ICD-10: Springboard to Value-based Reimbursement

In her talk at the ACR 2016 meeting, “How to Cope with ICD-10,” on May 17, in Washington, DC, Karna Morrow, manager of consulting services, Powder Springs, Ga.-based Coding Strategies, related an observation in the exhibit hall at a recent meeting. As a radiologist walked toward her booth, he stopped and turned on his heels, saying, “Oh no, I have nothing to do with coding.”

The greatest challenge of coding and billing operations in implementing ICD-10 over the past year has nothing to do with coders or billing personnel, Morrow notes.  “Our hardest challenge and biggest obstacle is getting the physicians to engage,” she said.

The stakes are high, because, according to Morrow, because the iteration of ICD-10 health care has worked with since October 2015 has been wearing training wheels. As of October 1, 2016, that trial period ended and practices no longer have the option of using an unspecified code.

“Hospitals hold training sessions and feedback meetings, and everyone is there but the physicians,” Morrow observed. “They are the ones dictating the reports, so they are the ones who need to be engaged.”

Furthermore, the successful adoption of ICD-10 has implications beyond just getting paid today. Many of the value-based payment mechanisms proposed and in current use are based on diagnosis codes.

Morrow emphasized three steps radiologists can take to ensure optimal adoption of ICD-10 in their practices. First of all, greater diagnostic specificity is crucial to value-based care, so get engaged with ICD-10 and stay engaged. Second, listen to feedback on performance and if all is well and denials aren’t a problem, push back, dig deeper and consider doing an audit. Third, retire the phrase, “Well, this is all I was given.” Reach out and find ways to get the information you need prior to reading a study.

Stay engaged

It is important to recognize that ICD-10 was not a go-live event, but represents a long-term investment. “The reality is, ICD-10 is the mechanism for your new fee schedules,” Morrow said. “We all know that medical necessity drives health care in the United States, and ICD-10 is your tool to describe that.”

Another reality Morrow was keen to point out is that a code freeze has been in place for more than five years, due to ICD-10 waffling, and was set to expire on October 1, 2016. Approximately 3,000 changes were scheduled to debut on October 1, and have been available for review since July 1.

“We are back on a schedule of those codes being updated annually,” Morrow advised. “As providers, I encourage you to carve out the time, quarterly or annually, to stay updated and engaged with what those codes are and how it impacts your documentation.”

Morrow also urged radiologists to ask the right questions to get the right answers. If you are getting paid, find out why you are getting paid. Is it because your coding/billing team is making liberal use of unspecified codes?

Many of the mechanisms that will be used to create a new value-based reimbursement model—value-based modifiers, bundled payments, the components of the Merit-based Incentive Payment program—are anchored in diagnosis codes, “I don’t care whether you call it quality, or merit-based, at the end of the day, it is all driven by the severity of your patients and that severity is communicated through diagnosis codes,” she emphasized.

Medical necessity, Morrow reminded, is defined as care that meets but does not exceed the need, and ICD-10 supports the specificity that medical necessity determinations require. She offered the example of a patient with abdominal pain: One clinical pathway and modality is indicated for a patient with abdominal pain, but if that patients is post-gastric bypass, a totally different pathway is indicated. Failure to properly identify the type of patient in the report can result in improper coding and denial of payment.

“We got lambasted as a society as radiologists because we are doing head scans on lung cancer patients,” Morrow said, referring to an article1 that appeared in the April issue of Chest. “Well, we know why [those scans were done], we were trying to rule out mets. But we did not communicate, through the diagnosis codes, the headache, the dizziness, the unstable gait—that would have told the story.”

“I know what you are thinking,” she continued. “‘I didn’t get that, the referring physician didn’t tell me that.’ That’s why we have to change some of our paradigm.”

For guidance on where radiology needs to prepare to demonstrate medical necessity, look at the hospitals. “They’ve been paid on DRGs [diagnostic related groups] for decades,” Morrow noted. “The hospital is not paid based on those chest procedures. If a patient has a chest procedure and no one documents the complications, they get nine grand. But if someone in HIM is very good at ferreting out those complications, suddenly they get $13,000 for exactly the same procedure. And if those complications happen to be on the MCC [major complicating or co-morbid condition] list for major complications, the exact same procedure now merits $25,000.

“The model already exists,” she continued. “It’s not about whether you did a PET, a CT or an MR. It’s hinged on the severity of your patients, and what are we doing collectively as a group to better communicate that to our payors.”

Listen to feedback

Think carefully about what you are hearing from your business office with respect to ICD-10 and billing efficiency, Morrow suggested. Accuracy in the long run is better than expediency in the short term.

“In billing companies and consulting firms, we are really struggling to get our coders back to [their previous] productivity level,” she said. “The same work queues that you have in the imaging center, we have at the billing companies.”

While the pressure to clear those queues exists, it should be done without sacrificing accuracy. After performing audits of many post-ICD-10 implementations, Morrow said that radiologist reports have stepped up dramatically.

“I have seen them give very specific locations of tears and fractures and locations on the bone,” she said. “They are giving all of those details in the impression—and then they also list the minor stuff. Effusion, edema, joint pain. Unfortunately, the coders, in their quest for efficiency, pick up the one impression that they have a code memorized for—and go with it.”

Taking the extra step mow to ensure that your coding is accurate can pay off down the road, Morrow said. extra step. “Payors have not turned on any of their edits yet,” she said. “If you are still throwing a lot of unspecified codes after October 1, that is going to be a problem for you.”

Morrow suggested that practices run frequency reports by diagnosis codes instead of CPT codes to get a better picture of the problem. “We have two quarters under our belts, you should be able to get a frequency report by diagnosis code, by physician, because I want you to find out how many unspecified codes are going out the door,” she advised. “That will help you.”

Frequency reports by diagnosis code by physician also will help you identify variation in the descriptive language being used in your practice. “Some physicians will document the condition as an AV malformation, and some will document it as an AV fistula even though they both read the exact same scan,” she said. “In ICD-10 those two are coded totally different. One is a coded as a congenital condition   and one is coded as an acquired condition. If I look at all of my radiologists doing ultrasound, I should not see drastic variations in how they are coding things.”

An audit of a musculoskeletal group turned up a major inconsistency between pre- and post-ICD-10 coding patterns. “Pre-ICD-10, most of their osteoarthritis was primary osteoarthritis, the default.” Morrow said. “All of the sudden on Oct 1, most of their osteoarthritis was post traumatic. Why?”

The coders had been told to be specific, so any patient with any history of a traumatic injury or a vehiular accident was coded as post-traumatic. “The problem is the reports didn’t support that,” Morrow noted. “Because you are not treating different patients than you were pre- to post-, any variation in the diagnosis codes—the conditions—should be seen as consistencies.”

Morrow recommended running the same report by referring physician to discover why, for instance, two orthopedic groups always order different studies for a stubbed toe. She calls it, “monitoring the severity of your practice.”  “These are the kinds of data mining activities that the payors are doing behind the scenes, and this is some of the foundation of clinical decision support,” she said.

Reach out

Finally, Morrow urged radiology practices to be proactive, not complacent, when it comes to getting the context it needs to interpret a study. “If it’s a Brave New World in medicine, then we need a different approach,” she said.

Some large radiology groups are training referring physicians on ICD-10, which helps them with their office visits and improves orders. They have revamped requisition forms to be very specific, decision-tree ordering algorithms which prompt the referrer for additional information based on the study ordered.

“It is in a very check-box format that works for paper or electronic orders,” she explained. “How many of your requisition forms still have a blank line after clinical history? You give them a blank line, and what are they going to give you? Nothing. Because they really are not sure,”

Likewise, take steps to research who it is in information services that can help you get what you need from the hospital. “IT is your most valuable resource and if you create a relationship with them, it is amazing how this field can magically merge and this field will magically show up on the HL-7 report,” she advised.

In conclusion, Morrow urged attendees to address these issues with referring physicians, hospitals, with your billing company. “Think about ways you can make yourself available to participate in some coding conversations,” she said. “Think about ways in which you can initiate the conversations to find the data that is going to give you the answers you need. Then, how can you work outside of your immediate scope of influence—with referring physicians, your community associates, hospitals—so that we can continue to move forward into our Brave New World?”  

Reference

• Balekian AA, Fisher JM, Gould MK. Brain imaging for staging of patients with clinical stage 1A non-small cell lung cancer in the National Lung Screening Trial: adherence with recommendations from the Choosing Wisely campaign.