A CMS representative solicited input from audience members on potential revisions to E/M documentation guidelines at the AMA’s 2018 CPT Symposium in Chicago this week, continuing the agency’s outreach on E/M reform that began with this year’s Medicare Physician Fee Schedule proposed rule.
Physicians may be angry at the increased documentation, coding, and billing workflow and compliance activities they must perform to be successful in new reimbursement models. However, to avoid accustations of fraud and upcoding, they must develop their own OIG-recommended compliance plan and be open to rigorous feedback and advice.
Currently, there are no national guidelines for how facilities should assign evaluation and management (E/M) levels in the emergency department (ED). Under Medicare’s ambulatory payment classification (APC) system, facilities create their own internal guidelines for determining the ED visit level, and each facility must follow its own system to demonstrate compliance.
The largest source of estimated revenue loss in the healthcare midcycle in 2016 was attributed to inadequate documentation, according to a report by the Advisory Board. The report analyzed a range of hospitals in varying size, from 0–500 beds, to determine the impact of midcycle functions. The revenue loss reported for an average 250-bed hospital was $2–$5.5 million.
Mastering hierarchical condition categories (HCC) is key to success under new reimbursement methodologies that rely on risk-adjustment, quality, and value metrics such as the Quality Payment Program (QPP). Organizations need to take a close look at their training and audit programs to ensure that valuable information isn’t being left out of documentation—and negatively impacting HCC scores.
My experience in ICD-10-CM documentation and coding integrity is that many physicians know in their heads what is wrong with their patients; however, they have not been taught to “think with ink” in describing their patients' illness in the EHR using ICD-10-CM’s language to ensure proper coding.
Patient care continues to move from the inpatient setting to outpatient. With this change, the challenge of securing comprehensive documentation that articulates the services rendered and the patient care provided now needs to extend across the care continuum.
Outsourcing some HIM functions is common at many organizations. The decision might initially be spurred by staffing shortages or budgetary concerns, but many outsourcing arrangements become long-term projects.
The new ICD-10-CM codes for FY 2018, effective October 1, represent significant changes in our documentation and coding practices. Let’s discuss some of these new codes and their potential impact upon your diagnostic decision-making and documentation.
