November 14, 2016

Coding’s Role in the MACRA Quality Payment Program

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The coding landscape in physician practices is changing rapidly as healthcare moves toward value-based care and quality payment models. Medical practice coding for ICD-10 plays a key role in quality reporting under the new Quality Payment Program (QPP), which was recently solidified by the Medicare Access and CHIP Reauthorization Act (MACRA) final rule. This marks a big shift for medical practice coders who traditionally have focused only on CPT® coding. 

Since most medical practice coders remain squarely focused on 2016 coding and billing compliance, they have yet to carve out time to learn about MACRA and prepare for QPP participation in 2017. Penalty avoidance flexibilities available to providers in MACRA’s inaugural year offer an opportunity to educate coders and implement coding process improvements at the practice level.

According to a May 2016 Black Book survey, 67 percent of high-volume Medicare doctors feel they will not have the technology, capital, or staffing necessary to sustain their practices under the conditions of the Merit-Based Incentive Payment System (MIPS) introduced by the QPP. A follow-up Black Book Revenue Cycle Survey released in September 2016 provides additional insight into coding and billing concerns in practices:

  • 96 percent reported inefficient billing processes
  • 83 percent reported having trouble recruiting business office candidates experienced in ICD-10, value-based care, risk contracting, and MACRA
  • Nine in 10 small, independent practices remain unprepared for the challenges of implementing value-driven care
These findings emphasize the need for practices to reach out to industry experts for support and consultative assessments of their existing coding, billing, and clinical documentation practices in preparation for MACRA.

While practice coding teams may initially find themselves out of their comfort zone with value-based reimbursement and quality reporting, proactive attention to ICD-10 coding specifics, physician documentation improvement, and Hierarchical Condition Category (HCC) coding can help practices execute an effective QPP game plan for 2017.

Greater Focus on ICD-10 Code Selection

Coding specificity, accuracy, and compliance will have a growing impact on Medicare reimbursement in the year to come, warranting greater attention to ICD-10 coding for physician practice success. These coding objectives can be achieved through targeted, specialty-centric code focus on behalf of practice coders and physicians. Coders should understand the specifics required of various claims cases in order to code appropriately. Those specifics should be documented at the point of care to support reimbursement. 

It is also important that coders remain well-versed in ICD-10 guidelines for coding and reporting. Particular attention should be paid to recent changes and any annual updates to the coding index. Understanding the intricacies of common coding scenarios can mitigate coding accuracy missteps and denials.

Consider the following: hypertensive heart failure (I11.0) is one example of a diagnosis code that also requires a code for the specific type of heart failure (I50.1-I50.4). Coders must also code tobacco history, use, or dependence. Per coding guidelines from the 2017 fiscal year that went into effect Oct. 1, 2016, all hypertension codes require an additional ICD-10 code if the patient is a current or former tobacco user.

Hierarchical Condition Categories’ Role in MIPS and APMs

Coding for HCCs can have big reimbursement implications for medical practices under the new MIPS and advanced alternative payment model (APM) paths. HCCs factor into the risk-adjustment methodology CMS uses to evaluate patient case-mix index and predict future care costs.

HCC risk-adjustment measures ensure that providers are not unfairly penalized for seeing patients with complexities that impact outcomes and costs beyond the caregiver’s control. As with former value-based payment modifiers, the system seeks to secure reimbursement adjustments for physicians serving at-risk patient populations. Including applicable HCC codes in claim submissions directly impacts reimbursement. Provider documentation is required to support diagnoses that map to HCC codes. 

Coder Assistance with Medical Practice Documentation 

Physician practice coders extracting data for claims from clinical documentation can only code what is available in the patient chart or encounter note. Thus, physician education on coding requirements is vital to correct reimbursement and quality reporting under MACRA’s quality payment program.

Documentation by physicians must be thorough, and granular enough to support the right degree of acuity in claims and quality reporting. In lieu of formal clinical documentation improvement (CDI) programs in physician practice settings, aligning physicians with expert coders helps educate physicians on needed documentation specifics and best practices for ICD-10 in the era of value-based reimbursement.

In practices where clinicians are coding for themselves, the onus is on physicians to stay abreast of coding guidelines and protocols. Physicians using electronic health record (EHR) dropdowns for coding may benefit from training on how to quickly and effectively find diagnostic terms in the alphabetical index, which can be challenging for reasons related to classification labeling specifics. Establishing familiarity with ICD-10 codes most commonly used in a practice is the best place to start.

Collectively Building Medical Practice Coding Expertise

Internal expertise and communication among coding and documentation staff will be paramount to coding success as practices advance with QPP plans. Given the health information management (HIM) market’s broader experience with ICD-10 coding to date, hospital coding leadership should assist owned, managed, and affiliated practices with getting started and heading in the right direction. 

A number of excellent additional outlets are emerging to better support physician practices and their coding teams during 2017, the first year of quality reporting under MACRA. CMS, MGMA, and service partners each offer medical practice resources for assessments, training, and education.

Some online resources include: 

Practice initiatives related to ICD-10 coding preparation for quality reporting should involve coders and physicians alike. Practices can engage busy clinicians through online training resources, working lunches, and memos that routinely highlight key coding documentation tips and best practices. Coding professionals can help physician stakeholders understand coding’s impact on their practice’s future revenue stream. Collaboration and communication to facilitate better payment and quality reporting benefits every stakeholder in the medical practice, and it will be integral to future success under QPP.
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.
Renee Stamp, CPC, COC, CPC-I, CPMA

Renee Stamp has spent over two decades directing revenue cycle management and coding operations. Her areas of expertise include all aspects of revenue cycle management, coding and billing compliance, and CPT and ICD training and education. Ms. Stamp’s certifications include: Certified Professional Coder (CPC), Certified Professional Coder-Instructor (CPC-I), and Certified Professional Medical Auditor (CPMA). She is involved with several professional organizations, including AAPC (American Academy of Professional Coders), HBMA (Healthcare Billing and Management Association), and POEAG (Provider Outreach & Education Advisory Group – Kentucky/Indiana).