ICD-10. It’s here. It’s not. It’s here again. It’s pushed back further. In the wake of the unexpected ICD-10 delay, healthcare organizations remain at odds over what happened and what comes next.
While some providers are deeply relieved, other organizations are worried about how the delay will affect their financials.
Many organizations have already spent millions of dollars in preparation, readiness assessments, gap analysis audits, education and training to mitigate the risk associated with the ICD-10 transition. The efforts put forth toward ICD-10 transition have likely improved the documentation in the inpatient setting to increase reimbursement with proper MS-DRG assignment and resulting case mix index.
However, have we adequately addressed documentation and its impact on quality measures such as patient safety indicators, mortality and hospital-acquired conditions?
Supporting these and other categories of quality regulation goes hand in hand with how we show how sick our patients are. This impacts patient care resourcing, population health modeling and severity-adjusted modeling.
AHIMA lists quality measures as number 1 on the top 10 reasons to move forward with ICD-10. “Without ICD-10 data, serious gaps will remain in the healthcare community’s ability to extract important patient health information needed for physicians and others to measure quality care.”
Many hospitals focus their efforts to mitigate risk associated with ICD-10 transition and associate that with revenue. But what about your current risk of penalty associated with value-based purchasing (VBP) and with Patient Quality Reporting System (PQRS) programs? The penalties associated with VBP are increasing in October 2015, which could represent 5.5 percent of Medicare reimbursements for hospitals. Those penalties are based on what was documented in FY2013.
And we’re already behind the eight ball!
For example, a physician who documents a pneumothorax, but doesn’t specify that it was intentional will aggregate toward the penalty. Simply educating the coders, CDI staff and physicians on the need to specify this would reduce risk associated with VBP.
Physicians in the outpatient setting have not had an incentive to improve or clarify their documentation because they are paid for their professional services based on procedure codes rather than diagnosis codes. Now physicians will have to participate successfully in the PQRS program to avoid payment penalties in 2016 as well.
Until now, PQRS has been voluntary and a bonus was paid. But in the 2014 Medicare Physician Fee Schedule Rule, CMS finalized its proposal to base 2016 PQRS penalties off of 2014 reporting. Therefore, physicians who don’t participate in PQRS in 2014 will receive a 2 percent penalty in 2016.
With the extra time to get prepared, organizations can take the time to ensure coding is accurate. It’s imperative to identify opportunities by analyzing historically billed data, PSIs, HACs and core measures. Only with this analysis can we acknowledge the gaps and engineer a plan to address them.
This post appeared first at Action for Better Healthcare.