Updated on: November 28, 2016

Getting ICD-10 Right: 2017 Claims Data Will Determine 2019 Payments

Original story posted on: May 9, 2016
Last week at the Health Care Payment Learning and Action Network Spring Summit, there was some great information shared with representatives of the industry.

For those who don’t know about the HCP LAN, they say in order to help achieve better care, smarter spending, and healthier people, the U.S. Department of Health and Human Services (HHS) is working to transform the nation’s health system to emphasize value over volume. HHS has set a goal (PDF) of tying 30 percent of Medicare fee-for-service payments to quality or value through alternative payment models (APMs) by 2016, and 50 percent by 2018. HHS has also set a goal of tying 85 percent of all Medicare fee-for-service to quality or value by 2016, and 90 percent by 2018.To support these efforts, HHS has launched the Health Care Payment Learning and Action Network to help advance the work being done across various sectors to increase the adoption of value-based payments and alternative payment models. AAPC is actually a committed partner to the HCP LAN, providing education and awareness.

We are, according to numbers cited at the Summit, already at the 30-percent mark. Accountable care organizations (ACOs) have saved $380 million already, but we typically don’t see that in the headlines. ACOs need to be well-managed to share in risk and remain sustainable, and that is where we see some struggles.

Here’s the real story though. Throughout ICD-10 implementation, we have stressed the importance of coding to the highest specificity. This Summit, as well as information in a newly released proposed rule, pushes us even harder to get there. One thing in particular has stood out to me so far, and that’s the fact that 2017 claims data will be used to determine 2019 payments under the advanced payment models. This means we need to do ICD-10 right, right now. Clinical documentation improvement (CDI) in the physician setting needs to happen quickly. It’s one of the main reasons we launched the CDEO: the Certified Documentation Expert for Outpatient. We need to help physicians and those working with them to make sure we collect the best information and then also promote that information through our claims. Claims data is key to the APM frameworks. Revenue cycle management has never been more important.

APMs and other payment reforms look to deliver better care at lower cost, and they share a common pathway for success: providers, payers, and others in the healthcare system must make fundamental changes in their day-to-day operations in order to improve quality and reduce the cost of healthcare. The plan is to push past our current traditional bundles for short stays and such to longer bundle episodes, as demonstrated in the new cardiac model and through the primary care initiatives.

Depending on our roles, there are many ways we can help our practices evolve and get a solid foothold prior to the implementation of these programs:

  1. Work on CDI – whether you are a physician or a CDEO, make it happen
  2. Coders: code to the highest level of specificity available, and enhance your skills so that you know exactly what you are reading in that medical record.
  3. Work on patient engagement, focusing on what you can do to keep patients compliant and engaged in their healthcare.
  4. Review your claims data often to make sure you are meeting your goals.
  5. Reach out to those that can help you get there.
Recently I started doing some work with a group called the ECL group; you will likely hear me talking about them more as I engage more with them, as I have been so impressed. We have to stop trying to do everything on our own if we expect to get ahead, and my engagement with this group has highlighted that. Under one umbrella they offer electronic medical records (EMRs), practice building, consulting, revenue cycle solutions, and financing to help providers strategically turn things around. In the area of collections they dig down deep to make sure that every area of a practice is protected and on target.

This group is primarily focused on eye care, but if you work outside of eye care, look for this same type of umbrella and this range of expertise, which is going to help you make the right decisions and keep you moving forward, not staying stagnant.

We have a long way to go to make APMs work for the physician market, but we need to make sure we do everything we can now to get the best claims data out there so we don’t suffer in 2019. You can check out more on the progress of these types of reforms at innovations.cms.gov.
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.

Rhonda Buckholtz is the vice president of practice optimization for Eye Care Leaders. She has more than 25 years of experience in healthcare, working in the management, reimbursement, billing, and coding sectors, in addition to being an instructor. She is a past co-chair for the WEDI ICD-10 Implementation Workgroup, Advanced Payment Models Workgroup and has provided testimony ongoing for ICD-10 and standardization of data for NCVHS. Rhonda spends her time on practice optimization for Eye Care Leaders by providing transformational services and revenue integrity for Ophthalmology practices. She was instrumental in developing the Certified Ophthalmology Professional Coder (COPC) exam and curriculum for the AAPC. Rhonda is a member of the ICD10monitor editorial board and makes frequent appearances on Talk Ten Tuesdays.

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