All I Want for Christmas is Fewer RAC Denials

This December, coders across the country got the ultimate Christmas present: a bill passed the House and Senate without the addition of language that would further delay ICD-10 implementation.  As we breathe a sigh of relief and get ready for a worry-free Christmas (at least as far as coding is concerned), we aren't fully exhaling until the end of March when the SGR bill comes up again for a vote.

But how many people are aware that there is another type of legislation at work that could cut down on the number of RAC denials we get?  Sounds almost too good to be true, doesn't it?  While the legislation is real, it's in very draft form right now.  Unfortunately, from where I sit, it also seems to be flying very low under the radar among my peers and I think it deserves some attention.

First of all, if you are not yet familiar with RACs, those are the Recovery Audit Contractors hired by Medicare to recoup improper payments to hospitals and physicians and return that money - with penalties - to the Medicare program.  The idea is great - run all the claims data through proprietary software and analyze it to see what looks weird.  This can be anything from improperly coded claims to admitting a patient to the hospital for a short stay rather than treating them as an outpatient.  Side note: contrary to what a lot of Medicare patients are told, hospitals do not get paid more for outpatient claims; they actually get paid less.  Medicare patients pay more out of pocket for hospital outpatient services and in most cases, hospitals get paid less than if patients were inpatient.  But if hospitals admit patients who could be treated as outpatients for short stays, they can have to pay the money back plus RAC penalties.

There are two types of RAC audits: automated and complex.  Automated reviews can be identified just by looking at data without reviewing the medical record.  Complex reviews require review of the medical record (e.g., for coding errors).  But the RACs don't have the final say; there is a rather lengthy appeals process that providers can - and should - take advantage of because several RAC denials have been overturned.  The problem is, there are about eight levels of appeals that end with the administrative law judge and currently there is a backlog of appeals at the administrative law judge level.

Enter the Hospital Improvements for Payment (HIP) act of 2014 (don't you just love that so many healthcare laws start with "hip?!").  This is a draft proposal aimed at reducing RAC audit backlogs by creating a new Hospital Prospective Payment System (HPPS) for Medicare short stays (less than 3 days length of stay), including observation services.  In short, it calls for the following;

• Creation of the new HPPS by the year 2020
• Creation of an alternate reimbursement system for short stays from fiscal year 2016 to fiscal year 2019 as data is gathered for the 2020 system
• Elimination of RAC reviews for short hospital stays until HPPS is implemented

By now, there may be a lot of people jumping up and down with joy, but of course there is a catch.  The proposal calls for dual submission of claims by hospitals in fiscal year 2016 in order to establish payments.  This means that hospitals would have to submit both ICD-10-PCS and CPT codes for short hospital stays for 2016.  Yes, the proposal assumes that we will be coding ICD-10-PCS in fiscal year 2016, which incidentally, begins on October 1, 2015.  The proposal would also implement an ICD-10-PCS to CPT crosswalk.  If the dual coding of claims didn't make you nervous, the crosswalk should.  I've never met a crosswalk I trusted.  Let's face it, if one coding system easily crosswalked to another, then we wouldn't need two different coding systems, would we?  I can see lots of operational challenges starting with the productivity dive that would surely occur and ending with training challenges since it's getting harder to find inpatient coders who code CPT and many facilities have decided not to train their outpatient coders in ICD-10-PCS.

Read All About It

This is just a small snipit of what HIP is about, but I encourage you to read up on it yourself, starting with information from the House Committee on Ways and Means and checking out the industry commentary to see where you stand.  Here are some links you should check out:

• Document from the House Ways and Means Committee - section by section of proposed bill 
• AHA Comments to Rep. Kevin Brady Re: Hospital Improvements for Payment Act of 2014 Discussion Draft dated December 18, 2014

Let Your Voice be Heard

For more information from the House Ways and Means Committee, including information on submitting comments, click here.  This proposal has the potential to rock the world of hospital reimbursement (again) and has some definite pros and cons.  While it's still only a draft and is not a done deal, it's time to take the opportunity to let our voices be heard and submit comments.

I don't want to live in a world where Ebola is sold out at the Giant Microbe store - and there's no code for it

There is a super cute little toy shop in Coeur d'Alene, ID called Shenanigan's Toy Emporium that sells vintage toys and other unique items.  When traveling there on business, we usually make a stop in to shop from their wall of amazing salt water taffy and check out their selection of toys that don't come with a power button.  You know, the kind of toys we had prior to the Atari and Game Boy era!

Shenanigan's also has a great display of giant microbes - small plush renderings of everything from the common cold to diarrhea.  I am still marveling at how they could create a plush toy out of liquid stool!  I'm sure it's just the geeky coder in me (and my colleagues), but we decided to buy a few and put them out during our training sessions along with our baskets of Play Dough, pipe cleaners, and candy (we like to have FUN in our training sessions!).  Needless to say, they were a big hit with our clients and we noticed on one of the tags that there was a website where we could order more.  By now your interest is surely piqued, so be sure to check out the online Giant Microbes store.

You're probably thinking what I'm thinking right about now, which is, wouldn't these giant microbes make great white elephant gifts for Christmas?  My thoughts immediately went to what would be appropriate for my family's white elephant gift exchange.  Don't worry, my family has a great sense of humor - there's still a copy of Pamela Anderson's novel (yes, she wrote one) complete with the "naughty" pages clipped together courtesy of my grandmother who was sheltering her daughter from the filthy parts.  And what better gift for someone in 2014 than the Ebola virus?  There's just one problem.

Sold out.

Apparently I am not the only person who thinks that Ebola would make a great Christmas gift.  It's a sign of recent headlines that this virus, which is actually kind of cute in plush form, is unavailable.  What's even more worrisome given that this was the year Ebola came to the US, is that we don't have an ICD-9-CM code to report it.  Here's the best we can do in ICD-9:

• 065.8, Other specified arthropod-borne hemorrhagic fever
• 078.89, Other specified diseases due to virus

What about ICD-10-CM?  How about this?

• A98.4, Ebola virus disease

YESSSSSS!  Way more specific!

In previous years as we've prepped for ICD-10 implementation, the opponents have given a laundry list of extensive and admittedly ridiculous (yet fun!) ICD-10 codes that begged the question, why do we really need this?  And this year, Ebola was delivered to our health system and we have nonspecific codes to report it.  But in ICD-10, we have a very specific code.  Hmm.  Perhaps this ICD-10 thing really could help with reporting and impact patient care.  Just a thought.

So Santa, if I can't have Ebola for Christmas this year, could I please have ICD-10 so that I can code it for those people who did get it?

Author's Note: I am not affiliated with Shenanigan's Toy Emporium or giantmicrobes.com in any way. I am just a really big fan!

Diversity - and Flexibility - is Key

I've been pretty quiet lately around the blogosphere and some may even think I've disappeared.  And for about a year, up until about October, I really had disappeared a bit to plan and live through my wedding.  After a couple months of an identity crisis, I'll announce here that Coder Coach Kristi Stanton has disappeared and the new Coder Coach is now Kristi Pollard.  The new last name will take a couple of decades to get used to, but I am hopeful that if I'm quoted in the future, it won't be as the first actress to play Buffy the Vampire Slayer. True story.

For the last couple of months I've been waiting for inspiration to strike so I could once again become passionate about the blog.  I've been observing.  Don't get me wrong, with all the legislation and talk about more ICD-10 delays, I've also been writing my congressmen, participating in Twitter rallies (follow me at @codercoach), and making posts on Facebook, but I've spent more time just watching.  Watching the industry.  Watching my colleagues.  Watching hopeful coding professionals trying to break their way in.  And this is what I've deduced: if you want to make it in the coding field, you've got to diversify.

It didn't take long after the ICD-10 delay was announced in March to see the fallout.  Some of our clients stayed the course while others postponed some training.  There have been very few canceled trainings all together for ICD-10. A couple of months ago, I dusted off a couple of our CPT training manuals that hadn't been updated in awhile to get them ready to train in 2015.  It was comforting to fall back into something that still required the skill of a senior consultant that was a sure thing.  Of course, I hope for a future with ICD-10 and will continue to advocate for it, but there's always CPT as well.

Here is my message to the coding students and aspiring coders.  Coding is not steady and it's not comfortable.  Even without ICD-10, annual updates to the coding industry can rock your world (case in point all the new lower GI endoscopy CPT codes for 2015).  This field has a tendency to attract detail-oriented people who like to organize everything in pretty and neat little black and white buckets.  As coders, we don't like gray areas.  Well, as a coder, be ready for gray, purple, and yellow polka-dotted areas.  You need to be flexible.  You need to be ready when the House throws language into a bill at midnight the night before a vote that will impact your daily work.  And you need a backup plan just in case.

I feel a bit like a financial adviser as I tell you you need to diversify.  DI.  VER.  SI.  FY.  Don't put all your coding eggs in one basket.  As someone who has coded in ICD-9-CM, ICD-10-CM/PCS, CPT, and HCPCS, I understand what I'm asking you to do.  It's not easy.  They all have different rules and methodologies.  I understand that I'm asking you for a lifetime of education.  But the payoff for doing the work is immeasurable.  And the more you have exposure to, the more marketable you are as a coder.

From the Trainer: ICD-10 FAQ #1 - If the US is the last to implement, why are there so many unknowns?

For the last year, I've traveled across the country providing ICD-10-CM and ICD-10-PCS education to coders and clinical documentation specialists.  Our company's model provides three separate training sessions for our clients: basic, intermediate, and advanced.  This means lots of repeat visits to each client, lots of really hard questions, and tons of professional growth for me.  I thought it was time to start a new series here on my Coder Coach blog: ICD-10 FAQs.  This is a question I've been asked a lot lately as we get into advanced trainings and more controversial topics:

If the United States is the last country to implement ICD-10, why are there so many unanswered coding questions and why do we have to wait for Coding Clinic advice?

While it seems logical that someone would have figured out all of this ICD-10 stuff within the last 20 years as we've been "messing around" here in the US (please note the sarcasm, because I don't really think we've been messing around; we've actually been quite busy), the reality of the situation is that the US version of ICD-10 is different from everyone else's.  The core ICD-10 code set was developed by the World Health Organization (WHO) and classifies causes of morbidity (i.e., diagnoses) and every country has the ability to adapt it further (e.g., ICD-10-CA in Canada, ICD-10-AM in Australia, ICD-10-CM in the US).  Two things should have jumped out at you based on this statement:

1. ICD-10 diagnosis codes may be different in Canada, Australia, and the US
2. The international code set does not  include procedures

Let's tackle #1 first.  The US version of the ICD-10 diagnosis codes, ICD-10-CM, is a clinical modification (BTW - that's what the "CM" stands for; it's not "coding manual" like some people seem to think).  It is based on the WHO version, but has been adapted for use here in the good ole United States of America.  I haven't had a ton of time to compare it to the original, but what I do know about the CM version is this:

• The Excludes1/Excludes2 convention, which solves a lot of problems from ICD-9 (and creates a few new ones) is not part of the WHO version
• The use of 7th character extensions for injuries and poisonings is not part of the WHO version
• The expansion of the external cause codes, which are not required for reporting, are not nearly as extensive in the WHO version
• While we have adapted diabetes terminology in the US to Type 1 and Type 2 diabetes, the WHO version still uses the insulin-dependent diabetes mellitus (IDDM) and noninsulin-dependent diabetes mellitus (NIDDM) terminology that we've worked so hard to banish from our medical record documentation here in the States

Most of the really hard diagnosis questions I get about coding ICD-10 diagnoses revolve around the changes that are unique to the CM version.

As for the procedural component, ICD-10-PCS (which stands for procedure coding system), that was developed in the US by CMS under contract with 3M.  Although I've heard that other countries have plans to adopt PCS, right now the US is the only country using it.  Although other countries have procedural coding systems, it's important to remember that we are the only ones using coding for reimbursement.  For that reason, we will likely place more weight on those procedure codes than other countries and when it comes to PCS, it's uncharted territory.

Hopefully that answers a couple of questions about the ambiguity of ICD-10.  And may I also just point out that this is nothing new.  Coding has always undergone an evolutionary process.  We have seen it with ICD-9-CM and CPT.  It's the reason we have official publications like the Coding Clinic and CPT Assistant.  If you are not familiar with these publications, you need to be.  They are official resources that answer a lot of questions.  And as of second quarter of this year, the American Hospital Association has stopped publishing Coding Clinic for ICD-9-CM and is only publishing Coding Clinic for ICD-10-CM/PCS.  My colleagues and I have been monitoring the publication very carefully each quarter because their advice does change some previous assumptions many have made based on what we know about these new coding systems.

Are Legislators Suffering from R41.9?

In terms of the blogosphere, I've been severely slacking for the last several months. In terms of ICD-10 preparation, I would argue I've done my fair share. As an AHIMA-Approved ICD-10-CM/PCS trainer for nearly 5 years, AHIMA ICD-10 Ambassador, and a senior consultant specializing in ICD-10 education, I've spent much of the three years with my current employer writing ICD-10 web-based and instructor-led training, coding cases using the ICD-10 code sets, and spending countless hours face-to-face with coders across the country conducting basic, intermediate, and advanced ICD-10-CM and ICD-10-PCS training. For three years I chaired Colorado's ICD-10 Task Force, which has worked hard to raise awareness and push implementation efforts forward. 

I've been in the coding industry for 19 years and we've been talking about ICD-10 for my entire career. I remember where I was when the proposed rule for ICD-10 was released and who told me. It was that big of a deal. I remember reading the final rule with elation. I remember ICD-10 being held just after Obama took office because the final rule was released in the last month of the Bush's administration. That delay was short-lived. And, of course, I can still feel the utter frustration I felt the day CMS announced that ICD-10 would be delayed until October 1, 2014. 

And now the fate of ICD-10 hangs in the balance. Again. For crying out loud, US Government, can't we just move on?

If you haven't heard, some language was slipped into House bill 4302 late Tuesday night that would delay ICD-10 for another year. And this morning, the bill passed. Now it's on to the Senate. 

I can only believe that the reason this passed is because our legislators are suffering from R41.9, Unspecified symptoms and signs involving cognitive functions and awareness.  They just don't know what they don't know. 

I'm just not buying the excuse that we can't be ready for ICD-10 in 6 months, even after we've been given a one-year delay already. I've been getting ready for several years, my company has been getting ready for several years, and providers and insurers have been padding their budgets for ICD-10 prep over the last 2 years. I've never seen hospitals buy into IT and training initiatives like they have for ICD-10. And I just don't think postponing ICD-10 again because some providers aren't ready because they didn't think it would really be implemented is a viable reason for a delay. 

To be fair, this bill isn't really about ICD-10. It's about the sustainable growth rate for physicians that they are trying to address before a 24% pay cut for physicians goes into effect on April 1.  The last payment fix for them expires at the end of the month. However, I am bewildered as to how 7 lines of text calling for a one-year delay on ICD-10 managed to make its way into this bill. I am also bewildered as to how a bill that was released 24 hours before it was sent to vote actually passed. Did our congressmen and congresswomen really read the whole bill? And by "read," I mean "read for comprehension." I can only hope that the bill gets killed in the senate. Seriously, the government can't keep leading us on like this!  And more importantly, how will we, as an industry, get enough credibility to ever implement ICD-10 if we have another delay?  If we delay now, we lose all momentum (and dollars) spent by the parties who actually thought the government was serious about ICD-10. 

Here's what you can do: become informed and get your senators informed. The bill claims it will save more than $1 billion over the next 10 years. But what no one is telling them is that those 7 lines that address the ICD-10 delay are projected to cost between $1 billion and $6.6 billion by delaying ICD-10 by one year. And that is only 10-30% of the money that has already been spent by the healthcare industry so far. Are we really willing to throw all that money away when our healthcare industry is already under too much scrutiny for spending?

Go to www.ahima.org and see how you can contact your senators by phone or email.  You don't need to be an AHIMA member to do this and you can even read more information about why the language to delay ICD-10 implementation should be removed. Please act today and share this information with your fellow professionals so they can respond too. 

Now if you'll excuse me, I have some emails to write and phone calls to make...