The need for quality documentation and International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) coding in physician practices is rapidly changing in the new value-based care and quality models, including the new Quality Payment Program (QPP), recently confirmed by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The MACRA final rule was published October 14, 2016, and is available on the Centers for Medicare & Medicaid (CMS) website.
The MACRA QPP includes the Merit-based Incentive Payment System (MIPS) that defines the following categories of eligible clinician performance in which provider quality will be measured:
- Advancing care information (previously meaningful use)
- Clinical practice improvement activities
- Resource use
MACRA also includes Advanced Alternative Payment Models. This requires participants to use certified electronic health record technology and provides payment for covered professional services based on quality measures. These quality measures are comparable to those used in the quality performance and similar to those used in MIPS. Data collection for the four MIPS categories begins in 2017, and the data will begin to affect provider reimbursement in 2019.
For success, these programs must include documentation and coding related to relationship categories, the episode grouper for Medicare and hierarchical condition categories (HCC). Episode groupings apply algorithms designed for constructing episodes of care in the Medicare populations.
Providers have a long-term history of inaccurate coding and documentation in the Part B revenue cycle, with often occurring Current Procedural Terminology or Healthcare Common Procedure Coding System codes that result in fee-for-service reimbursement. Because programs within the QPP are risk-adjusted for severity, the focus is transitioning to appropriate assignment of ICD-10-CM codes.
A patient’s diagnosis or diagnoses are used to categorize the patient based on how sick (at risk) they are, which is based on accurate diagnosis coding. Measuring the risk-adjusted diagnoses for severity adequately reveals to payors the true costs of treating patients. Other factors included in the risk-adjustment severity are age, sex, socioeconomic status and geographic location.
Clinical documentation improvement (CDI) and coding professionals play an important role in a practice’s success by ensuring that physician profiles and patient severity are accurately reflected. Select diagnoses ensure a patient’s severity can be appropriately managed throughout the payment year. Disease interactions within certain disease categories may affect the scoring, much like major complications or comorbidities and complications or comorbidities in Medicare Severity-Diagnosis Related Groups within the Inpatient Prospective Payment System. Assignment of HCC-related diagnosis codes requires specific documentation that must reflect evaluation and management of supported conditions by a qualified provider in a face-to-face encounter.
The year 2017 requires an increased importance placed on complete and accurate documentation and coding as it relates to MACRA and upcoming quality and reimbursement effects to providers. While the focus of documentation and coding previously has been placed on the hospital setting, the focus will now turn to outpatient physician practice settings. HCC coding tips include:
- Ensure all diagnoses coded are being reported on the CMS-1500 claim form that allows 12 diagnoses per claim.
- Ensure that physician practice coding or billing staff have been properly trained for ICD-10-CM assessments and obtained certifications.
- Hospital-owned practices may consider sharing hospital CDI and coding resources.
- Document and code all active chronic conditions annually and ensure these conditions are identified during a face-to-face encounter with the qualified physician.
- Define the current state of a disease, whether acute, chronic or exacerbated.
- Code signs and symptoms when a definitive diagnosis is unknown.
- Show the relationship of one diagnosis to another by linking terms such as “with,” “due to” or “secondary to.”
- Have a good understanding of coding guidelines history in the outpatient setting when condition is no longer under active treatment and shouldn’t be reported.
The importance of accurate documentation and coding often is understated by physicians. It’s important to remember that accurate documentation coupled with compliant coding affects almost all areas of quality reporting and ultimately provider reimbursement. Our BKD coding and documentation specialists work with health systems and physician practices to improve clinician engagement, develop policies and procedures, streamline internal processes for data collection, perform external coding and documentation compliance assessments and provide education and training on CDI and accurate coding processes. Our specialists will assist organizations in producing measurable improvements in quality that can result in increased financial performance.
Contact your BKD advisor for more information.