August 11, 2011

Billy's World: What’s Up With the Docs?



The key to success with ICD-10 is the same as it is with ICD-9: documentation is everything. Unfortunately, ICD-10 is significantly more complex than ICD-9, and this begs the number one question related to the entire ICD-10 implementation experience:

How do I convince a recalcitrant physician to document their care adequately so we (the hospital, ASC or other institution) can optimize ICD-10 coding and realize the greatest possible benefit from this system?


In a prior article I used my trike to symbolize the relationship between clinical care, HIM and PFS, noting that each played a critical role in an organization’s success. But that article focused on facility staff, not the lynchpin in the system: the medical staff. It is time to correct that omission. This article describes several specific talking points you can use with the physician who cares very little about any of this, and cares not at all about ICD-10 or any other government requirement.

Once Upon a Time

My mother once told me a story about an old man who was attempting to lead a donkey across a foot bridge, but the animal sat down, refusing to cross. After some time a stranger came by, asked if he could help and listened to the old man’s tale of woe. With a smile, the stranger bent down to recover a fairly large piece of a fallen tree limb, approached the donkey, brought the stick to bear near the donkey’s head and then whispered in its ear. The donkey stood and proceeded to cross the bridge. The farmer – amazed at the stranger’s success – asked how he had accomplished this near-miracle. The stranger smiled once more and said “sometimes you must get their attention before you tell them what you want.”

Physicians who say things like “I didn’t become a physician to follow a bunch of Medicare rules” may require that you “get their attention” first if you want to effect any change in their behavior. While this article may seem to preach doom and gloom, these situations typically require definitive, even dramatic action, and this article is intended to provide you a few “sticks.”

Advantage: Provider

Correct and complete coding yields correct and fair payments, and correct and fair payments are necessary to an organization’s (or practitioner’s) survival. Without a consistent revenue stream and cash flow, a provider – institutional or individual – cannot continue to provide any level of care, never mind quality care.

ICD-10, while admittedly a considerable and considerably expensive interruption to a provider’s normal workflow, offers a number of advantages to all providers, researchers, lawmakers and others who influence or even control aspects of our professional lives:

  • It provides more specific data than ICD-9;
  • It better reflects current medical practice (ICD-9 was developed 40-odd years ago);
  • Its structure accommodates the addition of new codes, so it is less likely to become obsolete;
  • Conversely, ICD-9 is running out of capacity and cannot accommodate changes in the state of healthcare;
  • It has expanded data capture capabilities;
  • It has enhanced quality measurement functionality;
  • Its greater specificity has the potential to reduce coding errors;
  • It permits better analysis of disease patterns, both endemic and epidemic;
  • It supports enhanced tracking of, and response to, public health outbreaks;
  • Once coding is completed, ICD-10 makes claim submission more efficient; and
  • It has the potential to help identify fraud and abuse of payment systems.



“It’s HIPAA, Man…”

Some people apparently have little regard for Medicare, often falling back to positions like “I don’t care what Medicare says” or in some cases “I don’t take Medicare.” With those statements, they believe their point is made and the conversation is over.

Unlike the perennially ill-informed, we know that ICD-10 isn’t a Medicare requirement, it’s a HIPAA Transaction Rule requirement, and thus it applies to all providers, payers and clearinghouses. Furthermore, it applies to both 837i (institutional) claims and 837p (professional) claims, so no provider who bills any third-party payer is exempt.

While CMS is the enforcing agency for the Transaction Rule under the authority of which we all joyfully are embracing ICD-10, it is a universal requirement. Let’s be blunt: it’s not just another onerous regulation; it is the law. Institutions must comply, but so must each and every one of those resistant practitioners. Fortunately, this may be exactly the leverage you need; read on.

“Take Me for a Ride in Your Truck, MAC…”

Medicare started years ago with fiscal intermediaries (FIs), carriers, DMERCS (DME regional carriers) and HHRCs (home health regional carriers). We still have four DMERCs and four HHRCs, but the FIs and carriers are gone (and not likely to be missed). They’ve been replaced by Medicare Administrative Contractors (MACs), of which there are only 13. Each covers all providers except DMEs and HH agencies in one or more states. That is, the MAC for Texas (TrailBlazer) processes all Medicare 837’s (institutional or professional) produced in Texas except those from DMEs and home health agencies.

Now consider the ramifications of this administrative efficiency initiative:

  1. Mr. Jones, a Medicare beneficiary, is admitted to Big City Medical Center for chest pain.
  2. While there, some aspect of his care is monitored or managed by a radiologist, a cardiologist, a pathologist, his admitting physician, his primary care physician, perhaps a hospitalist, and so on. Each of those professionals will generate an 837p.
  3. All those 837p’s and the 837i generated by the hospital go to the MAC for Mr. Jones’s state for payment.

Presently, each claim is processed individually, in isolation from all the others, but it’s only a matter of time before the MACs start comparing all the claims for episodes of care (EOCs) and denying payment based on inconsistencies. And it is likely that the 1500s (837p) will be the claims that are denied. In this scenario, coding quality affects not only hospital payments but physician payments as well, and the MACs will presume that hospital coding is better than the physicians’ coding simply because this often is true. Add to this the pending reality of true episodic payments, through which the hospital probably will pay the physicians, and it becomes clear that even a truly self-serving practitioner has much to lose by not working with the facility.

This scenario provides an opportunity for the hospital to leverage its coding expertise to the benefit of the physicians while offering an inducement to that one physician who doesn’t care about documentation. With electronic health records becoming de rigueur it would be easy for a physician’s billing staff to access the ICD-10 diagnosis codes reported by the hospital so the physician’s claims would match. Furthermore, the procedure codes (ICD-10 for inpatients, CPT/HCPCS for outpatients) could allow the physician’s staff to code in a manner consistent with the hospital’s claim, and ICD-10 has the added value over ICD-9 of allowing a much more accurate crosswalk to CPT/HCPCS because ICD-10 is so much more detailed.

Were this approach put in place, physicians would have a vested interest in their hospitals being able to code correctly. This addresses the old question of “what’s in it for me?” The short answer is that good documentation means good coding, which in turn means timely and accurate payments that benefit everyone. The goal, of course, is to eliminate the “us vs. them” mentality too many private practitioners embrace.



At this point you may brush this notion off with the reasoning that providing coding to a physician’s office would be a violation of Stark I/II, and to some extent that might be true. It also appears to violate the original Medicare Anti-fraud and Abuse Act of 1966, which prohibits inducements “in cash or in kind” to secure admissions. But the PPACA, accountable care organization and CMS push for episodic care payments combined with the federal push for electronic health records (which require sharing of information to be effective) makes the risk of providing coding to a physician much less problematic than it would have been even a few years ago. Furthermore, it would be very difficult for a bureaucrat to argue that providing ICD-10 information to a physician would cause them to change their hospital admission practices, even though it would save them some of the cost of coding in-office.

Standards of Care

The “community standard of care” often is a defense in malpractice suits as well as for other investigations, such as those performed by quality improvement organizations (QIOs) and government agencies. But what is that standard of care for any particular physician?

Generally, the standard of care for a primary care practitioner (family practice, general practice, pediatrics, general surgery, OB/GYN and the like) is defined by the practice standards of the local community. That is, the practice patterns of each pediatrician are compared to the practice patterns of other pediatricians in the same community.

When a small community has only one pediatrician, then the comparison is expanded as little as possible, just enough to capture several more pediatricians. If that can be accomplished by drawing on only the next town over, such is the case. If it requires capturing all pediatric practices in a 75-mile radius, so be it.

The standard of care for specialists is considerably more complex, extending to include the state, the region or even the entire country if the specialty is sparsely populated. After all, how many mitochondrial geneticists practice in your community?

Comparisons of standard of care will be impacted by ICD-10 in that poor documentation on a physician’s part results in poor coding, which in turn may result in poor comparisons with the applicable standard of care. Consider this exchange:

“Dr. Smith, the record shows that you did not perform a serum epoxy level even though every other orthopedist in Wyoming does. Since that test indicates whether or not the patient is becoming unglued, why did you not order it?”

“But I did order it; everyone knows you do that for a patellar transplant!”

“But doctor, it’s not in the chart, so as far as this court is concerned, you didn’t do it.”

Poor documentation impacts a physician’s ability to defend oneself when his or her care is questioned, and this is not limited to legal proceedings. Every hospital has some sort of quality assurance committee, typically operating under the auspices of the medical staff, and the findings of those committees can be every bit as damaging to one’s career as the typical lawsuit.

As value-based purchasing and episodic care payments become common, those physicians who choose not to “play the game” with the hospital at the highest possible level are the physicians who will find their income deteriorating and their ability to secure staff privileges at any hospital diminished. Documentation of care defines quality of care, for better or worse.



Make a Decision Already!

Decision Support Systems are one of the big trends in healthcare informatics; they tie nicely to electronic health records, which in turn make the implementation of DS systems much easier. The core of any DS system is cost accounting and its attendant product line analysis. But what is a product line? Certainly, product lines include:

    • Orthopedic patients;
    • Blue Cross patients; and
    • Patients older than 65 or under 18.

But they also include:

    • Dr. Jones’s patients;
    • Dr. Jones’s patients from ZIP code 99999; and
    • Dr. Jones’s patients from ZIP code 99999 who died.

In fact, a hospital manager using a fully-implemented DS system can define a product line as any two or more claims that share at least one element (demographic or care-related), and a perfect use of that capability is to identify those physicians who do not contribute to the hospital’s success.

In some cases, non-contributors will be physicians who don’t use the hospital much or who use it only for their non-paying patients, for example. In other cases, they will be physicians who overspend for care, performing “shotgun” testing, duplicating tests for confirmation, allowing unnecessary inpatient days (typically for someone’s convenience), and so forth. In still other cases, non-contributors will be identified as such even though they actually provide quality care, provided that they don’t document that care adequately. If it isn’t in the record, it didn’t happen.

As payments ratchet down, payers adopt value based purchasing in one form or another and accountable care organizations (ACOs) become more common, hospital managers will grow increasingly intolerant of practitioners who do not contribute to the hospital’s success. You simply cannot make up a per-unit or marginal loss with increased volume. If you lose $100 on each patient a physician admits, then additional volume only increases your losses. The plain truth is that we are far past the time when physicians were allowed to treat a hospital or other institution as their personal playground.

To Finish

In virtually every aspect of healthcare and healthcare management, documentation often is the difference between success and failure. It impacts payments, protects the financial condition of all providers, mitigates losses when quality of care is questioned and provides objective support when a practitioner or healthcare manager seeks costly change.

The individual professional practitioner who refuses to document care in accordance with your medical staff bylaws and applicable rules, regulations and federal laws is compromising your organization’s prospects of continued existence. It matters not if his or her admissions represent 20 percent of your business; it matters not if he or she is recognized as the “leading specialist in his field.”  What matters is that your organization can prove that it provides the best possible care to all patients, and that you can keep your doors open. When you close your shop for lack of funding, it’s too late to talk about what you should have or could have done. And any professional practitioners who refuse to meet the documentation standards defined for them are not professional and soon will not be practitioners at all. It’s not a matter of if, but when.



About the Author

Billy K. Richburg, M.S., FHFMA is HFMA-Certified in Accounting and Finance, Patient Accounting and Managed Care. Bill graduated from the U. of Alaska, Anchorage and earned his M.S. in Health Care Administration from Trinity University, San Antonio, TX. Over a career spanning more than 40 years, Bill has held positions including CEO, COO, CFO, and CIO in hospitals ranging from 75 beds to over 300 beds, and in home health agencies, DME stores, and a home infusion company. Bill is a Board Member of the Lone Star Chapter, HFMA, and is Director of Government Programs for the Revenue Cycle Technologies business segment of MedAssets, Inc. His office is in Plano, Texas.

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Read 300 times Updated on September 23, 2013
Billy Richburg, M.S., FHFMA

Billy K. Richburg, MS, FHFMA is HFMA-Certified in Accounting and Finance, Patient Accounting and Managed Care. Bill graduated from the University of Alaska, Anchorage and earned his MS in Health Care Administration from Trinity University, San Antonio, Tex. Over a career spanning more than 40 years, Bill has held positions including CEO, COO, CFO, and CIO in hospitals ranging from 75 beds to over 300 beds, and in home health agencies, DME stores, and a home infusion company. Bill is a Board Member of the Lone Star Chapter, HFMA, and is Senior Director of Government Programs for the Revenue Cycle Technologies business segment of MedAssets, Inc. His office is in Plano, Texas.