ICD-10 Monitor: Talk Ten Tuesday

By Keegan Garrity
Oct 14th, 2014

Two AAPC members were recently invited to speak on the Talk Ten Tuesday podcast.

Deb Grider,CCS-P CDIP CPC CPMA CPC-H CPC-P  emphasized the importance of testing. She suggested providers make a list of their top 10-15 payers, and get on their testing schedule. “…we’re probably going to go live with ICD-10.” said Grider, in reference to the upcoming implementation date. “We’ve had so many delays that we have to start getting ready.”

Leigh Williams, MHIIM, RHIA, CPC, CPHIMS reported that when she talks to those preparing for ICD-10, they often admit ICD-10 isn’t the only area needing improvement; specifically citing process improvement and language improvement as examples. “Wouldn’t it be great to improve those [areas] regardless of ICD-10?” she asked. Framing the question in this way tends to “relive the anxiety about whether there’s a delay or not.” she pointed out.

Leigh Williams then argued how an expanded code set can improve public health, using the current Ebola crisis as an example. “We have a specific code, we didn’t in ICD-9,” she said.  “So how can ICD-10 be impactful in a very real situation today?” she asked rhetorically.

Listen to the full episode that aired on Oct. 7.

OIG Proposes Safe Harbor and CMP Exception Expansion

By Michelle Dick
Oct 10th, 2014

October 3, the Office of Inspector General (OIG) proposed a rule amending expansion of federal Anti-kickback Statute safe harbors and the civil monetary penalty (CMP) rules. The proposed rule expands safe harbors that protect certain activities from Anti-kickback Statute prohibition and adds new safe harbors, such as (Excerpted from the October 9 Ropes & Gray, LLP,  Alert):

    • Part D cost-sharing waivers by pharmacies;
    • Cost-sharing waivers for government owned and operated emergency ambulance services;
    • Payments between Medicare Advantage plans and federally qualified health centers;
    • Drug discounts under the Medicare Coverage Gap Program; and
    • Free and discounted local transportation for established patients of certain providers.

The proposed rule also would codify in regulation existing statutory provisions, including:

    • Exceptions to both the federal anti-kickback statute and the civil monetary penalties law that would protect against liability for certain inducements to beneficiaries; and
    • The long-standing statutory prohibition on gainsharing, for which OIG solicits comments on how to interpret in a way more accepting of such arrangements than the agency’s historic position.

The OIG is asking for comments on the proposed rule by December 2, 2014.

For more information, see the October 3 proposed rule, “Medicare and State Health Care Programs: Fraud and Abuse; Revisions to Safe Harbors Under the Anti-Kickback Statute, and Civil Monetary Penalty Rules Regarding Beneficiary Inducements and Gainsharing,” in the Federal Register.

CMS to Cover Colorguard Test

By Renee Dustman
Oct 10th, 2014

The Centers for Medicare & Medicaid Services (CMS) announced October 9 in a decision memo that it will cover the Colorguard™ test — a multitarget stool DNA test — as a colorectal cancer screening test.

Conditions Apply

The Colorguard™ test will be covered under Medicare Part B once every three years  for asymptomatic, average risk beneficiaries, aged 50 to 85 years.

An effective coverage date was not provided in the decision memo. Watch for the national coverage determination for complete details.

USPSTF Recommendations

The U.S. Preventive Services Task Force recommends the following parameters for colorectal cancer screening:

Population Recommendation Grade
Adults, beginning at age 50 years and continuing until age 75 years The USPSTF recommends screening for colorectal cancer using fecal occult blood testing, sigmoidoscopy, or colonoscopy in adults, beginning at age 50 years and continuing until age 75 years. The risks and benefits of these screening methods vary. A

(High certainty of benefit)

Adults age 76 to 85 years The USPSTF recommends against routine screening for colorectal cancer in adults 76 to 85 years of age. There may be considerations that support colorectal cancer screening in an individual patient. C

(Moderate certainty of benefit)

Adults older than age 85 years The USPSTF recommends against screening for colorectal cancer in adults older than age 85 years. D

(High certainty of no benefit)

Computed Tomographic Colonography and Fecal DNA testing as screening modalities The USPSTF concludes that the evidence is insufficient to assess the benefits and harms of computed tomographic colonography and fecal DNA testing as screening modalities for colorectal cancer. I

(Evidence is insufficient)




ICD-10-CM: Ready or Not, Here It Comes

By John Verhovshek
Oct 10th, 2014

If you’re gambling on another delay in the transition to the ICD-10-CM code set, it’s time to change your bet.

five-diceOn July 31, the U.S. Department of Health & Human Services (HHS) issued a rule finalizing October 1, 2015 as the compliance date for healthcare providers, health plans, and healthcare clearinghouses to implement ICD-10-CM. Although previous deadlines were moved “to allow insurance companies and others in the health care industry time to ramp up their operations to ensure their systems and business processes are ready,” HHS has dubbed further delay of ICD-10 a myth, and announced  “no plans to extend the compliance date for implementation of ICD-10-CM/PCS; therefore, covered entities should plan to complete the steps required to implement ICD-10-CM/PCS on October 1, 2015.”

ICD-10-CM implementation is inevitable for several key reasons. Most significantly, the ICD-9-CM code set currently in use contains “outdated, obsolete terms that are inconsistent with current medical practice, new technology, and preventive services,” as stated in the July 2014 press release, and lacks the needed flexibility to keep up with changes. ICD-9-CM hasn’t received regular updates in several years. And because ICD-9 will receive no updates beyond 2015, even non-covered entities are best served by the transition to ICD-10.

ICD-10-CM has received limited updates since 2012, and regular (quarterly) updates will commence in 2016, thereby ensuring the code set remains up-to-date.

Skipping ICD-10 and holding out for ICD-11, as some have proposed, isn’t a viable solution. As reported in FierceHealthIT, ICD-11 isn’t expected to be ready for use for at least a decade, and perhaps much longer. The American Medical Assocations’s Board of Trustees estimates that ICD-11 won’t be available for use in the U.S. for 20 years, and expressed reservations about skipping ICD-10, stating that such a move “is fraught with its own pitfalls and therefore, based on current information available, is not recommended.”

The benefits of ICD-10-CM, as compared to ICD-9, have long been heralded. As expressed in a CMS press release:

By enabling more detailed patient history coding, ICD-10 can help to better coordinate a patient’s care across providers and over time. ICD-10 improves quality measurement and reporting, facilitates the detection and prevention of fraud, waste, and abuse, and leads to greater accuracy of reimbursement for medical services. The code set’s granularity will improve data capture and analytics of public health surveillance and reporting, national quality reporting, research and data analysis, and provide detailed data to enhance health care delivery. Health care providers and specialty groups in the United States provided extensive input into the development of ICD-10, which includes more detailed codes for the conditions they treat and reflects advances in medicine and medical technology.

Many potential downsides of ICD-10 have been overstated or are simply false, as effectively demonstrated in ICD-10-CM/PCS Myths and Facts. For example, although the greater number of codes in ICD-10 relative to ICD-9 will allow greater specificity, it’s incorrect to assume that finding the correct code will be more difficult.

“Just as an increase in the number of words in a dictionary doesn’t make it more difficult to use, the greater number of codes in ICD-10-CM/PCS doesn’t necessarily make it more complex to use,” CMS argues. “In fact, the greater number of codes in ICD-10-CM/PCS make it easier for you to find the right code.” As well, “the improved structure and specificity of ICD-10-CM/PCS will likely assist in developing increasingly sophisticated electronic coding tools that will help you more quickly select codes.”

Some have argued that the proliferation of ICD-10 codes will spell the end of the superbill. But because most physician practices use a relatively small number of diagnoses related to their specialty, they can continue to use super bills containing the most common diagnosis codes reported in their practice, and supplement with additional tools.

Furthermore, the cost of ICD-10 implementation has been greatly exaggerated, causing widespread discouragement from starting training. Recent surveys have demonstrated costs could average only $3,500 per provider.

The bottom line is, it’s time to stop stalling on ICD-10 and ready yourself and your practice for the inevitable October 2015 implementation deadline.

Fingerprinting Required for High Risk Providers, Suppliers

By Renee Dustman
Oct 9th, 2014

You might not remember, but back in 2011, the Centers for Medicare & Medicaid Services (CMS) published a rule that added a new security provision to the provider enrollment process. That provision has come to fruition: CMS implemented a fingerprint-based background requirement on August 6.

Fingerprint-based background checks are now required for all individuals with a 5 percent or greater ownership interest in a provider or supplier that falls into the high-risk category and is currently enrolled in Medicare or has submitted an initial enrollment application.

Expect a Letter

Medicare administrative contractors (MACs) have begun sending letters to such providers/suppliers, listing all owners who require fingerprinting. If you receive such a letter, you have 30 days from the date of the letter to comply. Noncompliance could result in denial of your Medicare enrollment application or revocation of your Medicare billing privileges.

CMS awarded a contract for fingerprinting-based background checking to Accurate Biometrics, Chicago, Illinois, on July 8.

Who Is High Risk?

Per 42 CFR 414.518, “Screening levels for Medicare providers and suppliers,” CMS has designated the following home health agencies and suppliers of durable medical equipment, prosthetics, and supplies (DMEPOS) as “high” categorical risk for Medicare fraud, waste and abuse:

  1. Prospective (newly enrolling) home health agencies
  2. Prospective DMEPOS suppliers

For more information, see MLN matters® Special Edition Article No. SE1427.

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