Monday, March 31, 2014

AAPC Alert - Keep Calm and Code On

The United States Senate just passed HR 4302, the Protecting Access to Medicare Act. If signed into law by President Obama, then this bill will delay ICD-10 and shift required implementation from October 1, 2014 to as early as October 1, 2015. The act also extends the “doc fix” for Medicare’s Sustainable Growth Rate (SGR) payments for a year.

The bill was rapidly introduced to the House of Representatives on Thursday, March 27th, for vote. After a voice vote passage, it moved to the Senate for today’s vote. Primary arguments cited for delaying the ICD-10 implementation included lack of readiness surrounding clinical documentation, vendor solutions, and systems testing.

We encourage you to keep calm and code on. 

If you are ready for implementation, then we know this delay may be difficult; we will support you with both access extensions and refresher courses. If you need another year, then this change offers an opportunity to increase your readiness through proactive education, practice, and testing. The postponement allows improvement of anatomical knowledge, review and adjustment of documentation quality and clinician education, and adjustment of coding and billing procedures.

AAPC remains committed to serving you with the highest quality training and support to help you adapt to the ever-changing healthcare environment.

ICD-10: Translation 101

Never let it be said that the implementation of ICD-10 has not been exciting.

ICD-10 is still a critical project that will continue to require our full attention. One of the areas of implementation that seems to create the most anxiety is translation. So let’s talk about it.

You’ve probably heard about the concept a hundred times and in several ways, such as mapping, crosswalking, translating, converting, etc. But what does it really mean? And what is the best verb to describe it? I offer, for your consideration, a breakdown of the verbs that are associated with the act of identifying the ICD-10 counterpart for a given ICD-9 code, or vice versa:
  • Mapping – Using a starting point (ICD-9 code) and plotting an end point (ICD-10 code).

  • Crosswalking – Identifying a code that is the equivalent of a starting code (ICD-9 or ICD-10).

  • Converting – Changing policies, processes, and systems from current ICD-9 logic to ICD-10 logic, including the codes themselves.

  • Translating – Using all methods available (including mapping, crosswalking, and converting, along with review of business requirements, clinical equivalence and appropriateness, and standard coding methodologies and guidelines) to identify the equivalent code or codes in ICD-10.
Many people use these terms interchangeably, but I am here to offer a little perspective, having done all of the above with my own two hands. These are not the same actions, but each can be a step in a much larger process that we all must embark upon if we are to implement ICD-10. 

We can’t use just one technique and call it a day. Case in point: we have all heard of the general equivalence mappings, or GEMs, that were developed by the Centers for Medicare & Medicaid Services (CMS) and 3M and released for free to the public for use in the transition to ICD-10. These mappings are also the standard “crosswalk” as required by the Patient Protection and Affordable Care Act. But these mappings, of which only a small percentage could be considered an actual “crosswalk,” are only a starting point in a much larger process. Look at this statement found in the GEMs User’s Guide:

“There is no simple ‘crosswalk from I-9 to I-10’ in the GEM files. A mapping that forces a simple correspondence — each I-9 code mapped only once — from the smaller, less detailed I-9 to the larger, more detailed I-10 defeats the purpose of upgrading to I-10. It obscures the differences between the two code sets and eliminates any possibility of benefiting from the improvement in data quality that I-10 offers. Instead of a simple crosswalk, the GEM files attempt to organize those differences in a meaningful way, by linking a code to all valid alternatives in the other code set from which choices can be made depending on the use to which the code is put.”

A simple solution is not always the best solution, and the translation process is anything but simple. In fact, it is a dynamic process that can change between business areas based on the use of codes or code data. Not everyone uses the codes in a standard way. If we’re completely honest, not everyone applies the codes according to the official coding guidelines. What we code is wholly determined by our understanding of the codes and how to apply them. The same is true for how codes are used within a payor system and how claims processing and adjudication rules are coupled with codes in the systems. Therefore, a standard “crosswalk” is not a solution based in reality in today’s healthcare environment.

But we shouldn’t feel defeated or start looking at ICD-10 implementation as some sort of insurmountable obstacle. Instead, let’s set aside our frustrations, breathe, and take a moment to assess what needs to be done to translate our ICD-9 world into the language of ICD-10. Here are some tips to get you started:
  1. Assess and prioritize what requires modification. Because the implementation clock is ticking, don’t waste your precious time on efforts that can wait until after the implementation date has come and gone. Focus on what absolutely needs to get done in time for testing and ahead of implementation.
  2. Take stock of your internal coding expertise. Leverage the human resources you have to help in any translation efforts you may have going on, regardless of whether they are expert coders or know “just enough to be dangerous.” Get started and assess where your gaps in knowledge are.
  3. Identify your clinical resources. Clinical knowledge may be all you need to address any gaps that can’t be filled by your coding expertise. Sometimes it’s only a small piece of the puzzle that will yield the solution.
  4. Take advantage of free resources – GEMs and ICD-10 manuals are available free of charge through CMS ( along with the new Road to 10 provider portal ( Start by familiarizing yourself with the ICD-10 code set using the manual, and then you can begin any translation by looking up your ICD-9 codes in the GEMs. Use the manuals, which provide coding guidelines, to identify any codes that the GEMs do not identify. Remember, the GEMs are only an approximation.
  5. Align your translations with your business requirements. Translation does not end with the identification of the appropriate ICD-10 codes. Review your translations in the context of your business requirements. Some ICD-10 codes may not be applicable, and there may be additional gaps that will need to be addressed.
  6. Create a review and approval process. Employ more than one set of eyes to review the translations, ensuring that all solutions are as complete and accurate as possible. Formalize the approval process by identifying the owner of the process, and make sure he or she is responsible for approving any translation solution along with when the approval was given.
  7. Archive your translation solutions. Who knows what will be needed in terms of documentation, post-implementation, so make sure you have all solutions and their related information archived and available for future reference.
Don’t sweat the small stuff. And don’t bite off more than can be chewed properly before October 1, 2015. But do get started sooner rather than later!

About the Author
Mandy Willis is a Certified Coding Specialist and AHIMA Approved ICD-10 Trainer with 15 years of experience in the healthcare industry. She has worked in the small physician practice environment, commercial payer and Medicare and Medicaid. Currently, her focus is on assisting all sectors of the healthcare industry in making the transition to ICD-10.

Contact the Author

Expert panel recommends functional status quality measures for skilled nursing facilities

Expert panel recommends functional status quality measures for skilled nursing facilities
Expert panel recommends functional status quality measures for skilled nursing facilities
An expert panel convened by federal regulators has offered recommendations for functional status quality measures in skilled nursing facilities. Released Friday was a summary of the experts' advice to create a functional status quality measure in SNFs, as well as inpatient rehabilitation facilities and long-term care hospitals.
The panel also announced that it had decided against recommending that items from Section G of the Minimum Data Set be used to determine a restorative goal. 
The Centers for Medicare & Medicaid Services contracted with nonprofit research organization RTI International to convene the experts, including rehabilitation clinicians, administrators and researchers.
The discussion centered on the use of items from the Continuity Assessment Record and Evaluation (CARE) set, which was developed as part of a demonstration project to standardize assessments across different post-acute settings. Specifically for SNFs, the experts examined four outcome measures: the change in self-care and change in mobility scores for medical rehabilitation patients, and the discharge self-care and discharge mobility scores for these patients.
Most CARE mobility and self-care items already are assessed in SNF settings, as well as in IRFs, the experts noted. However, “challenging mobility activities” such as car transfers are not routinely assessed in these settings. Assessing these abilities is important for residents who are returning home or to a community-based setting, they concluded.
The panel also addressed risk adjustment. Individuals who have an incomplete stay — including those who die or are unexpectedly transferred to a hospital — should not be included in calculating the quality measure, they recommended. Neither should those who have maximum scores on the self-care and mobility items at admission, since they have no room for improvement. Gender and Medicaid status should be excluded, but age, history of falls and prior functional status would be appropriate risk-adjustment factors, the panel determined.
Not all self-care and mobility items would be applicable in each post-acute setting, the panelists noted. For example, they discussed dropping the “wash upper body” item for SNFs, because most residents bathe in a tub or shower.
Click here to access the complete CMS document.

Hospital medicine doctors are key to improving patient satisfaction

Improving patient satisfaction and enhancing the hospital experience is all the buzz today in health care. Every hospital executive across the country is talking about it, and coming to terms with how their organization’s reimbursements will be directly tied to their performance in this area.
A decade ago, none of us had ever heard of HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores, the core metric by which health care facilities are now being evaluated. And while improving patient satisfaction scores is a complex issue that requires a multifaceted approach from all levels of the organization, one thing is certain: As the most visible frontline clinicians during any medical patient’s hospitalization, hospital medicine doctors are key to driving this improvement. They are the face of the hospitalization, act as the main point of contact for the patient, and are the doctors who will be most involved in their care. The old model of the hospitalist being present “to just round” on patients in place of their regular PCP is long outdated. It’s therefore crucial to recognize their role in improving the hospital experience. Here are some everyday ways hospitalists can do this:
  • Making clear to the patient from the beginning the role of the hospitalist, their relationship with the patient’s PCP, and how they will be in charge of the patient’s complete care as part of a collaborative care team. This helps to reassure an often anxious elderly patient and their family.
  • Regular use of aids such as explanatory introductory cards, pamphlets and business cards. Leave them on the table in the room so that family members can also see them and know the doctor who’s in charge of the care.
  • Making a clear plan for the patient every day. Utilize whiteboards in the patient’s room and keep them updated.
  • Developing more optimal patient rounds, including multidisciplinary rounding models to ensure that all members of the health care team are on the same page.
  • Setting aside dedicated time for extended patient and family meetings each day, usually in the afternoons.
  • Making clear that you are regularly communicating with the specialists who are also involved in the patient’s care.
  • Developing and maintaining good communication skills, always displaying empathy and compassion.
Statistics show that two of the most frequently cited patient complaints are a lack of time with their doctors and health care staff exhibiting poor communication skills. On a practical level, in order to maximize time with patients, hospitalists obviously need a manageable daily patient census. Formal communication skills training is often well received by physicians, especially if feedback is given in a friendly and collegial atmosphere. It’s traditionally been an area that the health care profession hasn’t got into, and older physicians in particular are much less likely to have ever received any formal training or skills advice.
Worried about pushback if you bring up the concept? Most physicians actually enjoy thinking about the topic, and are very keen to improve their skills. Ultimately, it’s all about making the patient feel comfortable, at ease, and listened to. Some proven communication techniques that physicians should utilize include making eye contact, sitting down, and asking open-ended questions. These are very basic, but often forgotten about during a typical hectic day. They can all be taught, improved upon, and coached.
Specialists also need to step up to the mark. They need to be encouraged to maximally collaborate with the hospital doctor and to make the patient feel like all their care is being coordinated. The other touches that go into improving a hospital stay, such as regular nursing checks, being clear on wait times, and following up post-discharge with a personal (non-automated!) message from a nurse or administrator, should all be added to the mix.
Let’s remember that this isn’t simply about saying that you’ve “improved patient satisfaction” and raising survey scores for the sake of reimbursements. Patient satisfaction is really about understanding what the patient is experiencing and the emotional roller coaster that goes with being sick. HCAHPS scores, while by no means the perfect survey, may be the jolt the medical profession needs to strive for what it should have been doing all along: providing patients with a high level of customer service at a low point in their lives.
Hospital medicine doctors are best placed to engage the patient from the beginning, and by focusing on the hospitalist group to lead the way, organizations can soar to new heights.
Suneel Dhand is an internal medicine physician and author of Thomas Jefferson: Lessons from a Secret Buddha and High Percentage Wellness Steps: Natural, Proven, Everyday Steps to Improve Your Health & Well-being.  He blogs at his self-titled site, Suneel Dhand.