What’s in it for me? Accurate reimbursement!

February 10th, 2017 / By Rebecca Caux-Harry

I paraphrase, but this is essentially the question we hear from providers when we talk about ICD-10 coding accuracy. Most recently, I was asked this question by an HIM department looking into starting an outpatient CDI program. Many facilities and large physician practices are searching for ways to improve physician documentation and therefore ICD coding specificity prospectively in preparation for the change from fee-for-service to value-based reimbursement. This shift has come about because of the passage of MACRA (Medicare Access and CHIP Reauthorization Act). But providers have stated in no uncertain terms that they are overwhelmed with all of the requirements associated with getting paid. What they really want is a reduction in the administrative burden allowing them to practice quality medicine. So, their push-back is understandable.

Payment for professional services has historically depended on valuation of CPT codes, with ICD codes supplying the medical necessity. So, with providers focused on CPT-based reimbursement, their selection of ICD codes has been somewhat inconsistent with many using the “close enough” method. That must now change. Providers’ future reimbursement depends on it.

When we take into account that more care is provided in a clinical setting than anywhere else, and most, if not all of those services are coded by non-coders, specifically providers, it’s easy to understand the need for better, more accurate coding. In fact, even if coders are looking at a portion of the codes submitted for clinic services, we professional coders spent far more time perfecting our CPT coding skills rather than our ICD coding. At least I know I have. Luckily, we all have a fantastic learning opportunity ahead of us.

So, here is the answer to the “What’s in it for me?” In order to receive rightful reimbursement for managing their patient population moving forward, physicians MUST report the full complexity of their patients using ICD-10 codes to their fullest capability. We can do that now with great accuracy due to the specificity of ICD-10. In order to use these better codes, however, the documentation must allow the provider or the coder to code accurately and completely.

Our environment is changing. Reimbursement is now based on much more than quantity of services and meeting medical necessity.  More and more patients are switching from Medicare to a Medicare Advantage plan resulting in Hierarchical Condition Categories (HCCs) impacting more and more healthcare dollars. HCCs are based entirely on ICD codes and the more specific the ICD code, the more appropriate the reimbursement is for managing that patient. This is our transition year.  We need to use it wisely in order to protect future reimbursement.

Rebecca Caux-Harry, CPC, is the CodeRyte product specialist for cardiology with 3M Health Information Systems.

When it comes to HCCs, what are the biggest challenges and how can hospitals address them?