It wouldn’t surprise most health providers to know they’ve likely interacted with a victim of human trafficking. Research has shown healthcare providers are often among the first or only points of contact for trafficked individuals.
But how does healthcare even track the problem to begin getting a handle on how to address it? There really hasn’t been a way, said Mindy Hatton, AHA’s general counsel.
“We can tell you how many people last year were bitten on the left arm by a shark. But we couldn’t tell you whether or not a victim of human trafficking came into one our facilities,” Hatton said. “There’s just something fundamentally wrong with a coding system where you can’t capture that kind of important information.”
That is, until several new ICD-10 codes (PDF) took effect Oct. 1 to allow health providers to report suspected or known cases of different kinds of trafficking including labor trafficking and sex trafficking.
Across the globe, approximately 21 million people are victimized by human trafficking, according to the report, making the ability of clinicians to identify them and provide treatment critical. Research indicates 87% of human trafficking survivors said they received medical treatment from a hospital or clinic while they were being trafficked, but the problem still often goes undetected, she says.
The effort was led in part by Wendy Macias-Konstantopoulos, M.D., an emergency physician at Massachusetts General Hospital in Boston and co-founder and director of its Human Trafficking Initiative.
Her group, along with officials from Englewood, Colorado-based health system Catholic Health Initiatives, brought the issue to the AHA a while back. In the spring, AHA hosted a meeting with officials from around the country to discuss the issue.
“It became clear people around the country who are experts on this problem were feeling the need for some way to be able to quantify the problem to help them marshall resources and find other ways to help the victims,” Hatton said.
Macias-Konstantopoulos, as well as Nelly Leon-Chisen, the AHA’s director of coding, led the charge to propose and push the new coding forward through a process to convince officials at the Centers for Disease Control and Prevention that they were workable and needed.
The new codes were announced in June and went into effect at the beginning of this month.
For now, the new coding doesn’t have reimbursement implications. But the codes could help guide new approaches to address trafficking, Hatton said.
“There’s just a widespread agreement it’s a problem, it’s a growing problem and we as a society have to devote more time and resources to stopping it and helping the victims.”
Even if the World Health Organization finalizes ICD-11 in May, it will take years for U.S. doctors to start using the next classification system.
ICD-11 made something of a surprise appearance last week.
Hospital executives and staff reading that the next iteration of the International Classification of Diseases system will contain a new code for diagnosing patients with so-called gaming disorder might get a chuckle from it. They may laugh a little more when they encounter this tidbit about timing: The World Health Organization plans to release ICD-11 in May of 2018.
That’s because so many media outlets are making a bit of an uproar by reporting on the new gaming disorder code as if it will happen in that timeframe – but it won’t.
Yes, the WHO’s timeline calls for presenting the final ICD-11 to the World Health Assembly next May. And yes, the draft specification includes 6D11, or Gaming Disorder, under the subcategory “Disorders Due to Addictive Behaviors” – which, in turn, falls within “Mental, Behavioral and Neurodevelopmental Disorders.”
WHO characterizes gaming addiction as a behavior pattern not altogether unlike substance abuse in which a person has impaired control over gaming, gives gaming precedence over necessary daily activities and life interests, and continues escalating gaming despite negative consequences.
“The pattern of gaming behavior may be continuous or episodic and recurrent,” the beta ICD-11 description reads. “The gaming behavior and other features are normally evident over a period of at least 12 months in order for a diagnosis to be assigned, although the required duration may be shortened if all diagnostic requirements are met and symptoms are severe.”
While arguments are brewing that it trivializes mental health issues or is entirely unnecessary, adding gaming disorder is most likely a good thing for patients, as well as public and population health efforts. And one could be forgiven for thinking that, come May Day, doctors all across America will use the new codes to diagnose kids pretty much en masse as suffering from gaming disorder.
But there’s a history here that should not be overlooked. It’s one all-too-familiar to health and technology professionals who lived through the ICD-10 transition. That particular implementation was fraught with delays – and it took more than two decades from the time WHO finalized ICD-10 in 1992 to the dreaded U.S. deadline of October 1, 2015.
That switch flipped after previous compliance mandates were pushed back, largely because physician groups comprising the people who invariably feel ICD-10’s impact the hardest were against the more complex code sets.
Many doctors did not want to pay for the transition, they didn’t like the idea of having to actually use the codes and they were opposed to the greater granularity that, the pre-compliance argument went, would make it easier for payers to deny claims and make the collections process even more burdensome than it already was.
Indeed, the debate over ICD-10 reached high levels of American government. President Barack Obama signed a law that pushed the ICD-10 deadline back from October 1, 2013 to what eventually became the then-new October 1, 2014 deadline. Then former Republican Pennsylvania Rep. Joe Pitts introduced the Protecting Access to Medicare Act, which carried a provision that kicked the ICD-10 can down the road to October 1, 2015.
Converting to ICD-10 took so long, in fact, that an argument arose in certain circles suggesting the U.S. skip it entirely and hold out for ICD-11 instead. The real counterpoint was that ICD-11 had already faced its own delays, and since the U.S. was trailing the rest of the developed world in still using a 20-year-old classification system, we could no longer afford to wait.
The somewhat comical lining in all the mainstream media reports about this latest development, and the banter about whether gaming’s benefits will be lost because of it, is that unless CMS adds gaming disorder to a future iterative update of ICD-10 – which is hardly impossible though the agency has not yet indicated its plans – doctors won’t actually use the new code for years.
On October 1, 2016, new ICD-10-CM and ICD-10-PCS code sets went into effect. Updating these codes traditionally occurs on an annual basis, however, during the immediate years leading up to the ICD-9 to ICD-10 transition there was an extended freeze to code updates to support a smooth transition. Therefore, for fiscal year (FY) 2017, updates and revisions include changes since the last completed update (October 1, 2013).
As a result of the consolidated coding updates, a large number of new codes were added or removed from the ICD-10 code set. CMS is acutely aware of the relationship between the ICD-10 update and quality reporting. Under PQRS, calendar year (CY) 2016 is the performance period for the following:
- 2018 PQRS and Value Modifier payment adjustments.
- Eligible professionals (EPs) who were part of a Shared Savings Program Accountable Care Organization (ACO) participant TIN in 2015 and are reporting outside their ACO for the special secondary reporting period, because their ACO failed to report on their behalf for the 2015 PQRS performance period
CMS has examined impact to quality measures and has determined that the ICD-10 code updates will impact CMS’s ability to process data reported on certain quality measures for the 4th quarter of CY 2016. Therefore, CMS will not apply the 2017 or 2018 PQRS payment adjustments, as applicable, to any EP or group practice that fails to satisfactorily report for CY 2016 solely as a result of the impact of ICD-10 code updates on quality data reported for the 4th quarter of CY 2016. The Value Modifier program will consider solo practitioners and groups, as identified by their taxpayer identification number (TIN), who meet reporting requirements in order to avoid the PQRS payment adjustment (either as a group or by having at least 50% of the individual eligible professionals in the TIN avoid the PQRS adjustment) to be “Category 1,” meaning they will not incur the automatic downward adjustment under the Value Modifier program.
Consistent with previously communicated electronic clinical quality measures (eQCM) reporting requirements, EPs must submit eCQM data corresponding to the 2015 versions of the measure specifications and value sets (2015 Annual Update) for 4th quarter 2016 reporting.
For the 2017 performance period, CMS will publish an addendum containing updates relevant to the ICD-10 value sets for eCQMs in the Merit-based Incentive Payment System Program (MIPS). CMS will provide additional information on the addendum later this year.
The Centers for Medicare and Medicaid Services ceased the year-long grace period wherein it accepted ICD-10 claims as long as they were submitted in the right family of codes on October 1, 2016.
CMS has revised its Q&A regarding ICD-10 flexibility, highlighting what providers need to be wary of. Here are the key revision hospitals and coders need to understand:
Do the ICD-10 Medicare fee-for-service audit and quality program flexibilities extend to Medicare fee-for-service prior authorization requests?
No, the Medicare fee-for service audit and quality program flexibilities only pertain to post payment reviews. ICD-10 codes with the correct level of specificity will be required for prepayment reviews and prior authorization requests.
Do the Medicare fee-for-service audit and quality program flexibilities apply to Medicare Advantage?
No, the Guidance applies only to Medicare fee-for-service claims from physicians or other practitioners billed under the Medicare Fee-for-Service Part B physician fee schedule. Medicare Advantage risk adjustment payment and audit criteria remain unchanged.
Does the Guidance change coding guidelines?
No, coding guidelines are unchanged.
Will the Medicare review contractors be auditing the Medicare Advantage services according to this Guidance?
The Medicare review contractors only review Medicare fee-for-service claims. This Guidance does not apply to the Medicare Advantage plans.
Currently the guidance document only applies to services paid under the Medicare Fee-for-service Part B physician fee schedule.
Will the Guidance be expanded to other provider/claim types?
No, the Medicare fee-for-service audit and quality program flexibilities have not been expanded to other claim types. They only apply to physicians and other practitioners who bill under the Medicare Fee-for-Service Part B physician fee schedule.
The reason we focused on claims billed under the Part B physician fee schedule is because many physicians are in small practices that need additional flexibility to gain experience with the ICD- 10 coding set. Claims billed under the Part B physician fee schedule are paid using CPT codes and not ICD-10 codes. Other services, such as institutional services, are paid based on the ICD- 10 codes.
The ICD-10 Ombudsman will listen to issues raised by all suppliers and providers and will evaluate any specific issues that are raised during implementation. CMS’s ICD-10Coordination Center will be actively monitoring for any problems that may develop after October 1. This center will quickly identify and initiate resolution of issues that arise as a result of the transition to ICD-10.
Will physicians be allowed to submit a single advance payment request for multiple claims for services provided over a period of time?
CMS and its Medicare Administrative Contractors have conducted extensive testing forICD-10 and are ready for the transition on October 1, 2015. If the Part B Medicare Administrative Contractors (MACs) are unable to process claims within established time limits because of administrative problems, such as contractor system malfunction or implementation problems, an advance payment may be available.
Physicians would be allowed to submit a single advance payment request for multiple claims for an eligible period of time. Note an advance payment is a conditional partial payment, which requires repayment, and may be issued when the conditions described in CMS regulations at 42 CFR Section 421.214 are met. To apply for an advance payment, the physician is required to submit the request to their appropriate Medicare Administrative Contractor. Should there be Medicare systems issues that interfere with claims processing, CMS and the MACs will post information on how to access advance payments.
CMS does not have the authority to make advance payments in the case where a physician is unable to submit a valid claim for services rendered.
What are the “established time limits” to process claims?
Section 1842(c)(2) of the Social Security Act requires Medicare contractors to make payment on not less than 95% of “clean claims” within 30 calendar days.
If there are Medicare systems issues that interfere with claims processing, CMS and the MACs will post information on how to access advance payments.
Will institutional providers (Part A) be able to submit requests for accelerated payments from Medicare?
CMS regulations at 42 CFR Section 413.64(g) allows accelerated payments for Part A providers not receiving periodic interim payments. This authority can be applied in the event of a contractor(s) delay in making payments or in “exceptional situations” where a provider has experienced a temporary delay in preparing and submitting bills beyond its normal billing cycle. Note an accelerated payment is a conditional partial payment, which requires repayment, and may be issued when the conditions described in CMS regulations at 42 CFR Section 413.64(g) are met and subject to contractor and CMS approval.
Will anything change during the one-year period of Medicare fee-for-service audit and quality program flexibilities with respect to Medicare crossover claims and the crossover process?
No, Medicare’s processes regarding what elements are crossed over to supplemental payers (including commercial payers and State Medicaid Agencies) will be unchanged as a result of the flexibilities.
How does the CMS 24-month look-back period for Medicare fee-for-service audits intersect with the 12-month period of audit flexibility? Will the auditors review and deny claims from the October 2015-October 2016 period for ICD-10 code specificity after October 2016?
Contractors conducting medical review (Medicare Administrative Contractors/Recovery Auditors/Supplemental Medical Review Contractor) will not deny claims solely for the specificity of the ICD-10 code as long as there is no evidence of potential fraud. This is consistent with current medical review policies and is not applicable to prepayment denials because of a National Coverage Determination or a Local Coverage Determination.
Just as ocean tides shift with the earth’s gravitational pull, physician practice administrators align staff and focus resources to address their organizations’ most pressing concerns. This year, the tsunami grabbing administrators’ attention is the conclusion of a one-year grace period for ICD-10 post payment reviews related to code specificity in claims filed under the Medicare Part B physician fee schedule.
While the correct level of ICD-10 code specificity has always been required for National Coverage Determinations, Local Coverage Determiniations, other claims edits, prepayment reviews, and prior authorization requests, physicians were granted amnesty from post payment reviews due to unspecified codes. This grace period concludes on October 1, 2016.
This article summarizes three areas for physician practices to address before the final phase of ICD-10 implementation comes ashore.
Mitigate Risk of Unspecified ICD-10 Codes
Proactive practices are already conducting internal audits to identify trends in unspecified clinical documentation and diagnosis code assignment. A three-step process can then be utilized:
- Review reports of top ICD-10 diagnosis codes, paying particular attention to identify unspecified codes.
- Conduct analysis of diagnosis codes assigned by clinician and/or coder to identify any patterns or trends in unspecified ICD-10-CM (diagnosis) coding.
- Review clinical documentation: A) If more specific diagnosis codes can be assigned based on the documentation, provide education to the appropriate staff on proper code assignment. B) If documentation is not complete for desired level of diagnosis specificity, provide clinical documentation improvement education to clinicians.
While there are a few instances where usage of unspecified ICD-10-CM codes may be appropriate, widespread use of numerous unspecified codes should be the exception, not the rule. Practices submitting unspecified ICD-10 codes after October 1, 2016 may potentially experience an increase in post payment audits and quality reporting errors. As audits increase, so will payer requests for medical records and clinical documentation.
A spike in medical record requests by payers is a trigger for medical practices to conduct in-depth clinical documentation and coding audits as mentioned above. However, failure to submit requested clinical documentation upon payer request also leads to the practice not getting paid for those claims, and an increased suspicion by auditors.
Hire a Credentialed Coding Professional
Physician practices are also re-evaluating the importance of a credentialed clinical coder to tighten ICD-10 coding practices and establish a compliance coding program. Trained coding professionals evaluate electronic medical record (EMR) code assignments, identify software errors, and conduct advanced ICD-10 training for non-specific documentation and coding problem areas.
However, for many smaller practices, hiring a full-time, credentialed coding professional may be cost prohibitive. In this case, the following four strategies may be effective:
- Partner with another practice to share the cost.
- Employ a certified coding professional via a contract arrangement or consulting engagement. Click here to learn more about DAS Health’s Revenue Cycle Management services.
- Select a current staff member to complete coder training and certification, using the training as an internal career advancement opportunity.
- Bring in an interim coding professional to prepare for the final phase of ICD-10 implementation, improve clinical documentation specificity, and investigate EMR software glitches.
Check EHR Software
Since the 2015 CMS and AMA announcement regarding unspecified ICD-10 codes, physician practices have tended to maintain the status quo—relying on EHR software to suggest correct ICD-10 codes.
Some glitches in EHR software and encoder decision trees have been reported. These errors, if left uncorrected, lead to claims rejections and reimbursement delays. Examples of specific encoder software issues that have been identified include these three ICD-10 diagnoses areas:
- Motor vehicle accidents
- Joint replacements
- Traumatic fractures, tibia spine
Make sure your EHR software is certified and up to date, and ready to tackle ICD-10 codes.
Physician practices face two final coding challenges in the year ahead: a plethora of new ICD-10 codes and year-over-year statistical reporting inconsistencies. October 2016 brings a flood of new ICD-10 codes as CMS thaws a three-year partial code freeze. Physician practices must prepare for the addition of nearly 2,000 new ICD-10-CM codes. While no individual physician practice uses all of the new codes, each specialty should carefully review the changes ahead, focusing particularly on the subset of codes applicable to their practice or patient population.
Finally, practices will face statistical reporting challenges as unspecified ICD-10 codes used in 2016 must be compared against more specific ICD-10 codes in 2017.
A proactive approach to mitigate unspecified documentation, coding, and billing is the best remedy for post-grace period concerns. Now is the time for practices to consider hiring credentialed coding professionals and/or partnering with coding consultants.
The CMS has updated a question and answer page to help guide providers on their use of ICD-10 codes, which were finally implemented after much delay and controversy last October.
While the implementation of ICD-10 is approaching its one-year anniversary, one thing will be new this coming October: The end to a concession initially bestowed by CMS on providers due to pressure from the American Medical Association and other industry groups.
The concession had been that for one year following the ICD-10 start date, providers would be granted some “flexibilities” in that they would not be denied Part B claims as long as they used a code from the correct family.
The updated CMS document on ICD-10 codes provides a Q&A for providers on what to expect with the end of the flexibility and confirms there will be no further extension to them beyond the October date.
It stresses that providers should already be coding to the highest level of specificity and that many already are because “many major insurers” did not offer flexibility.
To ensure they are complying, providers should avoid using unspecified ICD-10 codes whenever a more detailed code is possible. “Check the coding on each claim to make sure that it aligns with the clinical documentation,” the page says. It adds that unspecified codes do have their place, however and will still be accepted where appropriate, noting, “You should code each healthcare encounter to the level of certainty known for that encounter.” It suggests, for example, it would be correct to use the appropriate unspecified code for a diagnosis of pneumonia when the specific type has yet to be determined.
The CMS added even with the end to the flexibilities, it is well prepared to process new codes going into effect this October 1. “As demonstrated by the successful ICD-10 transition, CMS is well equipped to handle changes to codes and to processes, and we do not anticipate any delays,” it stated.