIPS, physicians still need to focus on accurate reporting for PQRS. Especially in 2015, as the program has moved out of the incentive phase and into the penalty phase - 2 percent this year for failing to report 2015 data.

Practices also have through Nov. 9 to appeal 2016 PQRS penalties for data reporting from 2014, so McLaughlin urged attendees to take a good look at their data.

"Since this is the first year of the penalty phase, there is some confusion," she said. "I'd encourage [practices] to look at their PQRS report and see if maybe they missed the reporting requirements on something that was out of your control. If that's the case, it can't hurt to try [to appeal] and get out of that penalty."