Quality and Precision Matter in Medical Coding

August 21, 2014

Medical providers need to be wary of vendors who sell compliance products. All companies who espouse compliance are not necessarily compliant.

Within the past few weeks, CMS issued final rules on items that physicians care a great deal about – ICD-10 and reimbursement. Before I delve into the rules themselves, I wanted to provide a "tip" on an item I recently reviewed for a client. The product was a HIPAA Manual to construct the necessary policies and procedures. When I got to the back of the documents and reviewed the "Glossary of Terms" that the company had provided as a supplement to its generic template, I noticed they used "ICD-9-CM and ICD-9-PCS" and that it correlated to "ICD-10-CM and ICD-10-PCS." Anyone with any healthcare industry knowledge knows that CMS only defined ICD-9-CM and that it is broken down into three volumes.

In terms of translating ICD-9-CM to ICD-10, the breakdown follows: ICD-9-CM Vols. I & II translate to ICD-10-CM, while ICD-9-CM Vol. III translates to ICD-10-PCS. ICD-10-PCS, which addresses inpatient treatments and procedures, is specific to the United States as part of the regulations. No other country in the world has this designation. My point in relaying this is that it raised a "red flag" in terms of the other areas of the product, and that providers should not hesitate to send such an item back for a full refund. It also underscores the importance of due diligence - all companies who espouse compliance are not necessarily compliant.

On Aug. 4, HHS issued the final rule implementing section 212 of the Protecting Access to Medicare Act of 2014 (Pub. L. 113-93). The compliance date for ICD-10 was confirmed as being Oct. 1, 2015, representing the third delay. ICD-9 will continue to be used through Sept. 30, 2015; however, some patients will have charges in both ICD-9 and ICD-10 coding designations for a single hospital stay, so particular attention will have to be given to those charges when they are submitted.

According to the Federal Register, HHS delayed ICD-10 again utilizing "the same rationale and methodology in our analysis of costs and benefits in the Regulatory Impact Analysis (RIA) of this final rule, and conclude that a delay of 1-year, as opposed to a longer delay, will be the least costly and most fiscally responsible way to implement the requirements of section 212 of PAMA. We estimate the cost of a 1-year delay to HIPAA covered entities will be $1.1 to $6.8 billion." (Emphasis added).

As I previously mentioned, all is not lost by the delay. The increased knowledge of anatomy and more precise coding can still have a positive impact on physician communications, reimbursement, and the quality of patient care. This last item is important for the FY 2015 Medicare payment policies and rates under the Inpatient Prospective Payment System and Long-Term Hospital Prospective Payment System. The final rule is scheduled to be published in the Aug. 22 Federal Register, but two key quality items are the 1 percent reduction of payments for hospitals in the top quartile for hospital acquired conditions, and readmission penalties are increased from 2 percent to 3 percent.

Taking time to conduct adequate due diligence and continuing with ICD-10 preparation can lead to a positive impact on operations, patient care, and the revenue cycle.