Sunday, May 26, 2013

The Translation Gap: ICD-10 and HCC

5/26/2013 – Kameron Gifford, CPC

Where will ICD-10 impact your organization the most? What are you doing to protect your revenue?

The greatest hurdle in transitioning to ICD-10 will be improving clinical documentation.

Are your providers documenting with the specificity required for ICD-10? If not, where do you focus your education?

If you have not already completed a revenue risk assessment, I urge you to do so now! This will be your greatest key to success!

Start with a Revenue Risk Assessment for your Organization:

Medicare Advantage Plans/ MSO’s / IPA’s:

1.       Compile a list of your most frequently billed ICD-9 Codes per provider. (A list of 25 is sufficient).

2.       Map these codes into the corresponding ICD-10 Codes.

3.       Map ICD-10 Codes to Corresponding HCC’s to determine potential impact on revenue.

Prior, Proper, Planning…

Once you have determined the potential impact on revenue we can use this same information to create meaningful education to improve clinical documentation.

We are by nature, creatures of habit, and we must start changing the behavior of providers now to ensure adoption of new concepts.

A few examples of these include:

• Laterality – left, right, bilateral or unilateral

• Trimester of pregnancy and weeks of gestation

 • BMI calculation in Obesity

 • Which finger, and which level in a finger amputation

• The type of surgical approach for procedures

 • The severity of seizures

• The severity of retinopathy or renal disease in diabetics

Compliant coding begins with compliant documentation. Through accurate risk revenue assessments organizations can concentrate their efforts; thus encouraging greater engagement.
If your organization needs help contact ERM. We will audit up to 10 dates of services or map 10 codes at NO CHARGE.

Prosthetic tentacle

Taiwanese design student Kaylene Kau created this motorized prosthetic tentacle for a class project: "For this project we were pushed by our Professor to push the boundaries of current upper-limb prosthetic design. Through extensive research I found that the prosthetic functioned as an assistant to the dominant functioning hand. The prosthetic needed to be both flexible and adjustable in order to accommodate a variety of different grips."
 at 2:37 pm Thu, May 23, 2013

AHRQ-funded journal supplement offers lessons on primary care practice transformation

Findings provide practices with a roadmap on how to achieve transformation

LEAWOOD, Kan. – Primary care practice transformation on a large scale is the cornerstone of current health care reform efforts aimed at achieving better outcomes, better value and better experience of care. Amid emerging evidence that transformation toward the patient-centered medical home model offers a viable solution in today's health care environment, the U.S. Department of Health and Human Services' Agency for Healthcare Research and Quality funded 14 studies to learn more about the processes and determinants of successful change from practices that had already demonstrated successful transformational activities and improved outcomes. Key findings of these 14 projects, which the funders hope will inform more widespread change efforts, are published in a special supplement of Annals of Family Medicine.
The supplement, Transforming Primary Care Practice, features insights from 14 natural experiments undertaken in a wide variety of settings across the United States including independent practices, integrated delivery systems, community health centers and large government systems. The projects, which were funded by AHRQ grants awarded in 2010 totaling more than $4.1 million each year for two years, begin to identify the approaches and methods for transforming the structure, characteristics and function of primary care that are likely to be successful in a wide variety of practice types and settings.
"The lessons learned from these analyses demonstrate that true transformation toward the patient-centered medical home model is not only possible, but desirable, although not without its challenges," writes Robert J. McNellis, MPH, PA, AHRQ [insert title] and colleagues, in a commentary about the lessons learned that cut across all the projects.
In the editorial, McNellis and colleagues outline five overarching thematic findings that emerged from the projects despite the wide variety of practices studied, geographic locations, sizes, structures and motivations:
1) A strong foundation is needed for successful redesign. Existing baseline capabilities of a practice are important determinants of successful transformation. Practices must accurately assess their readiness for change and their ability to handle the change process before undertaking substantive change.
2) The process of transformation can be a long and difficult journey. The process of transforming is complex, challenging and ambitious. It takes time and is constantly evolving. Progress is a process that ebbs and flows, and practices should prepare for a taxing journey.
3) The approaches to transformation vary. The ingredients of a successful change process vary, but a few key elements seen across the projects include: integration of more team-based care, expanded access to care, use of measurement and feedback tools and the use of learning collaboratives to facilitate team communication.
4) Visionary leadership and a supportive culture ease the way for change. Having strong internal change drivers is an important facilitator of successful transformation. The two internal drivers seen to have the most influence on change were leadership and culture.
5) Contextual factors are inextricably linked to outcome. The context within which transformation occurred is critical to understanding a practice's success.
In addition to the overarching findings above, the articles raise several potential cautions, including the difficulty of measuring the financial impact of transformation on a practice. Overall, the teams found it was very difficult to understand the ultimate impact of transformation on the bottom line of the practices. Additionally, many investigators noted a difference between a true PCMH and external recognition as one, concluding that a practice could be a true PCMH without having received recognition, and a practice that has received PCMH recognition may not be a true PCMH. They warn that the journey to recognition, in contrast to true transformation, can create a culture of "box checking" rather than making the deep changes necessary to become truly patient-centered.
"Annals is excited to publish these important findings, and we hope they will inform efforts to improve health care systems' ability to support changes to improve the effectiveness and sustainability of primary care practices to better meet patient needs across the country," said Kurt Stange, MD, PhD, Annals of Family Medicine editor and corresponding author of a supplement article on the importance of reporting contextual factors. "We especially hope the grantees' innovative reporting of relevant contextual factors – information critical to understanding what happened and why in the studies – will help other practices as they attempt to transport these findings to their unique settings and circumstances."
"Few practices realize or are prepared to make the substantive changes necessary for true transformation. However, this research demonstrates that change is possible even in the face of payment systems that do not yet adequately support transformative efforts within a deeply fragemented health care system," McNellis concludes. "Research like that presented in this supplement can serve as a roadmap, if not a how-to manual on achieving transformation."

Supplement articles include:

  • Lessons Learned from the Study of Primary Care Transformation
    Robert J. McNellis, MPH, PA, et al
    This editorial summarizes the interventions studied by the 14 grantees and synthesizes the major findings and lessons learned about the process of transforming.
  • Support and Strategies for Change Among Small Patient-Centered Medical Home Practices
    Sarah Hudson Scholle, MPH, DrPH, et al
    Financial support, practical training, and other help are important in spreading the adoption of the PCMH model among small practices.
  • Recognition as a Patient-Centered Medical Home: Fundamental or Incidental? 
    Daniel Dohan, PhD, et al
    Becoming patient centered and seeking NCQA recognition as a PCMH run along separate but parallel tracks in this case study.
  • Spreading a Medical Home Redesign: Effects on Emergency Department Use and Hospital Admissions 
    Robert J. Reid, MD, PhD, et al
    It is possible to reduce emergency department use with PCMH transformation across a diverse set of clinics using a clear change strategy and sufficient resources and supports.
  • Facilitators of Transforming Primary Care: A Look Under the Hood at Practice Leadership 
    Katrina E. Donahue, MD, MPH, et al
    Certain aspects of leadership help move practices forward in primary care transformation, including setting strategic direction and implementation.
  • Cultivating Engaged Leadership Through a Learning Collaborative: Lessons from Primary Care Renewal in Oregon Safety Net Clinics 
    Carmit K. McMullen, PhD, et al
    A group of safety net organizations cultivates engaged leadership with scarce resources by partnering with organizational leaders in design of transformation efforts, sharing lessons and overcoming implementation hurdles.
  • Process and Outcomes of Patient-Centered Medical Care With Alaska Native People at Southcentral Foundation: Findings From a Mixed Methods Evaluation 
    David L. Driscoll, PhD, MPH, MA, et al
    In this study of a tribally owned and managed primary care system, all reported measures of emergency care use showed a decreasing trend after PCMH implementation.
  • Quality, Satisfaction and Financial Efficiency Associated With Elements of Primary Care Practice Transformation: Preliminary Findings 
    Julie Day, MD, et al
    A study of multiple outcomes in a redesigned model of care underscores the importance of team-based-care and continuity of care.
  • Contrasting Trajectories of Change in Primary Care Clinics: Lessons From New Orleans Safety Net 
    Diane R. Rittenhouse, MD, MPH, et al
    The PCMH model can successfully address the needs of safety-net populations, particularly with the support of stable, committed leadership and deep community ties.
  • Becoming a Patient-Centered Medical Home: A 9-Year Transition for a Network of Federally Qualified Health Centers 
    Neil S. Calman, MD, et al
    This study, set in a large FQHC network serving a diverse population, reports on complex system change, including its component parts and the processes by which it was facilitated.
  • Assessment and Measurement of Patient-Centered Medical Home Implementation: The BCBSM Experience 
    Jeffrey A. Alexander, PhD, et al
    Approaches to PCMH measurement should be driven by the intended uses and users of the measure.
  • Patient-Centered Medical Home Among Small Urban Practices Serving Low-Income and Disadvantaged Patients 
    Carolyn A. Berry, PhD, et al
    Small practices can achieve important aspects of the PCMH model of primary care, often with informal rather than formal mechanisms and strategies.
  • Medical Home Transformation in Pediatric Primary Care—What Drives Change? 
    Jeanne W. McAllister, MHA, et al
    In pediatric primary care practices, medical home transformation requires continuous development, ongoing quality improvement, family partnership skills, teamwork and strong care coordination.
  • A Positive Deviance Approach to Understanding Key Features to Improving Diabetes Care in the Medical Home 
    Robert A. Gabbay, MD, PhD, et al
    Key factors in primary care practices' performance improvement during medical home transformation include baseline structural capabilities and ability to buffer the stresses of change.
  • Medical Home Transformation: A Gradual Process and a Continuum of Attainment 
    Leif I. Solberg, MD, et al
    Medical homes are not similar, change in outcomes is slow, and transformation occurs on a continuum.
  • Context Matters: The Experience of 14 Research Teams in Systematically Reporting Contextual Factors Important for Practice Change 
    Andrada Tomoaia-Cotisel, MPH, MHA, et al
    This study offers a feasible, systematic approach for research teams to identify and convey contextual factors for understanding and transporting findings from health care research.

Annals of Family Medicine is a peer-reviewed, indexed research journal that provides a cross-disciplinary forum for new, evidence-based information affecting the primary care disciplines. Launched in May 2003, Annals is sponsored by seven family medical organizations, including the American Academy of Family Physicians, the American Board of Family Medicine, the Society of Teachers of Family Medicine, the Association of Departments of Family Medicine, the Association of Family Medicine Residency Directors, the North American Primary Care Research Group, and the College of Family Physicians of Canada. Annals is published six times each year and contains original research from the clinical, biomedical, social and health services areas, as well as contributions on methodology and theory, selected reviews, essays and editorials. Complete editorial content and interactive discussion groups for each published article, including those in the supplement, can be accessed free of charge on the journal's website,

Contact: Angela Sharma
American Academy of Family Physicians 

Medical Home Transition Long but Worth It

The path to becoming a patient-centered medical home is long, rough, and varies for each practice, but getting there is essential to providing high-quality, affordable healthcare to all Americans, researchers concluded.
The Agency for Healthcare Research and Quality (AHRQ) came to that conclusion in summarizing the results of 14 grants it issued in the summer of 2010 to understand the processes and determinants of transforming primary care practices.
The grants -- which totaled $4.1 million each year in a 2-year study -- allowed practices of varying size, geography, and scope to retrospectively analyze the process of becoming a patient-centered medical home (PCMH). The results were published Monday in a special supplement of the Annals of Family Medicine.
"The lessons learned demonstrate that true transformation to the PCMH model is not only possible but desirable, although not without its challenges," wrote Robert McNellis, MPH, PA, and colleagues at AHRQ's Center for Primary Care, Prevention, and Clinical Partnerships in Rockville, Md. "These lessons provide valuable insight that will likely be helpful to other practices considering or beginning this transformation."
It is difficult to know whether practices that are successful in their transformation are successful because they've become a PCMH, or whether better-performing practices are more likely to become PCMHs.
"This uncertainty has implications for how to invest resources in those practices that are not currently highly functioning, many of which are resource-starved and understaffed, and often serving as safety-net practices for large groups of uninsured or underinsured patients," the authors wrote.
Most investigators concluded a practice can be a true PCMH without having formal recognition from an accrediting body like the National Committee for Quality Assurance (NCQA).
It was tough to measure financial impact on transforming a practice, they found. "It was difficult to measure new revenue or costs of delivering new services. It was also difficult to compare pre-transformational costs with post-transformational costs," McNellis and co-authors wrote.
In one study, Sarah Hudson Scholle, DrPH, of the NCQA in Washington, and others surveyed nearly 250 small practices (fewer than five physicians) on their barriers and motivations to becoming a PCMH.
They found that time and resources were the biggest obstacles for practices to overcome, but that receiving financial rewards for becoming a PCMH would help.
A similar survey by Carolyn Berry, PhD, of the New York University School of Medicine, analyzed small practices in New York City serving mostly Medicaid or minority patient populations and concluded more flexible strategies for PCMH implementation were needed.
"We were especially struck by the relatively low use of formal mechanisms such as formal care teams and designated care or case managers, but there was considerable evidence of use of informal team-based care and care coordination nonetheless," Berry and others wrote. "It appears that many of these practices achieved the spirit, if not the letter, of the law in terms of key dimensions of PCMH."
In a study of 12 high-performing pediatric medical homes, Jeanne McAllister, MHA, of the Center for Medical Home Improvement in Concord, N.H., and colleagues identified four common attributes that drove change: a culture that promoted quality improvement, a family-centered care plan involving parents, and team-based and coordinated care.
"Delivering care within a family-centered medical home proved highly satisfying to physicians and coordinators," the authors wrote. "As efforts expanded, professional gratification and staff resilience appeared linked."