Updated on: August 17, 2018

Clobbering MACRA with CDI and Coding

Original story posted on: June 26, 2017
Just as we’re getting our minds wrapped around the 2,398-page Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, published by the Centers for Medicare & Medicaid Services (CMS) on Oct. 14, 2016 and becoming effective Jan. 1, 2017, a new proposed rule for 2018 was published on June 20, 2017.

Only a mere 1,058 pages in length, the proposed rule seeks to expand access to MACRA to more clinicians, especially those with small practices, through virtual grouping, facility-based physicians, and with those participating in non-CMS Advance Payment Models (APMs). It also has some additional documentation requirements in the form of attestations that either health information management (HIM) or the practice’s electronic health record (EHR) will need to address. 

For many health information professionals, MACRA and its sister acronyms, APMs and MIPS (the Merit-Based Incentive Payment System) are popping up in email subject lines routinely – and probably being ignored, because on the surface, they seem to have nothing to do with HIM or coding. However, it is clinical documentation improvement (CDI), data integrity, and coding that can clobber MACRA and send the physician practices to success with one crack!

Under MACRA, regardless of whether the provider is being evaluated by MIPS or APMs, there is a direct correlation between coding and reimbursement. Under MIPS, 60 percent of the weight determining physician reimbursement rates hinges on quality measures – and those measures hinge on coding. 

Coding completeness and quality, along with measures that add up to 40 percent of the equation (such as Meaningful Use and access measures) will be the defining point for clinicians, allowing them to potentially lose up to 9 percent or gain up to 36 percent in reimbursement from 2019 to 2023. And under straight APMs, the quality measures drive one-third of the total cost of care factor.

So, for our CDI and coding professionals, here’s the scoop:

  1. Providers can no longer slide by with unspecified coding in their offices. What they are being encouraged to document at the hospital today is exactly what they must document in their offices. This means:

    1. Outpatient CDI and certified coders will be a must in every practice.
    2. Unspecified diagnoses must be banned, to the extent possible.
    3. All conditions, as well as those preventive care and screening services that were addressed during the encounter, must be captured on the claim – not just the four that are used to link ordered tests. This means the provider needs to document what he or she is thinking as they develop their plan of care or assessment.
    4. Sequencing of diagnoses will be important to ensure that all the significant diagnoses make it to the claim.
    5. Linking conditions to manifestations will be an absolute imperative.
    6. And sadly, physicians need to realize that the “way we were” under E&M reimbursement is slowly eroding as CMS financially entices more providers to move to the APM shared-risk models.

  1. As for the cost factor, what the provider does in the hospital (and what it doesn’t do) to ensure that their patients are compliant with discharge instructions will count against them as both Part A and Part B costs go into the equation starting in 2019, if the proposed rule remains unchanged. Those readmissions, granted, are sometimes out of our control, but they will need to be scrutinized to confirm if they are truly readmissions for the same condition and then analyzed in the same way we perform other root cause analyses to prevent them from reoccurring. If the provider treats many patients with COPD, asthma in older adults, or heart failure, there will be opportunities for admissions, and hence, readmissions.

    Additionally, using the more expensive instruments, prosthetics, medications, etc. for those inpatients will come back to bite the ordering provider. This may be an opportunity for hospitals and medical staffs to come together to agree on a single set of standardized supplies that will be used by all providers rather than the individualized supply sets used by each provider. Finally, if the Part A and B claims are coming together for the cost factor, they are coming together for the diagnoses as well. This means that the Medicare Administrative Contractors (MACs) will have another reason to scrutinize claims from both sides.

  1. I predict that CDI and coding will be melded into the same role in many physician practices. Those folks reading that do not have both their CDI and coding certifications: hit those books now!

  1. Both coders and CDI specialists must cultivate a culture of documentation excellence (built on quality data) by partnering with the providers:
    1. Coding professionals need to translate the quality measure options into ICD-10 codes and then analyze the provider’s practice data to determine which measures are represented by a significant portion of the practice’s volume. 
    2. Next, assess the existing documentation and conduct targeted education with the providers, modify EHR templates to facilitate data capture, and if necessary, shadow the physicians on rounds at the hospital to ensure that documentation excellence does not deteriorate outside the office.

Instead of thinking of MACRA as the Medicare Access and CHIP Reauthorization Act, think of it as Measuring All Care, Resources, and Aftereffects.
Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.
Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS, AHIMA-approved ICD-10-CM/PCS Trainer

Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS, is a past president of the American Health Information Management Association (AHIMA) and recipient of AHIMA’s distinguished member and legacy awards. She is chief operating officer of First Class Solutions, Inc., a healthcare consulting firm based in St. Louis, Mo. First Class Solutions, Inc. assists healthcare organizations with operational challenges in HIM, physician office documentation and coding, and other revenue cycle functions.

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