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Posts Tagged ‘ICD-10’

Inpatient Psychiatric Facilities Impacted by Affordable Care Act, ICD-10

Sunday, August 2nd, 2015

Section 1886(s)(4)(C) of the Social Security Act, amended by sections 3401(f) and 10322(a) of the Affordable Care Act requires IPFs to report quality data for 6 quality measures starting in fiscal 2013 for Medicare beneficiaries.   Beginning in FY 2015, two quality measures are added.   Failure to comply with these regulations will result in a 2 percent reduction to the applicable base rate for IPFs.  (Source: Medicare Learning Network publication Inpatient Psychiatric Facility Prospective Payment System).

Mike Arrigo, Managing Partner & CEO No World Borders, Inc.

Michael Arrigo, Managing Partner, No World Borders

A Behavioral specialty provider recently stated, “…we don’t use DRGs we use Inpatient Psychiatric Facility Prospective Payment System (IPF PPS).”  In fact, the facility is indeed using DRGs. According to CMS:

…IPF PPS, Federal per diem rates include inpatient operating and capital-related costs (including routine and ancillary services) and are determined based on:

  • Geographic factors:
    • A hospital wage index value is assigned to account for geographic differences in wage
    • The non-labor-related portion accounts for higher cost of living for IPFs located in Alaska and Hawaii;
  • Patient characteristics:
    • Medicare Severity-Diagnosis Related Group (MS-DRG) classification;
    • Age;
    • Presence of specified comorbidities; and
    • Length of stay; and
  • Facility characteristics:
    • A 17 percent payment adjustment for rural facilities due to their higher costs; and
    • Teaching hospitals receive payment to account for indirect medical education costs…

Why does this matter in the context of ICD-10?   The quality measures will be based on diagnosis and procedures coded in ICD-10 beginning October 1, 2015.

For more information on behavioral health, ICD-10, DSM-5 and DSM-IV see related blog posts.

Related Posts:

ICD-10 and DSM-5 for Behavioral Health

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Value Based Care Regulations Yield Physician Discontent, No Change in Behavior

Monday, July 13th, 2015
Mike Arrigo, Managing Partner & CEO No World Borders, Inc.

Mike Arrigo, Managing Partner & CEO No World Borders, Inc.

The Patient Protection and Affordable Care Act seeks to change medicine from Fee for Service (FFS) to a value based model.   Is it working? A RAND study, sponsored by the American Medical Association (AMA), describes alternative health care payment models (i.e., models other than fee-for-service payment):

“Alternative payment models have not substantially changed how physicians delivered face-to-face patient care. Additional nonclinical work created significant discontent. Most physicians in practice leadership positions were optimistic and enthusiastic about alternative payment models, while most physicians not in leadership roles expressed at least some level of apprehension.”

In other words, many well-intended regulations are simply creating a higher administrative burden for clinicians.  The alternate payment models explored  capitation, episode-based and bundled payment, shared savings, pay for performance-based practice, accountable care organizations, and patient centered medical homes (PCMHs).

Remember that the sponsor of this study is the AMA which has generally been against additional regulations that impact physicians (see our post regarding CMS’s grace period for Medicare Part B providers and ICD-10).  Rather than take an anti-regulatory approach, let’s examine the facts and consider a different perspective to help solve the problem.

Price vs ValueRAND Recommendations to Address the Problem

Recommendations from the RAND report included ensuring physician practices get support and guidance, improving effectiveness of alternative payment models, and addressing concerns by physicians about the extra burden of these models vs. enabling them to realize the benefits in terms of reimbursement and improved care.  Aligning physician incentives with population health care goals is also essential.

 

New Regulations, More Data

Let’s go beyond the RAND study and dive a bit deeper on what physicians are being asked to do.  Recent regulations burden health care providers to increase the data they capture and the data they report.  For example:

  • ICD-10 increases the need for improved clinical documentation and more specificity in medical diagnosis and procedure codes. Use of the codes is required starting October 1, 2015. Not using the codes means physicians may not get paid (excepting Medicare Part B providers for one year).
  • Medicare Advantage and Accountable Care Organizations require additional reporting to receive financial incentives
  • Meaningful Use of Electronic Health Records require clinical quality measures (CQMs) with beneficial and punitive financial provisions relating to compliance
  • PQRS has a set of quality measures with beneficial and punitive financial provisions relating to compliance

Risk Adjustment, New Standards

Another standard that is important to consider in alternative payment models is risk adjustment.  Medicare  classified ICD-9 diagnosis codes into HCCs (Hierarchical Condition Categories) for chronic conditions that end up costing  more money over the long run, such as diabetes, kidney failure, old myocardial infarction, etc. When patients are assigned these ICD-9 codes, Medicare sees those beneficiaries as being more severely ill than the “average” Medicare beneficiary.   Unfortunately the groupings for HCCs and ICD-10 aren’t clearly defined as of this date.

Gaps and Data Silos

When evaluated as a single initiative, each regulation has standards to collect and report discrete data.  When taken together, these initiatives sometimes conflict invite questions. For example, how will clinical documentation developed in an electronic health record work to support ICD-10 requirements?  How will documentation of the patient condition expressed in ICD-10 impact reimbursement in Medicare Advantage and ACOs that use the companion coding HCC standard?

Optimization vs. Fraud, Waste, Abuse

New tools to document the patient condition, risk adjust populations, and code with more specificity can be used to provide better information, create documentation for medically necessary care, and valid reasons for higher reimbursement.  They can also be abused.  CMS defines fraud in several contexts, and specifically states, “Misusing codes on a claim, such as upcoding or unbundling codes” constitutes fraud.   The companion to Fraud in the same CMS publication is the False Claims Act (FCA).  FCA provides for treble damages.  Complexity requires tools to analyze and manage information and make it available to those who need it using secure methods to investigate exceptions.

Missing? A Biomedical Informatics Perspective

Clinicians  are in a knowledge management crisis – there is a massive amount of data, but getting the right information to clinicians, IT personnel and others at the right time is the challenge. What was missing from the RAND report were biomedical informatics perspectives.

  • Informatics is the logic of healthcare. Digital information has made knowledge infinitely larger and more available for clinicians, but contextual knowledge is often unavailable.
  • Biomedical Informatics seeks to discern the difference between data, information, knowledge and wisdom by increasing sharing and comprehension when needed.
  • The world is aging and there are increasing numbers of people with chronic disease; it is recognized that a key sustainable strategy is planning and delivery of healthcare through technology innovation.

Caveat:  innovation without clinician engagement is likely to fail, just as well-intended regulations are failing so far to realize change.

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