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23 posts from September 2015

September 30, 2015

ICD-10 Transition Begins Tomorrow, October 1


The time is finally here. After delays and much deliberation between government and physicians, the ICD-9 code sets used to report medical diagnoses and inpatient procedures will be replaced by ICD-10 code sets. This goes into effect tomorrow, October 1, 2015.

 ICD-10 basics

ICD-10 stands for the International Classification of Diseases, version 10. It is a coding system that attaches a number for every disease of trauma known to the medical world. According to the World Health Organization, ICD is “the standard diagnostic tool for epidemiology, health management, and clinical purposes.  It is used to monitor the incidence and prevalence of diseases, providing a picture of the general health situation of countries.”  In the U.S., the ICD has been adapted for billing. While work on ICD-10 started in 1983, HHS used ICD-9 until 2013 and was subsequently delayed twice by Congress. ICD-11 only exists in draft form and is not expected until 2020 or 2025.

Physician concerns

As we previously wrote, the U.S. has lagged behind other countries in updating to ICD-10, but the process is by no means a quick fix. The number of procedural and diagnostic codes is estimated to increase from about 17,000 unique codes in ICD-9 to over 140,000 unique codes in ICD-10. A procedure like an angioplasty, for example, will shift from having 1 code to having 854 possible codes, according to reporting done by MedPage Today.

Physicians are concerned the new system will cause additional administrative burdens with new documentation requirements that, if incorrectly applied, could result in denied claims (See Kevin MD). In fact, an August survey by Navicure/Porter Research shows that an "overwhelming majority (94%) of participants" anticipate an immediate increase in their denial rate, with 56% of respondents citing ICD-10's impact on revenue and cash flow as their top concern. Practice administrators and billing managers comprised the majority of survey respondents (58%), followed by practice executives (14%) and billers and coders (14%). While survey respondents represent a range of specialties and sizes, two-thirds (67%) are from organizations with one to 10 providers.

Some flexibility issued by CMS

In July, CMS announced that it would provide greater flexibility during the transition to ICD-10 billing codes. Specifically, while diagnosis coding to the correct level of specificity is the goal for all claims, for 12 months after ICD-10 implementation date, Medicare review contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family. Starting October 1, 2015, however, CMS will require a valid ICD-10 code.

CMS addressed its interpretation of “family of codes” in a recent document, saying the codes are the same as the ICD-10 three-character category. CMS writes: “Codes within a category are clinically related and provide differences in capturing specific information on the type of condition. For instance, category H25 (Age-related cataract) contains a number of specific codes that capture information on the type of cataract as well as information on the eye involved.”

“Examples include: H25.031 (Anterior subcapsular polar age-related cataract, right eye), which has six characters; H25.22 (Age-related cataract, morgagnian type, left eye), which has five characters; and H25.9 (Unspecified age-related cataract), which has four characters. One must report a valid code and not a category number. In many instances, the code will require more than 3 characters in order to be valid."

CMS remains fully committed to ICD-10

“As we work to modernize our nation’s health care infrastructure, the coming implementation of ICD-10 will set the stage for better identification of illness and earlier warning signs of epidemics, such as Ebola or flu pandemics.” said Andy Slavitt, Acting Administrator of CMS this July.

“With easy to use tools, a new ICD-10 Ombudsman, and added flexibility in our claims audit and quality reporting process, CMS is committed to working with the physician community to work through this transition.”

In a recent Q&A document, CMS outlined answers to several common ICD-10 questions. The agency writes that it “understands that moving to ICD-10 is bringing significant changes to the provider community. CMS will set up a communication and collaboration center for monitoring the implementation of ICD-10. This center will quickly identify and initiate resolution of issues that arise as a result of the transition to ICD-10. As part of the center, CMS will have an ICD-10 Ombudsman to help receive and triage physician and provider issues. The Ombudsman will work closely with representatives in CMS’s regional offices to address physicians’ concerns.”

Politico reports CMS contingency plans

According to Politico, CMS has plans in place depending on the scenarios that could take place during the transition to ICD-10. Politico writes the five specific CMS contingency scenarios include: (1) CMS’s systems are working fine, but providers have an inability to submit any codes; (2) Providers are submitting ICD-10 codes, but incorrect ones; (3) CMS’s systems are not working correctly; (4) There is an additional delay to ICD-10; and/or (5) There are problems with submitting claims unrelated to ICD-10. If Medicare systems are not working properly, CMS will hold claims while issues are resolved. If providers are having issues, the agency will remind providers of their options including submitting paper claims. You can read more at Politico’s website on the contingency plans (subscription required).

Some helpful tips

The advice from those who have already tried coding with ICD-10?

Hire a certified coder if you do not have one on staff already. Other recommendations include scaling back on the number of patient visits booked in October, giving physicians extra time to learn and incorporate ICD-10. Additionally, experts suggest a focused approach to learning the codes to help avoid becoming overwhelmed. Take the top 100 ICD-9 codes and become familiar with their ICD-10 version. Finally, thorough documentation will be a critical step to make a smooth transition into ICD-10 coding.


September 29, 2015

Improving Diagnosis in Health Care


When providing health care to patients, it is crucial to get the proper diagnosis as soon as possible to help the patient make the best decisions for their health and long-term goals. Recognizing that diagnostic errors have been around for decades, affecting the accuracy of patient diagnoses, the National Academies of Sciences, Engineering, and Medicine convened a committee of experts to research and better understand how diagnostic errors occur and to propose recommendations on how to improve patient diagnosis.

The committee defined diagnostic error as “the failure to (a) establish an accurate and timely explanation of the patient’s health problem(s) or (b) communicate that explanation to the patient.” The committee determined that while diagnostic errors stem from a variety of causes, the definition of diagnostic error should be defined from the patient’s perspective because they hold the ultimate risk of harm from diagnostic errors.

The committee understood that since diagnostic errors stem from multiple causes, a singular, narrow focus on reducing diagnostic errors would not achieve the extensive change the committee believes to be necessary. Instead, the committee developed a conceptual model to better articulate the diagnostic process and to identify eight goals to reduce diagnostic error and improve diagnosis.

Those eight goals centered around the importance of the continuous improvement of teamwork, education and training, technology, and research. For example, one particular goal was to enhance healthcare education and training in the diagnostic process. "Getting the right diagnosis depends on all health care professionals involved in the diagnostic process receiving appropriate education and training," the article stated. "Improved emphasis on diagnostic competencies and feedback on diagnostic performance are needed." Education to improve diagnoses is especially important as health care delivery has gotten increasingly complex, the authors note.

The committee concluded with a reminder that nearly everyone has a responsibility in working to reduce diagnostic error: “just as the diagnostic process is a collaborative activity, improving diagnosis will require collaboration and a widespread commitment to change among health care professionals, health care organizations, patients and their families, researchers, and policy makers.”

In addition to the recommendations made to physicians, the National Academies of Sciences, Engineering, and Medicine also put out a pamphlet geared toward patients. The pamphlet’s purpose is to help patients better understand how diagnostic errors occur and what they, as the ultimate risk-bearers of diagnostic error, can do to avoid them. The pamphlet emphasizes how important effective communication and collaboration with medical providers is. It provides a checklist for patients to ensure that they are doing their part in communicating with their medical professionals, including items like: be clear, complete and accurate when describing their illness; keep track of helpful treatments; and keep good medical records.

Overall, there are many factors that contribute to diagnostic error, and many possible solutions that have the potential to reduce the number of misdiagnosed patients. Effective education, collaboration, and continuous improvement are key components of the solution. 

September 28, 2015

“Confluence, Not Conflict of Interest: Name Change Necessary”


Last week, the Journal of the American Medical Association (JAMA) released an editorial entitled “Confluence, Not Conflict of Interest: Name Change Necessary.” In it, the authors make a number of important points about certain problems with the “conflicts of interest” label that they feel has been misused. Anne Cappola and Garret Fitzgerald, both of the Institute for Translational Medicine and Therapeutics (ITMAT) at the University of Pennsylvania, note that their editorial reflects themes that emerged from a recently convened international meeting on conflicts of interests.

The authors’ first disagreement stems from the phrase itself—“conflict of interest is pejorative” they write, and “confrontational and presumptive of inappropriate behavior.” The authors argue that better terms would be “confluence of interest,” and “the focus should be on the objective, which is to align secondary interests with the primary objective of the endeavor—to benefit patients and society—in a way that minimizes risk of bias.” The term “confluence of interest” expands the individuals who could be liable to bias beyond just the investigator and sponsor to include departments, research institutions, universities, and out to nonprofit funders, the National Institutes of Health, and journals, which the authors state “generate advertising revenue from sponsors.”

Their second point is that up to now, clinical research disclosure policies have focused on financial disclosure. The authors provide their views that money is only one part of the picture. “[I]n academia, the prospect of fame may be even more seductive than fortune,” they write. Bias may be stronger for a researcher who may benefit from the outcome of a study by having the study published in a prestigious journal, receiving invitations to speak at conferences, and even enjoying promotions or higher salary. “Even though an investigator may publicly eschew any direct financial reward from a sponsor, such fiscal and professional benefits may accrue to them indirectly from the institution, if they attract clinical trials with their attendant indirect costs,” the authors write.

They offer an idea on how to potentially track this: “Much like a heat map of gene expression, a dashboard would express and give weight to elements of fame and fortune on the y-axis, charted against individuals and entities on the x-axis that are likely to gain from the endeavor,” they write.

The authors next discuss another theme that emerged during their Conflicts of Interest meeting—that inventors of medicine or devices may have “a highly restricted skill set necessary to advance translation of the discovery from ‘bench to bedside.’” Despite the potential for bias, the authors note that there has been “a move away from blanket exclusion to permitting engagement by the inventor in clinical development, conditional on additional oversight, to assure the public and to mitigate bias.”

The article also notes that despite the benefits of public private partnership, the interests of these parties may sometimes diverge. “Just as universities foster relationships of their faculty with industry, their responsibility to the public interest behooves them to protect and ensure the independence of their faculty to disseminate the full spectrum of their discoveries, even when they may include uncomfortable truths for the sponsor,” the authors write. “Institutions also have an obligation to be governed by their mission, rather than profit, and maximizing profit may not always serve that mission.”

Finally, the authors place a high level important on education. “Education of trainees, investigators, administrators, funders, publishers, politicians, and the public—is essential for progress,” they state. “Academic institutions have a particular responsibility to inculcate, promote, and reward intellectual honesty in ways more imaginative and effective than in the past.”

 “Confluence of interest represents a complex ecosystem that requires development of a uniform approach to minimize bias in clinical research across the academic sector,” the authors conclude. “Such a policy must be at once simple and accessible, capturing the complexity of the relationships while being sufficiently flexible at the individual level not to intrude on the process of innovation.”

This article gives us a hint that there may be a change in the editorial direction at JAMA, earlier this year a competing journal the New England Journal of Medicine also ran a series of articles questioning the burden that the conflict of interest movement has had on medicine.

View the article in JAMA here


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