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ICD-11 Overview

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ICD-11 Overview

 

The World Health Organization (WHO) recently released the 11th edition of the International Classification of Diseases (ICD-11). This release was presented at the World Health Assembly on May 25, 2019 for adoption by member states, and will come into effect on January 1, 2022. However, before we all go into panic mode, note that it is still unknown when ICD-11 will be ready for implementation in the United States. But, it is not too early to review where we’ve been and overview what’s in store for the future!

Background review on ICD revisions

The table below displays the various revisions of ICD timelines. It is important to note that ICD-10 was adopted by the WHO and the World Health Assembly in 1989. But, ICD-10-CM was not fully implemented in the United States until 2015.

ICD-11

Why did the WHO move on from ICD-10?

Unfortunately, despite the updating process, ICD-10 is clinically outdated, and structural changes were needed in some chapters. There is also an increasing need to operate in an electronic environment, as well as the need to capture more information for morbidity-use cases. ICD is the international standard for systematic recording, reporting, analysis, interpretation, and comparison of mortality and morbidity data. According to the WHO, the 11th revision is the result of a collaboration with clinicians, statisticians, epidemiologists, coders, classification, and IT experts from around the world. ICD-11 is a scientifically rigorous product that accurately reflects contemporary health and medical practice, and represents a significant upgrade from earlier revisions.

The WHO ICD-11 revision goals included to:

1. Ensure that ICD-11 will function in an electronic environment by:
• Presenting a digital product
• Providing linkage with terminologies (e.g., SNOMED)
• Defining ICD Categories by “logical operational rules” on their associations and details
• Supporting electronic health records & information systems

2. Provide a multi-purpose and coherent classification for:
• Mortality, morbidity, primary care, clinical care, research, public health
• Consistency & interoperability across different uses

3. Deliver an international, multilingual reference standard for scientific comparability:
• English, French, Spanish, Russian, Chinese, Arabic

Basic Code Structure of ICD-11

ICD-11The diagnostic codes of ICD-11 are alphanumeric and cover the range from 1A00.00 to ZZ9Z.ZZ. The coding scheme always has a letter in the second position to differentiate from the codes of ICD-10. Chapters are indicated by the first character. For example, 1A00 is a code in Chapter 1, and BA00 is a code in Chapter 11.

ICD-11 has an explicit way of marking codes that are post coordinated to describe one condition, called cluster coding. This is a notable new feature in ICD-11 that creates an ability to link core diagnostic concepts (i.e. stem code concepts) when desired, and/or to add clinical concepts captured in extension codes to primary stem code concepts. Either way, it should be emphasized that the clustering ability inherent to ICD-11 is one of the significant changes relative to ICD-10. And the WHO is indicating that there may not be a need for an ICD-12 version, as ICD-11 is comprehensive and very expandable.

In addition, for the first time, ICD-11 will be fully electronic, providing access to 17,000 diagnostic categories, with over 100,000 medical diagnostic index terms. The index-based search algorithm interprets more than 1.6 million terms. Per the WHO, ICD-11 is easy to install and use online or offline, using free “container” software.

Implementation in the U.S.

There is no definite ICD-11 implementation timeline established yet. However, the National Center for Vital and Health Statistics (NCVHS) notes that there are numerous steps needed to move towards ICD-11 implementation including:

• Evaluation of ICD-11 for U.S. purposes (2018 – 2021? 2022?)
• NCVHS Hearings (2021-2027?)
• Notice of Proposed Rulemaking (NPRM) from HHS published in the Federal Register (? date unknown)
• Final Rule published in the Federal Register (? Date unknown)

It is also very important to note that ICD-11 is only for diagnoses. ICD-10-PCS is completely separate from ICD-10 and will not be updated with the transition of ICD-10 to ICD-11. ICD-10-PCS is not a WHO-developed or maintained vocabulary. ICD-10-PCS is a procedure classification system designed by CMS for coding hospital-based procedures. This development was undertaken, because the WHO retired its procedure coding system with the 10th revision of ICD. The ICD rubric was attached to the new U.S. system. Updates to the U.S. procedure classification system do not need to be tied to updates to ICD and vice versa.

While we wait for the 2022 implementation of the 11th edition, read up on the 2020 ICD-10-PCS Guideline Changes for Coding and Reporting.

YES HIM Consulting, Inc. will keep up-to-date on any and all changes to the implementation dates. In the meantime, if you wish to review the online ICD-11 coding tool, please refer to:

ICD-11 Coding Tool

ICD-11 Coding Tool Help

Crafting Your Organization’s Strategic Plan For A Successful Year

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Crafting Your Organization’s Strategic Plan For A Successful Year

 

The healthcare and health information management industry is no stranger to constant changes and evolutions. To successfully navigate the future – and be prepared for anything – healthcare organizations need to craft a strategic plan. But what does strategic planning entail? “Strategic planning is the process of documenting and establishing a direction of your company – by assessing where you are and where you’re going” (The Hartford/Small Biz Ahead, 2018).

strategic planningA strategic plan is beneficial for everyone: It allows the company owner to identify which goals will help grow the organization, and it helps the employees foster that growth by accomplishing the necessary objectives and increasing productivity. By including your employees in the planning process, you create a sense of ownership and accountability for the plan to succeed. Bottom line: Everyone is on the same page about the company’s direction and goals.

The strategic planning process should include:

  • Company Goals, Values, and Mission: Setting your company goals, values, and mission provides the framework of a strategic plan, and may be the most important step of the process. To successfully execute your strategic plan, you need to set performance benchmarks, and identify the initiatives to achieve that growth. For an example, review AHIMA’s strategic objectives they planned for 2018-2022.
  • Establishing Partnerships and Securing Clients: Without partners and clients, your organization would not be a success. It is paramount to dedicate a portion of your strategic plan to making new connections that will help your business grow. Identify all stakeholders in your industry, and develop a proposal that demonstrates your value and how your companies could work together for a profitable future for both parties.strategic planning
  • Creating a Budget: Your organization likely does not have unlimited financial resources, so it is crucial to set monetary boundaries that allow you to achieve your goals and meet all objectives without breaking the bank. Your company partnerships may help increase your budget, giving you flexibility on how you meet your goals.
  • Continuing Education for Coders and Auditors: There is a plethora of organizations that are in constant need of skilled, qualified medical coders and auditors. Build time into your plan for continuing education to ensure your team maintains the knowledge they need to make your organization successful. In addition, by encouraging ongoing education, you will increase your coder and auditor retention, as well as your return on investment.
  • Communication and Brand Guidelines: According to the Journal of AHIMA, one of the 10 best practices of strategic planning is communication. “Develop coherent strategic plan messaging using tools such as blogs and social media, newsletters, brown-bag [informal] meetings, conference presentations, collaborative tools, and FAQs. Execute outreach relentlessly” (Journal of AHIMA, 2013). Use trade shows to get your organization’s name in front of the companies with which you want to do business. Establish your brand guidelines, and adhere to them in all internal and external communications.

Most importantly, remain flexible and ready to adapt your plan to fit your current situation as needed.

Medical Coding Classes and the Importance of a Coding Education

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Medical Coding Classes and the Importance of a Coding Education

 

Medical coders fulfill a vital role. Every service or procedure administered by health care professionals and providers is assigned a numerical code that used for diagnosis classification. These codes are key in providing proper documentation and record keeping for insurance and medical claims. Medical coders work in a wide array of environments within the health care industry, such as hospitals, medical clinics, insurance companies, and health information management organizations.

There are a multitude of companies that are in constant need of skilled and qualified medical coders to bring on to their team. Whether it be opportunities that are directed to more of a contract or remote role, or in-house on a team, the right background and qualification can put you in a position of obtaining a rewarding role in the industry that can grow into a lifelong career.

Whether it be people looking to launch a new career in the coding and billing field or individuals who are already working in a medical records related field, medical coding classes are necessary and beneficial in assuring you acquire and maintain the knowledge you need in order to be successful in the industry. One thing is certain in the health information management industry- and that is the inevitability of change.  Keeping up with the industry’s constantly-evolving learning curve is something every coder must consider when determining the trajectory of where they want to be in their career. A great and failsafe way to ensure that you stay ahead of the curve when it comes to medical coding is by taking advantage of the mass of content that is available online in terms of medical coding classes. But, just because there is such a large amount of content at your fingertips, does not necessarily mean that it is all up to par. After all, quantity does not always equal quality. This is why it is essential to make sure that the information being provided to you is always the most up-to-date and accurate. Always consider how relevant the content is in terms of the specific areas you need to learn more about or brush up on.

Not all medical coding classes are created equal. A key tip in selecting the right content for your specific educational needs is looking into the reputation of the educational source. Always look for a vendor that is credentialed and experienced in providing the necessary training. These vendors coding classes and webinars will more often than not come with approved CEUs (or continuing education units). Acquiring these CEUs and building upon your medical coding repertoire is particularly important in terms of structuring your coding education. Medical coding and health information management can be an extremely rewarding and lucrative field, which makes the value of a coding education, priceless.

Best Practices for Providing Your Team with Valuable Coding Education

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Best Practices for Providing Your Team with Valuable Coding Education

 

Ongoing coding education has proven to be a necessity in terms of keeping up with the industry’s constantly-evolving learning curve, but how do you ensure your organization is receiving the proper coding education that it needs? This is a question that many HIM Directors and Coding Managers face, especially when efficiency and productivity are top priority. Many departments utilize internal education and in-house training, while others choose to outsource this task in order to broaden their educational options. This often leads to the question of, “how do I make certain that the coding education provided to my team is the most relevant and beneficial?” We believe that there are 2 main areas of focus to consider in order to ensure your team’s educational needs are met.

Coding Education

Relevancy of Educational Content:

An important fact to keep in mind is that coding guidelines change every year. This results in the constant need for coding education that facilitates proper documentation and payment to providers. So, whether you are going the internal route or taking the steps to outsource your educational needs, it is essential to make sure that the information being provided to your team is always the most up-to-date. Another factor to consider is how relevant the content is in terms of the specific areas where your team needs improvement. This can be achieved through performing regular coding audits, in order to evaluate the current effectiveness of your organizations coding procedures and processes. At YES, we offer both services in conjunction with one another, which, as a tip to those seeking to outsource, is a sign that you’re headed in the right direction. The end goal here is to not only provide education that will be beneficial to the coder’s day-to-day coding practices, but also focus in on specialized areas that require the most attention.

Coding Education

Reputation of the Educational Source:

A big reason that more and more HIM companies are choosing to outsource their educational needs is because of the peace of mind that goes along with selecting a vendor that is reputable within the industry. With many viable options available today, outsourcing coding education takes the pressure and potential added workload off of the provider and puts it in the trusted hands of the vendor of choice. Rather than having to decipher what areas of interest to focus on in order to successfully provide their coders with the necessary education, companies now have the option to contract with a consulting firm that has a reputation for providing a plan of action that is tailored to the specific needs of their team. As an example, our process at YES is one that spans all the way from the preliminary steps of evaluating and auditing, to post-education follow up sessions and coder mentoring. Our automated educational processes make is easy and accessible to obtain the critical knowledge that you and your team will benefit the most from. At YES, our credentialed and experienced team of nationally recognized experts aim to create and implement a plan of action for your team, in order to guarantee they receive ongoing and pertinent coding education. With continuing coding education becoming an industry norm, keeping these important factors in mind when looking to provide your team with ongoing coding education can ensure that your organization stays ahead of the curve.

 

Inpatient Prospective Payment System (IPPS) 2020 Proposed Rule: A Detailed Overview

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Inpatient Prospective Payment System (IPPS) 2020 Proposed Rule: A Detailed Overview

 

The 2020 Proposed Rule for the Inpatient Prospective Payment System (IPPS) CMS-1716-P, was released April 23, 2019 and was published in the Federal Register, May 3, 2019.  This rule discusses many changes related to reimbursement, and also releases the proposed ICD-10-CM and ICD-10-PCS 2020 codes.  This Proposed Rule provides a glimpse at what will occur on October 1, 2019 when these codes go into effect.  The purpose of a Proposed Rule is to provide a period for comments from the public. When the Final Rule is published in the summer, it will include all of the responses to each proposal, and the final outcome as well as including the final code changes.

The proposed rule seeks to update the payment policies and the annual payment rate of the IPPS system, adjust wage index disparities and to provide an alternative IPPS new technology add-on payment pathway for certain transformative new devices. It is also being recommended to revise the calculation of the IPPS new technology add-on payment, as well as requesting public comment on the substantial clinical improvement criterion used for evaluating applications for both the IPPS new technology add-on payment and the OPPS transitional pass through payment for devices. New requirements or revisions to existing requirements are proposed for quality reporting by specific Medicare providers. There are proposals to establish new requirements and revise existing requirements for eligible hospitals and critical access hospitals participating in Medicare and Medicaid Promoting Interoperability Programs and updating policies for Hospital Value-Based Purchasing Programs (VBP), the Hospital Readmissions Reduction Program and the Hospital-Acquired Condition (HAC) Reduction Program.

Inpatient Coding

ICD-10-PCS Codes: 734 new codes, 2 revised titles and 2,056 deleted codes

The 2020 code tables, guidelines and update summary are posted in the CMS.gov website.  These codes are essentially finalized since they have been posted to the CMS website. There are 734 new codes, 2 revised titles and 2,056 deleted codes with a total of 77,559 codes.  Some of the changes include:

  • Addition of new guidelines for Radiation Treatment section
  • Updates and expansion of guidelines for the New Technology section
  • Addition of body part values for the coronary arteries in the Insertion and Supplement tables; sinus body parts for Supplement procedures; jaw body part for Extirpation in the General Anatomical Regions
  • New qualifier values for Bypass procedures in the Central Nervous and Cranial Nerve, Heart and Great Vessels and Upper Arteries body systems; Transfer in the gastrointestinal body system
  • Addition of devices for the Upper Arteries, Subcutaneous Tissue and Fascia and Upper and Lower Bones body systems
  • Changes in the Administration section with new substances and qualifier
  • Addition of an intraoperative duration for ECMO codes
  • Addition of a new qualifier for Brachytherapy codes in the Radiation Therapy section
  • New Technology Group 5 changes with addition of Devices, Substances and Technology and 2 new code tables

 

ICD-10-CM Codes: 273 proposed new codes, 30 code revisions and 21 deleted codes.

There are 273 proposed new codes, 30 code revisions and 21 deleted codes.  New codes are found in Chapters 3, 8, 9, 12, 14, 17, 18,19, 20, and 21.  A brief discussion of some of the changes follows:

  • Four new atrial fibrillation codes to classify longstanding persistent, other persistent, chronic, and permanent
  • New codes for phlebitis and thrombophlebitis, acute embolism and thrombosis, and chronic embolism and thrombosis of peroneal vein and calf muscle vein
  • Expansion of category L89, pressure ulcer to indicate pressure-induced deep tissue damage
  • Added laterality to category Q66
  • Codes added for fractures of the orbital roof, medial orbital wall, and lateral orbital wall
  • Codes added for encounters involving multiple unspecified drugs for poisoning, adverse effect or underdosing
  • Specificity added to heatstroke and sunstroke
  • Large expansion at category Y35, Legal Intervention to classify injuries in encounters between law enforcement and civilians when the injured person is not specified.
    • Use of conducted energy device (TASER) added
  • Personal history of in-situ neoplasms added

Changes to CC/MCC List

Since ICD-10-CM/PCS data has been available for several years we continue to see changes to the MS-DRGs.  This year there is proposal for extensive changes to the CC/MCC designations; most of the changes involve a reduction in the severity.

New codes are also added to the MCC/CC lists as expected, but a few that we may be familiar with are listed here:

MCC List

  • Additions: candidal esophagitis and enteritis, moderate protein-calorie malnutrition, severe persistent asthma with exacerbation, bacteremia
  • Deletions (move to CCs): brain death, STEMI – initial and subsequent, ventricular fibrillation and flutter, stage 3 and 4 pressure ulcers, fracture femur
  • Deletions (to Non-CC): sickle cell, cardiac arrest, complicated acute appendicitis

 

CC List

  • Additions: neutropenia and agranulocytosis, stage 1 and 2, and unstageable pressure ulcers, acute bronchospasm, some foreign bodies, some drug resistance, homelessness
  • Deletions: many primary and secondary site neoplasms, Kaposi’s sarcoma, leukemia and lymphoma, acute posthemorrhagic anemia, chronic heart failure, Crohn’s disease, ulcerative colitis, abscess of skin, some joint conditions, CKD stage 4 and 5, some BMI codes, transplant status

Finding What You Need in the Rule

The ICD-10-CM/PCS code proposals and the changes to the MS-DRG lists are found in the applicable Tables in the Proposed Rule.  Here is a resource to use when trying to locate particular content:

  • Table 6A-New Diagnosis Codes;
  • Table 6B-New Procedure Codes;
  • Table 6C-Invalid Diagnosis Codes;
  • Table 6D-Invalid Procedure Codes;
  • Table 6E-Revised Diagnosis Code Titles;
  • Table 6F-Revised Procedure Code Titles;
  • Table 6G.1- Proposed Secondary Diagnosis Order Additions to the CC Exclusions List;
  • Table 6G.2- Proposed Principal Diagnosis Order Additions to the CC Exclusions List;
  • Table 6H.1- Proposed Secondary Diagnosis Order Deletions to the CC Exclusions List;
  • Table 6H.2- Proposed Principal Diagnosis Order Deletions to the CC Exclusions List;
  • Table 6I.1- Proposed Additions to the MCC List;
  • Table 6I.2- Proposed Deletions to the MCC List;
  • Table 6J.1- Proposed Additions to the CC List;
  • Table 6J.2- Proposed Deletions to the CC List;
  • Tables 6P.1a-6P.1e (ICD-10-CM and ICD-10-PCS Codes for MS-DRG Changes)

 

The Proposed Rule is available on the CMS.gov website. Stay tuned for more information when the Final Rule is published!

Provider Documentation: Delayed Entries Q&A

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Provider Documentation: Delayed Entries Q&A

 

Recently, we’ve had an influx of questions regarding compliance issues and the proper protocol for handling delayed entries in provider documentation and acceptable time frames.

In our research, we’ve found that the Florida MAC, First Coast Service Options, Inc. (FCSO) has made a clear statement regarding these issues in their bulletin that had been published in the third quarter of 2006. These guidelines are professional fee focused, however FCSO comments that these guidelines can apply to fiscal intermediaries as well: “The focus of this article is on professional services that are usually but not always billed to the carrier (Part B funds) as opposed to the fiscal intermediary (FI – Part A and B funds). However, the principles apply to FI services unless specific differences are noted in the Medicare manuals.” In regards to states other than Florida, we suggest that you confirm with your MACs in terms of their respective guidelines.

Provider Documentation and Delayed Entries

Q. What is considered a reasonable amount of time for a delayed entry/addenda to provider documentation?

A. Per the FCSO bulletin, 24-48 hours is within a reasonable time frame.

 

Q. What is an acceptable reasoning for a delayed entry in provider documentation?

A. Per the FCSO bulletin, delayed entries within a reasonable time frame are acceptable for: “purposes of clarification, error correction, the addition of information not initially available, and if certain unusual circumstances prevented the generation of the note at the time of service.” The AAPC Legal Advisory Board expanded upon this idea in an article published in September 2007 by stating: “Addenda to the medical record should not be a normal practice—these should be the exception and not the rule.”

 

Q. Can a delayed entry be utilized to meet medical necessity?

A. FCSO is very clear on the purpose of delayed entries. They are to be used for clarification only. “Delayed written explanations will be considered. They serve for clarification only and cannot be used to add and authenticate services billed and not documented at the time of service or to retrospectively substantiate medical necessity.”

 

Q. What is the expected timeframe for documentation completion without a delayed entry?

A. Per the FCSO bulletin, “Medicare expects the documentation to be generated at the time of service or shortly thereafter.”

 

Not sure if your provider documentation is up to par? YES provides organizations with the most up-to-date clinical documentation auditing, consulting, and training services, in accordance with current regulatory requirements.

Case Study: Coding Quality Improvement Plan for Healthcare Facility Acquisition of a Large Physician Group

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Case Study: Coding Quality Improvement Plan for Healthcare Facility Acquisition

 

As healthcare organizations strive for continuous efficiency and sustainability, merging and acquiring (M&A) diverse medical facilities provides organizations with new opportunities to reduce costs and generate a larger footprint in current, and even new markets. As an HIM and Coding consulting company, YES has encountered several opportunities to implement auditing, coding, and education improvement plans in these specific scenarios. This case study summary provides an analysis on the unique challenges a medical facility faces when merging with independent practices (I.E. the impact on overall medical coding quality, turnover rate, and productivity), and the solutions we have crafted to be implemented for maximum results. In addition, an included overview of the impact of these solutions presented to a facility and practiced over a 21-month period.

The solution we’ve proposed is one that can be achieved through implementing the four key objectives of our Coding Quality Improvement Plan:

– Identifying the significant pain points impacting coding quality, resulting from a

healthcare facility acquiring a large physician group

– Creating and conducting a coding quality improvement program

– Capturing comparison data & analyzing the solution’s impact on overall coding quality

– Providing recommendations for future programs and addressing similar challenges

 

Overall, the implementation of a Coding Quality Improvement Plan for a merger and acquisition scenario for a period of 21 months, yielded the following results:

ProFee coding accuracy increase at a constantly growing rate: ProFee coders increased coding accuracy by 14.33% in a 21-month period for CPT (1Q17 vs. 3Q18). For DX coding, ProFee coders increased accuracy by 16.41% in the same period. Coder turnover decreased while constantly increasing coder accuracy.

Successful transition of complex encounters to YES team while maintaining a higher accuracy rate in CPT and DX: The YES team consistently performed with a higher accuracy rate in CPT and DX in regards to the overall ProFee coding program and the physician group ProFee coders.

Coder turnover decreased while constantly increasing coder accuracy: Quality Audits are performed per ProFee coder. As the first Quality Audit results were presented in 2Q17, coder retention decreased by over 30%, which resulted in a needed shift in physician group coding personnel in order to continuously increase accuracy and achieve a 100% retention rate by 3Q18.

To conclude, this case study highlights the best approach to address these challenges: assess and develop a plan, with a holistic approach that positively impacts coding quality on an enterprise level. This approach requires an objective team with higher accuracy rates, higher level of expertise in the ProFee field, and proven experience in coder mentoring.

ProFee Coding

Selecting the right coding audit company for your organization

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Selecting the right coding audit company for your organization

 

The process of performing regular coding audits in order to evaluate the effectiveness of your organizations coding procedures has become a necessity throughout today’s healthcare industry. And with more and more companies looking beyond their own departments to outsource this task, it’s important to consider the key factors of choosing a coding audit vendor that is just the right fit. Providers and healthcare organizations that work with coding vendors are well aware of the many factors that go into selecting coding consultant companies. Ensuring the vendor is aligned to the needs and requirements of the organization and its members is top priority. But what are main items of importance to keep in mind?

Coding Audits

Experience: How long has the organization been performing in the field of medical coding consulting services? And is it one of their main areas of expertise, or just a side-service they offer. A good way to figure this is out is by doing some research. Check their company website; it usually highlights their credentials, achievements, and testimonials. The company website can prove to be a great resource to much of the information you are looking for without having to do a lot of digging. Another important question to keep in mind is if the company is experienced in working with small and large facilities. Do they handle on-site as well as remote audits? More often than not, determining how versatile a company is can lead you in the right direction towards the best possible choice. Does the coding consultant company knows how to partner with their clients? This is an important answer to seek. Providing an audit is not the same as partnering with a client to increase quality. Experienced auditing partners know the difference.

Planning & Communication: Does the healthcare coding audit vendor you are thinking about working with give you peace of mind through the way they communicate their plan for your organization? Choose a vendor that practices good communication techniques prior to a contract being signed. A good auditing partner will provide you with information and statistics from their past cases to ensure that you are making the right choice in working with them as well as show you how they stack up against the competition. Does their audit plan for your organization include periodic check-ins or education sessions? If so, you are headed in the right direction. A reputable vendor should include a “touch-base”, or what we call at YES, a coaching session in their plan to keep the client educated and informed on the processes taking place.

Performance & Follow Through: Make sure your vendor of choice will provide you with statistical findings, trend reports, and suggested paths to improvement that will not only help identify problematic patterns in your current coding and documentation, but educate you in the ways that you can improve in these areas. A good way to gauge a potential vendor’s performance is by checking their references and reviews. Would other reputable companies refer you to give them your business? How highly are they rated or reviewed? A smart way to find the answer to these questions is to look for testimonials or reviews from past projects. Be sure to keep an eye out for any trends in these reviews, where certain areas of service are repeatedly commended (or criticized). This can help you gauge if the areas that this vendor specialized in match the needs of your company.

When it comes to selecting the coding audit vendor that fits best for your company, knowledge is power. So, don’t be afraid to dive in and do the necessary research if your goal is to yield the best results for your team. Considering these key areas before making your choice can save you time, money and a lot of work in the long run.

 

Value-Based Care: Trends and Challenges in Revenue Cycle Management

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Value-Based Care: Trends and Challenges in Revenue Cycle Management

The effectiveness of value-based care models is measured based on how this type of reimbursement can improve the quality of a patient’s overall health. Reducing hospital readmissions and improvement in preventive care are good examples of critical factors to assess the effectiveness of these models. U.S. legislation is clearly moving towards the adoption of value-based care models; in 2015, the Medicare Access and CHIP Reauthorization Act (MACRA) put into place multiple quality programs under the new merit based incentive payments system (MIPS). The Health & Human Services Department (HHS) established the objective to convert 30% of Medicare charges into value-added payment models by the end of 2016. By 2018, the Agency’s objective was to make a transition to 50 percent of conventional payments.

Future Trends

Revenue Cycle Management (RCM) systems will eventually assist the industry in transitioning from fee-for-service to value-based reimbursement. The analytics of many of these RCM systems enable payers and providers to look at their patient population in more detail, such as the number of chronic disorders in their patients, allowing payors and providers to monitor claims data and identify potential abnormalities.

Revenue cycle managers are betting on data analytics to try to improve every phase in the revenue cycle process, in order to eventually obtain more cash flow from each phase. Information is being consolidated and evaluated to drive business process changes across the revenue cycle process, from scheduling appointments to claims denials. RCM systems will in due course, streamline routine processes such as claims processing and payer denials prevention.

Future Challenges

Challenge One: Lack of integration

Revenue cycle managers work with historical data from differing financial and clinical information systems. However, many hospitals and health systems have not been integrated to this level. The number of disparate information systems can continue to increase when hospitals merge and purchase physician practices and other healthcare entities. The incorporation of data from external sources can also contribute to the challenges of standardization. Large-scale analytics is still a considerable challenge, resulting in a lack of an all-inclusive view of a patient’s record.

Challenge two: Lack of preventive education

Many reimbursement problems arise from human errors, such as incorrect coding, missing items on a patient’s account, and problems with insurance eligibility. Health organizations that proactively promote appropriate coding techniques, comprehensive chart documentation, and financial policy reinforcement, have consistently reduced turnover and medical errors, which results in a reduced amount of denied claims.

Value Based Care

 

Challenge three: Lack of visibility and control on claim submission-denial process

Following up on a claim throughout its lifetime is another major challenge for healthcare revenue management. Healthcare professionals should closely monitor claims processes to identify errors. Revenue may be lost unless providers can identify where problems arise and quickly resolve mistakes. Providers can usually receive automated alerts or have a dedicated data analysis resource to produce custom and automated reporting, with the objective of identifying why payers deny claims for certain methods or codes routinely.

 

YES HIM Consulting, Inc. Largo, Fl.
Office: (727) 531-3839       Fax: (727) 240-4592