ED Coding Update: ACOs, RACs, and ICD-10 — Updates for the ED
ACOs, RACs, and ICD-10 Updates for the ED
[This quarterly column is written by Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, President of Edelberg Compliance Associates, Baton Rouge, LA.]
To say our specialty has a full plate is an understatement. We are facing down a number of issues that are guaranteed to transition us to a new world. Each has a distinct universe of requirements for preparation, orientation, and management, and each will require the collaboration of providers, compliance, coding, and billing.
Accountable care organizations
Health care reform will look different to you depending on how your community and state resolve issues. Section 3022 of the Affordable Care Act added a new section 1899 to the Social Security Act (the Act) that requires the Secretary to establish the Shared Savings Program by January 1, 2012. This program is intended to encourage providers of services and suppliers (e.g., physicians, hospitals, and others involved in patient care) to create a new type of health care entity, which the statute calls an "Accountable Care Organization (ACO)" that agrees to be held accountable for improving the health and experience of care for individuals and improving the health of populations, while reducing the rate of growth in health care spending.
Even in the early stages of implementation, health care reform is pushing providers to join together in order to control health care costs and quality. The ACO may receive payments for shared savings if the ACO meets certain quality-performance standards and cost-saving requirements established by the government. (Key words: "shared savings" and "quality performance standards!")
Hospitals are purchasing physician practices at a rapid rate, and this could challenge ED groups who want to remain independent but are in any way financially dependent on the hospital. With ED volumes increasing, and the impact of the economic downturn evident in higher numbers of uninsured or minimally insured, it will be challenging for ED practices to maintain their status quo or improve their financial picture without stepping out of the box and looking at new opportunities and methods to ensure today's challenges are met.
ACOs will come in a variety of packages: hospital-owned, physician-owned, or a combination of both. The new model provides an opportunity for providers to take back controls in a way that is similar to the Physician Hospital Organizations (PHOs) of the past. In this case, however, ACOs will be required to demonstrate quality using an objective method of measurement. And their ability to control costs will determine success or failure.
ACOs are likely to take many different forms. Some regions will spawn independent practice associations (IPAs), while others may prefer PHOs; quality and efficiency will be the top priorities. We would expect some element of fee-for-service to continue, with additional new payment methods that require greater integration and increased risks assumed by all participating providers.
Recommended solutions to manage the transition
- Prepare your practice/department to track quality indicators and monitor by provider and location;
- Maintain detailed reporting on frequency of codes, charges, and payment by major payers;
- Monitor local and regional activities by hospitals and physicians as ACOs are formed;
- Monitor changes in acuity, revenue, and volumes; and
- Collaborate with other specialties within your region particularly hospital-based to form alliances, share information and patient statistics, and begin development of shared "best practices."
Recovery audit contractor (RAC) program
We continue to monitor regional RAC activities and, so far, emergency physician groups have been bypassed by RAC audit activities while RAC contractors concentrate on hospitals and higher-priced provider services. Evaluation and management codes, the backbone of emergency medicine, probably won't be on the RAC radar for another year or so, but our hospitals are already being RAC'd for a number of issues that involve services performed in the ED: medication dosages/units, blood transfusions, bronchoscopy services, physician orders, IV therapy, medical necessity based on pre-admission documentation, validation of short stay, uncomplicated admissions, and timed services. Additional problem areas include medical conditions that are present on admission (POA), which require detailed documentation by ED physicians to allow inpatient coders to identify conditions that were present and not hospital-acquired conditions (HACs).
Recommended solutions to manage the transition
- Assign task force of ED physicians, nurses, compliance, and coding and billing representatives to monitor RAC issues;
- Perform routine audits and "what-if" exercises to assure immediate identification of potential risk areas;
- Plan processes to appeal audit findings; and
- Expand focus to include impact of ED documentation and orders on inpatient services.
ICD-10
Fast approaching is October 1, 2013, the implementation date for a total revision in reporting of diagnoses and, unlike many governmental initiatives, we don't expect a last-minute reprieve. ICD-10-CM codes are codes used to document diagnoses. They are 3-7 characters in length and total 68,000, while ICD-9-CM diagnosis codes are 3-5 digits in length and number over 14,000. The ICD-10-PCS are procedure codes that are alphanumeric, 7 characters in length, and total approximately 87,000, while ICD-9-CM procedure codes are only 3-4 numbers in length and total approximately 4,000 codes.
The transition to ICD-10 will impact all physicians in some way. The number of codes has increased significantly, and the reformatting of the number of characters per code, and the demand for increased code specificity, require significant planning, training, and software/system upgrades/replacements. Prior to implementation of ICD-10, we will be required to implement an updated version of HIPAA transaction standards, known as 5010, by January 1, 2012, as the current version, 4010, does not accommodate use of the ICD-10 codes.
Don't let an implementation date two years away give you a false sense of security! The dramatic change in code descriptions will impact the way physicians document all levels of differential diagnoses, final diagnoses, operative notes, diagnostic interpretations, and more. For example, providers will be required to provide a higher level of anatomical detail in notes, as well as note details such as stabbing, visible, extreme, and a more specific and exact location of a problem. Expanding documentation "macros" and templates will be a significant component of the transition to ICD-10.
Recommended solutions to manage the transition
- Begin documentation improvement efforts NOW;
- Identify the most frequent diagnoses in your ED and develop documentation-improvement templates for each;
- Conduct "transition" exercises to understand how most common diagnoses are coded today and how the transition to ICD-10 diagnosis codes will occur; and
- Plan to educate coding staff no later than the final 6 months prior to implementation of ICD-10 to assure all are trained, experienced, and good-to-go.
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