Tuesday, June 25, 2013

Preparing For ICD-10: Staying Ahead Of The Compliance Curve

Last Updated: June 24 2013
Article by Dan Vogt

Your deadline to implement ICD-10 is October 1, 2014. Beyond simply meeting compliance, this marks an opportunity to improve your delivery of data-supported health care outcomes.
ICD-10 may not be the flashiest aspect of the industry-wide effort to improve health care delivery, but it may be one of the most far-reaching. These codes touch almost every piece of the health care puzzle, from providers to payers. The challenge is that not everyone realizes the impact of the ICD-10 transition. The key is to understand how your organization is affected and how to identify which areas of operation will be impacted. You'll likely discover that your organization is highly impacted by ICD-10—nearly every area of your operations will be affected.
The World Health Organization put forth the updated ICD-10 codes in 1990. Other countries adopted ICD-10 starting in the mid-90s. The US is set to transition to ICD-10 on October 1, 2014, for Diagnosis and Inpatient Procedure Codes
Why is the US switching to ICD-10?
ICD-9 contains outdated terminology that is inconsistent with current medical practice. The code structure of ICD-9 is limited for further expansion, and the ICD-9 codes lack detail and specificity compared with ICD-10. The push for data analysis, outcome-based healthcare, and claim processing automation requires a more detailed, expandable, and flexible coding set.
Who is affected by the ICD-10 compliance deadline?
Everyone covered by the Health Insurance Portability and Accountability Act (HIPAA) is required to successfully conduct health care transactions using ICD-10 codes. All the entities involved in health care delivery and management use ICD coding, including payers, banks, clearinghouses for claims, providers, outsources services, employers, insurance brokers, and the Treasury.
What is affected by the ICD-10?
Changes in the diagnosis codes and inpatient procedure codes will impact your organization. In the tables below you can see the increase in the number of codes, code composition, and code complexity. This change will touch nearly all areas of your organization from the revenue cycle and coding teams to your providers.
Diagnosis Codes
Field Length
3 – 5 Characters
3 – 7 Characters
Available Codes
Approx. 13,000
Approx. 68,000
Code Composition
Digit 1 = alpha or numericDigits 2 – 5 = numeric
Digit 1 = AlphaDigit 2 = NumericDigit 3 – 7 Alpha or Numeric
Inpatient Procedure Codes
Field Length
3 – 4 Characters
7 alpha-numeric characters; all are required
Available Codes
Approx. 3,000
Approx. 72,000
Code Composition
Not Applicable
Specific meaning for character position by classification (e.g., med surg, mental health, etc.)
Why should you care?
If you don't meet the 2014 deadline, your claims can't be processed. This is an impact to revenue that no organization can weather.
According to the CMS FAQs for ICD-10 Transition Basics, "Claims for all services and hospital inpatient procedures performed on or after the compliance deadline must use ICD-10 diagnosis and inpatient procedures codes. Claims that do not use ICD-10 diagnosis and inpatient procedure codes cannot be processed."
Putting ICD-10 into context
We recognize that in the world of health care, ICD-10 is just one of the many large efforts that you are undertaking right now. You're dealing with Meaningful Use, ACOs, health care reform, IT security, EHR Adoption, consolidation, state budgets challenges, and on and on. The good news is that ICD-10 is a manageable project if you move through it in a deliberate, thorough, and organized manner.
Potential Pitfalls
We caution you to watch out for some possible issues that could complicate your execution of the transition process.
The "Silo Effect"occurs when you treat ICD-10 as a department level project. We often hear ICD-10 described as an IT project or a coding project. In reality, it is an enterprise-wide effort and will require all departments to participate in some capacity. ICD-10 crosses all areas, and you don't want to let a database or a legacy process get overlooked in the inventory or transition.
lack of granularity could lead to not assessing, testing, communicating, or training with enough detail or structure to fully identify areas of concern. This is a project that requires both a microscope and herding stick. You need to corral all of your departments to participate and then examine their operations at a pretty low level to determine how they will be impacted by ICD-10.
Be wary of relying too much on your vendor's statements of readiness. Just upgrading to the ICD-10-ready version of software is not enough. You'll have internal preparation activities, changes in business process, testing, and training. You also need to have a back-up plan in the event that your vendor does not meet the ICD-10 deadline.
The last possible pitfall is not engaging in enough planning, testing, and communication with your payers and partners. The testing, transition, and monitoring stages require work with your outside entities to determine whether the implementation steps you have taken independently will work together.
The Silver Lining

ICD-10 is a compliance initiative with a fast-approaching deadline, but it's also an opportunity to assess and improve the communication and practices across your whole organization. Check out our useful tool, Planning for Compliance, 5 Steps for Readiness.
The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.

U.S. Unveils Health Care Web Site and Call Center


WASHINGTON — The Obama administration announced new steps to expand coverage under the federal health care law on Monday, less than a week after the Government Accountability Office, a nonpartisan investigative arm of Congress, found that the federal government and many states were “behind schedule” in setting up marketplaces where Americans are supposed to be able to buy insurance.
The steps — establishing a Web site and a telephone call center to provide information to consumers — are in preparation for what the government anticipates will be a flood of people buying health insurance starting Oct. 1.
Kathleen Sebelius, the secretary of health and human services, said the call center would be in operation 24 hours a day. The phone number is 800-318-2596. The Web site, www.healthcare.gov, provides information promoting the 2010 health care law and describing new insurance options. The Web site and call center currently have only general information about coverage.
Details about the prices and benefits of health insurance plans to be offered by Blue Cross and Blue Shield and companies like Humana and Kaiser Permanente will be available later this summer. Consumers can file online applications starting Oct. 1. Coverage is to begin on Jan. 1, when most Americans will be required to have insurance.
In a statement, Ms. Sebelius said, “The new Web site and the toll-free number have a simple mission: to make sure every American who needs health coverage has the information they need to make choices that are right for themselves and their families or their businesses.”
The Congressional Budget Office predicts that seven million people will buy private insurance next year through marketplaces, or exchanges, while nine million people will gain coverage through Medicaid. By 2016, it says, the number of uninsured, now estimated at 56 million Americans, may be reduced by 25 million as a result of the law.
The federal government will be running insurance exchanges in more than half the states. The administration had said previously that the federal exchanges would be open — at least in 2014 — to any insurers that met basic federal standards.
But Ms. Sebelius, a former Kansas insurance commissioner, told reporters on Monday that “we will be negotiating for rates across the country.” She emphasized the federal role, saying that “we intend to do rate negotiation to make sure that plans are going to offer consumers the best possible choices.”
Federal officials said the negotiations would focus on rates that were much higher or much lower than those proposed by other insurers.
The Web site asks consumers for information about their household incomes, to determine if they may be eligible for federal subsidies, in the form of tax credits, to help pay premiums.
Ms. Sebelius said “we are very concerned” that low-income people in some states will not have access to either Medicaid or subsidies for the purchase of private insurance. However, she said, “there is no timetable” for states to expand Medicaid, and states that rejected the expansion of eligibility this year could reconsider next year.
The federal Web site acknowledges that some states are not expanding Medicaid. “Under the health care law,” it says, “states have the choice to cover more people.”
The Web site says that people eligible for Medicaid should not try to buy insurance in the exchange, because they will not receive subsidies. “A marketplace plan will be more expensive than Medicaid and usually won’t give you additional coverage or benefits,” it says. “You wouldn’t be eligible for any savings on marketplace insurance and would have to pay the whole cost.”
In states that do not expand Medicaid, insurance subsidies will generally be available to people with incomes from the poverty level up to four times that amount ($23,550 to $94,200 a year for a family of four). But in those states, the subsidies will not be available to some of the neediest — people with incomes below the poverty level who will generally not qualify for the new financial assistance with health insurance.
More than half of all people without health insurance live in states that are not planning to expand Medicaid.
Marketing insurance in those states “will be complicated,” Ms. Sebelius said.
Administration officials said the call center would eventually have 9,000 customer service representatives fielding calls. Consumers can also seek information in live Web chats.


Report: Va. AG wants rest of Medicaid settlement payment from feds

RICHMOND, Va. (Legal Newsline) — Virginia Attorney General Ken Cuccinelli reportedly is pressing the U.S. Treasury Department to release the remaining $105 million due to the state for the attorney general’s office’s role as the lead investigator into a 2012 Medicaid fraud settlement.
In a letter to Cuccinelli earlier this month, the department said it would release a total of $115 million.
The office received the initial $10 million Wednesday, a spokesman for Cuccinelli told The Associated Press.
The Treasury’s Executive Office for Asset Forfeiture, or TEOAF, said in its June 5 letter it would give Cuccinelli’s office an initial check for $10 million, but would need more information on how the attorney general planned to use the money before releasing the rest, the AP reported.
A deputy attorney general for Cuccinelli, in a letter last week, told TEOAF that the office wants the entire $115 million, and that the department’s demand for information is inconsistent with its guidelines and past practice.
According to the AP, John Childrey wrote that special authorization is required only when the attorney general plans to use the money on something other than law enforcement.
But the department argues that TEOAF has followed the same guidelines in the case that it adheres to in all asset forfeiture cases.
“The Treasury Department’s authority to make sharing payments is discretionary, and it has decided to share forfeited funds in this case,” a Treasury spokesman said in an email Thursday.
“TEOAF has informed the Virginia Attorney General’s office that its share of proceeds in this case will represent the largest equitable share in the history of the Treasury Forfeiture Fund — an amount that will likely exceed $100 million. This is a very significant sum of money and we have an obligation to the American taxpayers, including those in Virginia, to ensure that these funds are used in an appropriate manner.”
The attorney general says he has been fighting for months to obtain the money from the fraud settlement.
During a press conference held earlier this month, Cuccinelli said Treasury officials originally told his office they wouldn’t turn over the money because of the sequestration — a set of automatic federal spending cuts that were triggered March 1.
“This is despite the fact that it’s not federal money, but money that a private defendant paid to settle a case — money which was to be turned over shortly thereafter to our office and the other agencies involved in the investigation,” he said.
“Now the hold-up is the IRS, which, according to the Treasury Department, refuses to complete its paperwork so the money can be properly distributed.
“The exact amount of the forfeiture was known since September 2011 and finalized in a May 2012 plea agreement. It doesn’t take a year to complete the paperwork.”
The $1.5 billion settlement reached with Abbott Laboratories in May 2012 was divided into $800 million in civil settlements with the federal government and the states, and $700 million in criminal fines and forfeitures.
Abbott allegedly promoted the prescription drug Depakote to control agitation and aggression in elderly dementia patients and to treat schizophrenia, even though the federal Food and Drug Administration never approved the drug for those uses.
The drug was approved by the FDA to treat epileptic seizures, bipolar mania and migraines.
Under the criminal portion, Abbott paid the federal government a criminal fine of $500 million, it paid $1.5 million to the Virginia Medicaid Fraud Control Unit for investigative costs, and it forfeited assets of $198.5 million to go to the investigative agencies for law enforcement purposes.
Virginia’s $115 million comes from that asset forfeiture money, which is required by federal regulations to be used for law enforcement purposes.
Cuccinelli says he plans to use the money for law enforcement equipment and training.
From Legal Newsline: Reach Jessica Karmasek by email at jessica@legalnewsline.com.

Profiting From Pain

THE use of narcotic painkillers, or opioids, has boomed over the past decade as drug makers and doctors have promoted them for a new use: treating long-term pain from back injuries, headaches, arthritis and conditions like fibromyalgia. Insurers have also grown to see pills as a cheaper way to treat chronic pain than other methods.
Some patients are greatly helped by opioids, a large family of medications. Among the more widely used opioids are oxycodone, which is found in Percocet and OxyContin, and hydrocodone, which is used in Vicodin. Other potent opioids include fentanyl and methadone. Narcotic painkillers are now the most widely prescribed class of medications in the United States, and prescriptions for the strongest opioids, including OxyContin, have increased nearly fourfold over the past decade.
There is increasing evidence, however, that such drugs, along with being widely abused, are often ineffective in treating long-term pain and can have serious consequences, particularly when used in high doses. Along with the risk of addiction, side effects can include psychological dependence, reduced drive, extreme lethargy and sleep apnea.
The economic costs associated with the painkiller boom have also proved enormous, giving rise to a host of unanticipated medical, legal and social costs. Over the past decade, the legal — and illegal — use of these drugs has given birth to new businesses and expanded existing ones. These include urine-screening tests to make sure patients are taking the drugs properly, added sales of addiction treatment drugs, growing emergency-room expenses, law-enforcement budgets and skyrocketing costs for insurers.
In the short run, treating a patient with an opioid like OxyContin, which costs about $6,000 a year, is less expensive than putting a patient through a pain-treatment program that emphasizes physical therapy and behavior modification. But over time, such programs, which run from $15,000 to $25,000, might yield far lower costs.
Here is a brief guide to the economics of opioids.
Barry Meier is a reporter who covers business and medicine for The New York Times and the author of the Times e-book “A World of Hurt: Fixing Pain Medicine’s Biggest Mistake.”