Health Information Management

ICD-10 bill doesn?t account for massive payment, patient implications

HIM-HIPAA Insider, June 29, 2015

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Rep. Gary Palmer, R-Alabama, doesn’t want providers penalized for ICD-10 “errors, mistakes, and malfunctions relating to the transition” for two years after implementation. Unfortunately, it doesn’t appear the congressman considered the staggering implications of such a policy.
It was obvious during Congress’ February subcommittee hearing on ICD-10 that most politicians involved didn’t have anything but a cursory understanding of coding, billing, and reimbursement beyond the talking points they were working off.
In the months since, several Congressmen have demonstrated they weren’t listening to the overwhelming support for ICD-10 from the gathered witnesses, with successively unrealistic bills introduced. Palmer’s bill stands alone, however, with the ability to not only remove any incentive for providers to learn ICD-10, but also increase the potential for fraud.
CMS has already started to update the National Coverage Determinations (NCD) for ICD-10. NCDs provide information about which diagnoses need to be reported along with procedures in order to justify their use.
For example, Medicare will only pay for CPT® code 38240 (hematopoietic progenitor cell; allogeneic transplantation per donor) if ICD-10-CM code Z00.6 (encounter for examination for normal comparison and control in clinical research program) is reported along with one of the following codes:
  • D46.9, myelodysplastic syndrome, unspecified
  • D46.Z, other myelodysplastic syndromes
This is because the procedure is only covered as part of a Medicare-approved research study. Let’s assume Palmer’s bill passes and we now have a two-year grace period during which payers cannot deny a claim due to any ICD-10 errors.
A patient is in an approved study and receives the transplantation described by 38240 and the coder reports Z00.6 and accidentally reports D46.0 (refractory anemia without ring sideroblasts, so stated). The procedure would be paid, but the patient would have an incorrect diagnosis in his or her record.
If CMS can’t deny payments due to ICD-10 errors, it has no way to tell whether the coding is accurate without requesting and looking at the documentation for every claim.
For example, maybe the coder means to report E11.9 (unspecified diabetes), but accidentally codes E11.60 (Type 2 diabetes mellitus with other specified complication). Now the patient’s record shows a more serious type of diabetes and the claim would lead to a higher payment. This could be a simple mistake from a coder learning the new system, but it has clinical implications for the patient and payment implications for the provider.
Could these types of errors be prevented by encoders and system edits warning coders and billers? Potentially, but Palmer’s bill is even more problematic because it doesn’t solve the fundamental potential issue with ICD-10: documentation.
Provider documentation is already a problem with the codes we have. The American Medical Association claims that physicians simply don’t have the time to learn ICD-10 codes and their documentation requirements in addition to all of their other responsibilities.
Previous delays have killed the momentum for providers to learn about potential documentation changes for ICD-10 already. Palmer’s bill would go even further, by allowing coders to report ICD-10 codes with no oversight of their use. Does the bill take into account medical necessity? Does it prevent auditors from looking at these claims in the future? This not only impacts payers who could be responsible for paying claims with no medical justification, it will also directly impact patient care.
For example, ICD-10 contains the ability to track the healing process of injuries such as fractures through seventh characters. If providers do not need to document this level of detail (and coders do not need to accurately report it), all of that information will be left by the wayside. Without an incentive to improve documentation, providers won’t do it by themselves.
During the February hearing, politicians bemoaned the lack of impact ICD-10 would have for patients on day one of implementation. If we push off the requirement to track diagnoses and collect more specific information for two years, we’re only delaying benefits for researchers and, ultimately, patients.
Palmer also demonstrates his misunderstanding of how coding works, or is intentionally trying to undermine ICD-10 by requiring the Government Accountability Office (GAO) to perform a study on the code set’s impact on physicians by April 1, 2016.
Of course, if providers are not accountable for any errors in ICD-10 coding, the first few months after implementation will be chaos. There could be many examples of documentation not matching coding whatsoever, leading the GAO to inevitably conclude that providers can’t learn the new system. It’s a conclusion all but guaranteed by a grace period that doesn’t require any sort of accuracy. Even without the possibility of a few irresponsible providers taking advantage of the system, coding errors will simply happen regardless (as they do today), without an incentive to ensure they’re correct. The GAO report would give Congress the ammo it needs to permanently kill ICD-10.
Congress has tried to rein in healthcare costs for decades, but this shortsighted bill would end up doing the complete opposite, while stopping any incentive for providers to prepare for ICD-10.
This article originally appeared on HCPro’s ICD-10 Trainer blog.

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