How the CMS Physician Fee Schedule Determines Your Work’s Worth

Discover the Key to Earning More Under CMS’ Reimbursement Rates

Some equations are so famous, almost everyone recognizes them, even if they can’t explain them, such as Einstein’s equation for mass-energy equivalence: ‎E=MC2 or the Pythagorean Theorem: a2+b2=c2.

But here’s an equation not widely recognized, and even many among those it affects the most—hard-working healthcare providers like you—would be hard pressed to explain it:

(wRVU x wGPCI) + (peRVU x peGPCI) + (mRVU x mGPCI) = tRVU

Got that? It’s key to understanding the Medicare Physician Fee Schedule, as well as fee schedules other payers use. So if you can’t explain that equation, read on.

Once you finish, you’ll see how it demystifies Medicare’s fee schedule for CPT® codes—and how you can make the most of it to maximize your revenue.

 

A Rapid Review of Medicare Reimbursement Practices

Nearly 30 years ago, as part of the Omnibus Budget Reconciliation Act (OBRA) of 1989, Congress changed the way Medicare pays physicians.

Before Medicare, as Ira Burney and colleagues explained in a 1979 article in Health Care Financing Review, physicians were “predominantly” paid using schedules of fees set in several ways, including “relative value studies with conversion factors.” After Medicare started in 1965, “the CPR method”—so named for using “customary, prevailing, and reasonable” charges—“became more widely used.” CPR was actually a dual fee schedule—one specific to the provider’s charges; the other, to those of other local providers—and “physicians retain[ed] virtually complete control.”

But by the 1980s, critics of CPR argued it was “inherently inflationary, inconsistent and unfair,” favoring high-tech procedures, urban settings, and specialists, as David Juba wrote in Health Care Financing Review in 1987. Increasing national health expenditures also helped fuel re-evaluation of Medicare’s payment method.

OBRA 1989 replaced CPR-based reimbursement with a physician fee schedule based on relative value. But unlike pre-Medicare fee schedules, this schedule would be tied not to charges but to resource costs.

Based on a model studied by Harvard economist William Hsiao and colleagues, the resource-based relative value scale (RBRVS) attempts to measure physicians’ work objectively and consistently across disciplines. It marked “the first major change in establishing how physicians were paid for their services” since 1965, writes Gregory Przybylski in Neurosurgical Focus.

 

RVUs: Backbone of the Physician Fee Schedule

The RBRVS measures physicians’ work and costs in relative value units (RVUs). CMS determines Medicare reimbursement rates for CPT® codes by associating each code with a certain amount of RVUs.

CMS defines the total RVU as the sum of three distinct RVUs:

• Work (wRVU) – reflects the relative time and intensity associated with providing a service—the “technical skill and effort, mental effort and judgment, and stress,” as the National Health Policy Forum described it
  
• Practice Expense (peRVU) – reflects such operation and maintenance costs as rent, equipment, supplies, and staff expenses; and differs for facility (hospital) and non-facility (office) settings
  
• Malpractice (mRVU) –  reflects malpractice insurance costs

CMS multiples each RVU by a Geographic Practice Cost Index (GPCI) reflecting geographic variations in practice expenses and malpractice insurance costs. The University of California, San Francisco Medical Group expresses it as this equation, cited earlier:

Total-RVU = (wRVU x wGPCI) + (peRVU x peGPCI) + (mRVU x mGPCI)

CMS then multiplies the total RVU by a Conversion Factor (CF), which is updated every year (for 2018 it is $35.99), to determine how much a physician will be paid for each CPT® code. And so here’s UCSF Medical Group’s second equation:

Payment = (Total RVU) x (CF for the year in question)

Many private insurers also use the CMS Physician Fee Schedule, or a schedule modeled on it (though sometimes with lower conversion factors for E/M services than for procedures, as Dr. Thomas Felger cautioned in FPM).

Even as American healthcare moves toward value-based reimbursement,  RVUs are likely to remain key indicators of physicians’ efficiency and quality, as Dr. Douglas Leahy, who serves on the advisory Relative Value Update Committee (RUC), told Medical Economics. Cost-efficient, high-quality care will earn providers incentive payments under MACRA MIPS and APMs.

 

How to Claim the Most RVUs and the Best Reimbursement Rate for CPT® Codes

RVUs measure physicians’ productivity imperfectly, the AAFP’s Kent Moore pointed out for FPM. But understanding their role in physician fee schedules should drive home how much your revenue depends on optimal coding.

When you don’t assign a patient visit its optimal CPT® code, you’re not getting accurate credit for all the work you’ve done, which means you’re passing up revenue you’ve legitimately earned.

And if you’re not documenting visits the right way, you won’t be able to support the optimal CPT® code in case of an audit, which also means you’ll be forfeiting reimbursement to which you’re entitled.

But when you use the MDCodePro app, you’re taking action against both these money-losing possibilities.

You’re getting a series of short video lectures in which you’ll discover a cut-to-the-chase method for making CMS’ E/M documentation guidelines an integral part of your daily routine, so you’ll never have to worry that your notes and chart are anything but complete, fully compliant, and capable of supporting any appropriately assigned code.

And you’re getting an intuitive, powerful code generator to guide you, step by step, in finding the optimal CPT® code for every visit, based on the documented data you provide. You can assign this code with confidence, knowing it accurately and thoroughly communicates the care you provided and lays claim to all the reimbursement you deserve.

Deciphering CMS RVU and payment equations may take a little time, but you can find out right now how MDCodePro can help you make more money for the work you do. Click here to request more information or request a live demonstration.

The post How the CMS Physician Fee Schedule Determines Your Work’s Worth appeared first on MDCodePro.

source https://mdcodepro.com/blog/physician-fee-schedule/

Should Your Organization Use a Medical Billing and Coding Company?

Consider All of These Important Pros and Cons Before You Decide

Trying to decide whether your organization should use a medical billing and coding company can feel like an unfunny version of the party game “Fortunately/Unfortunately.”

For every “pro” you can think of about outsourcing these important but specialized and time-consuming tasks, you can also think of a “con.”

Should the “fortunate” or “unfortunate” factors carry more weight?

At MDCodePro, we think this decision is one of the most important a healthcare organization can make. It creates both immediate and long-term consequences for your records, your staff, and your revenue.

So we want to share what we see as some “fortunate” and “unfortunate” facts about using medical billing and coding outsourcing companies.

 

What Outsourced Coding Services Could Mean for Your Organization

Already worth $10.6 billion in 2016, expert analysts anticipate the global medical coding market will show a 10% compound annual growth rate through 2025.

Will your organization help drive that growth by signing a medical coding services contract with an outside company?

Consider these “fortunate, unfortunate” pairs:

• Fortunately, medical billing and coding companies will lower your staff expenses.
  When coders aren’t your staffers, you don’t pay their salaries. It takes a robust salary to get qualified, experienced coders on staff. They’re in demand—the Bureau of Labor Statistics forecasts 13% growth for the field through 2026—and certified coders earn $51,477 on average, the AAPC reports. Not only will you avoid having to pay salaries like that, you won’t have to provide benefits, vacation and sick days, or office space. 
• Unfortunately, medical billing and coding companies don’t have staff members’ advantages.
  Because your coders work remotely, you can’t manage them directly. You’ll have no say in how they’re trained, and you won’t know how turnover affects the team unless you ask. Your coders may not work in the same time zone as you do, making it harder to resolve questions about documentation efficiently, which could slow down how quickly you get paid.
• Fortunately, medical billing and coding companies can increase your revenue.
  Because these companies focus exclusively on getting your charts coded and submitting your superbills for payment, you may see your revenue cycle accelerate. And these companies may be able to appeal denied claims faster and at higher levels than your organization could. More money may head your way sooner than if you handled all your own coding and billing (though don’t forget: medical coding company fees grow as your income does). 
• Unfortunately, medical billing and coding companies can’t see extra revenue opportunities.
  Off-premise coders can’t watch patient visits take place, as in-house coders occasionally can (and should). They can’t point out something billable the doctor is doing but isn’t documenting. In-house coders can help providers start properly noting these actions in order to claim reimbursement for them, as coding and compliance strategist Barbara Hays told Physicians Practice.
• Fortunately, medical billing and coding companies tend to have the latest coding knowledge.
  Remote coders’ exclusive focus on their task means they have more time than you and your office staff do to study and stay on top of constantly changing diagnostic and procedural codes. As a result, their coding should be extremely accurate, which will mean fewer denials and faster reimbursement for your organization.
• Unfortunately, medical billing and coding companies won’t help you learn more about coding.
  Even if you outsource your medical coding, you don’t outsource your responsibility for complying with CMS documentation guidelines. In-house coders help physicians learn more about coding in the routine course of their work together, and documentation compliance grows as a result. Vendors of outsourced coding may save your organization time and money, but they can’t add the educational value coders on the premises can.

 

Grow Providers’ Medical Coding Knowledge with MDCodePro

Depending on your organization’s size and scope, outsourcing some or all of your medical billing and coding to other companies may make sense. But whether you use staff or outside coders, you can equip your physicians with a stronger knowledge of how and why to code patient visits optimally with the MDCodePro app.

The app is really an online medical billing and coding course helping busy physicians rapidly master the basics of the CMS guidelines, then rely on those basics every day to produce more accurate and compliant documentation supporting the highest appropriate CPT® code.

Efficient and effective, and validated in multiple audits, the MDCodePro method has allowed doctors who’ve learned it to increase their annual revenue by $30,000 on average.

Move toward less reliance on outside medical billing and coding companies and more revenue for your organization’s bottom line. Sign up for your MDCodePro subscription today.

The post Should Your Organization Use a Medical Billing and Coding Company? appeared first on MDCodePro.

source https://mdcodepro.com/blog/medical-billing-coding-company/

Raise Your Medical Practice’s Profitability With Renewed Coding Focus

Paying Attention to the Basics Will Help Your Bottom Line

It’s not easy making your medical practice profitable in the U.S. today.

In addition to the cash flow challenges confronting any business—office space, staff salaries, IT infrastructure, marketing, and more—physicians face several complex obstacles unique to the medical field.

Consider just a few features of the American healthcare landscape intersecting, and often threatening, medical practices’ profitability in recent years: 

• EHR Adoption Can Mean Major Expenses
  The HITECH Act incentivized adoption and “meaningful use” of electronic health records (EHR) through payments reaching more than $38 million as of March 2018. But those payments are finished, while the penalty for eligible providers who haven’t adopted an EHR will be 5% of Medicare payments. Thousands of providers nationally still use paper records—about 20%, reports Governing magazine. EHRs are major capital expenses. The average five-physician practice spends $162,000 to implement a system and $85,500 in first-year maintenance, Health Affairs finds. While EHR systems should pay for themselves over time, they can deliver a big immediate blow to profitability.
• MIPS Raises the Stakes on Value-Based Care
  CMS’ new Merit-Based Incentive Payment System (MIPS) promises to reward physicians who deliver quality, cost-effective care with increased reimbursements and bonuses for exceptional performance. But one recent survey of doctors found a widespread “lack of familiarity” (60%) with the program.So some practices may be setting themselves up for dramatic and disastrous hits to their revenue when the performance threshold rises in 2019. In addition, MIPS’ EHR requirement may prove a significant and costly barrier to participation for small and rural medical practices.
• Some U.S. Healthcare Policies Lower Physician Revenue
  Whatever your political opinion of the Affordable Care Act (ACA), it’s clear the law doesn’t benefit practices’ bottom lines. “Obamacare” brought more patients but not more revenue into doctors’ offices, due to low reimbursement rates. One survey found 41% of physicians taking second jobs to offset falling income. Though the Trump administration aims to undo the ACA, new policies may not help physicians’ profits either. For instance, David Blumenthal argues in the Harvard Business Review that the new tax law means “less revenue for doctors, hospitals, and myriad health care businesses.”

If you go looking for advice about achieving a bigger profit margin in medicine, you’ll find plenty of it. But some of it strikes us at MDCodePro as downright depressing.

Is working 75-80 hours a week really the best option (especially when at least 5% of U.S. doctors already do)?

Or turning away patients covered by Medicare and Medicaid—and in some cases, with any health insurance at all—and starting a more exclusive concierge practice?

We’re convinced dedicated, hard-working physicians like you can discover better ways to increase your medical practice’s revenue, ways grounded in the core of your calling to care for people who are sick and injured.

Money wasn’t your main motivation for getting into medicine. But with renewed attention to the basics of what you do and how you document it, you can raise your medical practice’s profitability while doing good.

 

Stop Undercoding the Services You Provide

If you don’t document enough information during patient visits to support the highest CPT® codes their complexity and risk warrant, you’re throwing profit away.

Undercoding is “the number one reason I find that physician practices lose money,” medical practice management consultant Keith Borglum writes for Healthcare Finance. In FPM, coding and compliance consultant Emily Hill shows how undercoding just five patients a day by one level (99213 vs. 99214) could cost $40,000 annually.

To correct undercoding, conduct regular internal audits. For example, review 20 charts from each provider twice a year to identify gaps between documentation and codes, as the AAPC’s G. John Verhovshek suggests in Physicians Practice.

Remind providers how important careful, complete documentation is for capturing all billable services at the proper level. Then give them training and tools to help. Borglum told Medical Economics a $1,000, 8-10 hour investment in coding classes “can easily yield $10,000 to $50,000 or more in higher income, each and every year.”

 

Raise Your “Clean Claims Rate”

Denied medical claims are a burden on your bottom line because the payer’s not paying—at least, not until you’ve spent more time and money correcting and resubmitting those claims. When each denied claim costs $25 on average to rework, it’s not surprising some 50-65% of them never are.

A higher first-pass resolve rate (FPRR), or percentage of claims paid on initial submission, is key to your medical practice’s profitability.

Do you know your FPRR? Most providers’ fall between 70-85%, according to Health IT Outcomes. The industry best practice 90% rate is hard to reach but worth striving for. Every percentage point means more profit for your practice.

To clean up your “clean claims rate,” various software solutions can help you “scrub” claims of mistakes like missing or incomplete information; but training your providers and staff in accurate and compliant coding will also substantially improve claims’ chances of being paid the first time.

 

Invest in Increasing Your Medical Practice’s Revenue with MDCodePro

Yes, mastering the essential principles of documentation and medical coding takes time and money. But when you use MDCodePro, it doesn’t have to take as much time as you worry it will, and you’re likely to recoup your cost many times over.

Dr. Alexander Stemer, MDCodePro’s founder, has taught the documentation and coding method at the heart of the MDCodePro app to hundreds of physicians. Once they started following it, they saw their average medical practice revenue grow by $30,000.

When you put the streamlined, easy-to-remember techniques taught in the MDCodePro video lectures to work, and use the app’s powerful, step-by-step code generator, you’re far less likely to undercode, make coding mistakes, or choose anything less than the optimal code for each patient visit. That means you capture and keep more revenue, increasing the profit margin for your medical practice.

No matter what trends intersect and potentially threaten your medical practice’s profitability, you can minimize their impact by maximizing your documentation and coding for accuracy, compliance, and revenue.

Ready to get started? Request more information about MDCodePro using this online form, or sign up and begin your subscription today.

The post Raise Your Medical Practice’s Profitability With Renewed Coding Focus appeared first on MDCodePro.

source https://mdcodepro.com/blog/medical-practice-profitability/

Why This Medical Coding Cheat Sheet Is Best for Your Organization

If You’re Not Using This Coding Pocket Guide, Here’s Why You Should Start

Whatever you call them—pocket guides, quick references, notes on “coding for dummies”— medical coding cheat sheets come in handy when you’re trying to choose the best CPT® code for a patient visit.

The long, complicated CMS guidelines for using CPT® codes spawned a “cottage industry of templates, cheat sheets, score cards, tool kits and the like,” coding expert Emily Hill wrote for FPM over 15 years ago. Her words are still true because the Medicare documentation guidelines are still burdensome.

A quick search for coding cheat sheets online returns hundreds of thousands of possible resources, some free, others for sale. Wading your way through coding and billing cheat sheets can seem almost as daunting as tackling the CMS guidelines themselves!

The MDCodePro app is much more than just another cheat sheet for physicians and other practitioners. But we can easily recommend the best medical coding cheat sheet out there.

It’s the cheat sheet you make yourself.

 

Benefits of Making Your Own E/M Coding Guidelines Cheat Sheet

Why spend time and effort making your own cheat sheet when so many are already available? Here are only three reasons: 

• Making your own cheat sheet ensures its relevance to your organization.
  No one else knows which codes your practice most frequently assigns or which payers you deal with most often. Creating your own medical coding and billing cheat sheet is a valuable exercise in matching specific codes with what specific insurers pay, as billing expert P.J. Cloud-Moulds explained for Physicians Practice. Doing this work reveals which codes generate the most legitimate revenue for you. A cheat sheet prepared by outsiders won’t prove as relevant or profitable.
• Making your own cheat sheet can improve your organization’s coding consistency.
  Inconsistent coding within a healthcare organization can lead to administrative confusion, lost revenue, and even greater risk of third-party audits. But having providers prepare and compare their own cheat sheets can improve all of these problems. Reviewing homemade cheat sheets can expose out-of-date or inaccurate knowledge, or clarify how to interpret specific coding choices your organization repeatedly faces, as AHIMA reported. Making your own E/M coding cheat sheets offers the chance to get everyone on the same page, literally.
• Making your own cheat sheet forces you to learn more about medical coding.
  Professional medical coders often wish physicians knew more about coding. In an AAPC survey, one coder expressed frustration with doctors who dismissed coding guidelines in ignorance: “I feel all Physicians should attend coding seminars each year . . . This should be written in their contracts.” That may not happen, but any practitioner who prepares her or his own medical coding cheat sheet will discover how to code more accurately and effectively every day. The project is a great model of practical learning.

 

Enhance Your Cheat Sheet with an MDCodePro Coding Education

At MDCodePro, we support any effort to improve practitioners’ firsthand knowledge of medical coding, from making your own cheat sheets to taking formal CME courses. That’s why we developed an app to convey a working knowledge of the Medicare documentation guidelines’ essentials as painlessly and as profitably as possible.

Make your cheat sheet even more helpful by grounding it in a solid understanding of not just what your organization’s optimal CPT® codes are, but why. Sign up for your subscription to MDCodePro today.

The post Why This Medical Coding Cheat Sheet Is Best for Your Organization appeared first on MDCodePro.

source https://mdcodepro.com/blog/medical-coding-cheat-sheet/

Are These 7 Medical Billing Issues Costing You Money?

Find and Fix These Common Mistakes Now to Stop Losing Revenue

To err is human. To forgive… is not insurance payers’ jobs!

At MDCodePro, we’ve noticed several medical billing issues that can hurt healthcare providers’ revenue.

We wouldn’t go so far as to call them the seven deadly sins of medical billing. But they’re definitely seven maddening mistakes when you’re trying—and failing—to get all the legitimate reimbursement you’ve earned.

 

Seven Common Medical Billing Mistakes You Must Avoid

Mistake #1 – Submitting Incorrect or Incomplete Information

A misspelled name. A wrong date of birth. An incorrect subscriber number. A missing date of service. Seemingly small mistakes can wreak big havoc on your revenue.

According to the AMA’s most recent National Health Insurer Report Card, almost a quarter (24.57%) of denied Medicare claims lacked needed information. This problem led the pack for several private insurers, too.

Why is it important to review claims prior to submission? Among other reasons, to catch any invalid or incomplete information before it renders claims unprocessable.

Mistake # 2 – Claiming Reimbursement When Patients Aren’t Eligible

If they’re verifying patients’ eligibility, front-end staff can be your front line against rejected and denied claims.

Another 9.44% of denied Medicare claims fell short because the beneficiary’s plan didn’t cover the provided service, equipment, or drug. And patients using private insurers don’t always know their coverage as well as they think they do.

Medical Billing Group’s Stan Loskutov told Software Advice “a two-physician practice should spend 1-2 hours per day performing eligibility verification.” That’s time well spent when payers reject fewer claims.

Mistake # 3 – Failing to Discuss Patients’ Financial Responsibilities

More high-deductible health plans mean patients are shouldering more medical expenses—and not always successfully.

In 2017, patients’ out-of-pocket healthcare costs rose 11% on average, according to TransUnion Healthcare. No wonder one survey finds 85% of patients more concerned about medical costs than costs of retirement, college, housing or child care.

But only 23% of providers always discuss patients’ ability to afford services, reports technology and communications company West. More than a third (36%) never do.

If you’re not having candid financial conversations with patients, you risk taking more time to collect less revenue than you’ve earned.

Mistake # 4 – Billing Twice for the Same Procedures

Avoiding duplicate claims sounds like common sense advice, but because duplication happens so frequently, CMS has appealed to providers to stop doing it.

Duplicate claims can happen for many reasons. Some are outside your control—for example, another provider performs the same service on the same date and has already been paid for it.

More often, your organization must crack down on the bad billing practices creating this medical billing issue. Don’t automatically resubmit claims that haven’t been processed within 60 days, for instance, and don’t assume payments not yet posted haven’t been made.

Mistake # 5 – Relying Too Much on Manual Procedures

The U.S. healthcare industry has made “only modest progress” automating its transactions, the 2017 CAQH Index found. Providers seem reluctant to stop pushing paper around.

For example, about 77% send patients paper bills. And 31% manage denied claims manually, despite manual processes’ drain on internal resources and greater potential for human error.

Crunching CAQH’s numbers for HIT Consultant, Fred Pennic says a practice using electronic transactions stands to save up to 40 minutes and $15 per claim. So taking steps toward automated billing could add up to significant savings.

Mistake # 6 – Filing Your Claims Too Late

While Medicare allows up to a full year from the date of service for claim submission, other insurers’ windows don’t stay open as long.

Time limits of 60 or 90 days are typical; occasionally, an insurer allows a full four months (120 days). Deadlines can differ for in-network and out-of-network providers, as well as for physician practices and hospitals.

If your billing staff doesn’t keep track of the deadlines different payers observe, your organization will waste time filing claims destined for denial.

Mistake # 7 – Choosing the Wrong Medical Billing Codes

Medical coding is complicated. AMA Wire editor Kevin O’Reilly recently singled out eight different coding mistakes that cause providers trouble. His article—which includes such problems as unbundling bundled codes, omitting or misusing modifiers, and failing to check CMS’ National Correct Coding Initiative (NCCI) edits—drives home just how much room for coding errors in healthcare today actually exists.

Why is entering the correct codes important for billing? Because submitting the wrong ICD-10 or CPT® codes on your claims means you’re not giving insurers the complete picture they need to pay you what your work is worth.

 

Fix One Common Medical Billing Mistake Now with MDCodePro

Fortunately, of all the mistakes we’ve discussed, reversing the revenue-damaging impact of improper coding is one area where we can offer you an immediate and practical solution.

The MDCodePro app equips your practitioners with an easily remembered and quickly implemented method for making CMS’ daunting documentation guidelines a vital part of their daily work. Its video lecture series teaches the regulations’ basics in a streamlined, common sense way; and its code generator guides physicians, step by step, toward each visit’s optimal CPT® code, based on the newly strengthened documentation they input.

Audit after audit has verified and validated the MDCodePro approach, which has increased the annual revenue of the hundreds of doctors who’ve learned it by $30,000, on average.

Better documentation leads to better coding, and better coding leads to better revenue. You can resolve this costly medical billing issue right now. Sign up for your MDCodePro subscription today.

 

The post Are These 7 Medical Billing Issues Costing You Money? appeared first on MDCodePro.

source https://mdcodepro.com/blog/medical-billing-issues/

How CMS Diagnosis Codes Can Improve Your Documentation and Revenue

Understanding ICD-10-CM Is Critical for Strengthening Your Bottom Line

Ambrose Bierce satirically defined “diagnosis” as “a physician’s forecast of the disease by the patient’s pulse and purse.”

It’s easy to joke about doctor’s earnings . . . unless you’re a doctor! You’re not in medicine just for the money. (It’s no fast track to riches anyway). But you do have to make sure you’re being paid what your hard work warrants.

That’s why CMS diagnosis codes matter.

Getting CMS and other payers to reimburse you fully isn’t only a matter of submitting the optimal CPT® code for patient visits (something the MDCodePro app helps you do with maximum accuracy and efficiency). Beyond identifying what procedures you perform, you need to choose the right diagnostic codes to establish why.

With CMS’ list of medical diagnosis codes running into the tens of thousands, that choice can seem overwhelming. But understanding how and why these codes developed can make them less intimidating and more useful to your patients, your profession, and your bottom line.

 

From 16 “Notorious Diseases” to 69K+ Diagnostic Codes

London haberdasher John Graunt published his statistical study of causes of death, Observations Made Upon the Bills of Mortality, in 1662. It included a “Table of Notorious Diseases” specifying 16 maladies, including “falling sickness,” “head-ach [sic]” and “lunatique.”  

Graunt’s Observations marked “a new approach to health issues,” states The BMJ: “reliance on evidence versus belief.” The book inaugurated modern demography. It also helped lay the foundation for what became today’s International Classification of Diseases (ICD), the system of codes used to report symptoms and diagnoses (as well as U.S. hospital inpatient procedures) in medical records and billing claims.

If Graunt could see how much disease classification has grown, he might feel as bewildered as many modern practitioners do. ICD-10-CM (the code sets’ tenth edition since adoption in 1893; “CM” stands for Clinical Modification) contains 69,823 diagnosis codes CMS and other payers recognize. That’s almost 400% more than the 14,025 codes in ICD-9.

 

How ICD-10 Diagnosis Codes Help Healthcare

By the time the U.S. adopted ICD-10 in 2015, ICD-9 had grown inadequate. It was placing a bigger documentation burden on providers because it lacked specificity; it was running out of space and numbers for new codes; and it was failing to usefully measure resources used, costs, or patient outcomes, as Anita Hazelwood wrote for AHIMA.

But utility and flexibility are hard-coded into ICD-10. Its codes can extend up to seven characters, as opposed to only three to five, allowing them to “represent more specific anatomic sites, etiologies, comorbidities, and complications, and . . . demonstrate severity of illness,” AHIMA trainer Donna Cartwright wrote. ICD-10 can easily accommodate new codes by means of an “x” placeholder. And it captures better data, yielding a better measurement of healthcare quality and effectiveness.

As you likely remember, the switch to ICD-10 caused a lot of consternation before it happened. But by and large, the changeover has gone smoothly. AHIMA deems logistical impacts largely negligible, limited in scope, and quickly resolved. That means the healthcare industry can now start taking advantage of ICD-10’s benefits.

More specific information in diagnostic coding means, as AHIMA’s Sue Bowman points out:

• Cleaner data for researchers to help them make advances in disease management
  
• More effective, customized treatment for patients, leading to more positive outcomes
  
• More accurate insights for policymakers so they can make better informed decisions about public health issues

 

How ICD-10 Diagnosis Codes Can Help Your Revenue

ICD-10 may also mean good news for your revenue—provided you’re accurately and thoroughly documenting all you do for your patients.

Because diagnosis codes on the ICD-10 lists have greater granularity, they demand more detailed support in your notes and charts. See how these ICD-9 vs. ICD-10 examples call for different degrees of documentation:

• ICD-9 had a single code (996.1) covering “Mechanical complication of other vascular device, implant and graft.” ICD-10 has 49 codes related to breakdowns, displacements, and leakages of heart-related equipment and grafts—codes like T82.312A (Breakdown (mechanical) of femoral arterial graft (bypass) and T82.525A (Displacement of umbrella device, initial encounter).
• ICD-9 had five typhoid fever codes (002.0-.3, 002.9). ICD-10 has 11 codes for typhoid and typhoid and paratyphoid fevers (A01.00-.05, A01.09, A01.1-.4).
• ICD-9 had nine location codes (707.00-707.09) for pressure ulcers. ICD-10 has 150 codes showing ulcers’ specific (not just broad) location and depth or stage (which ICD-9 codes didn’t address).

Despite the many new diagnosis codes payable by CMS and others in ICD-10, you’ll only be dealing with codes most relevant to your practice, as you were under ICD-9. And working with these codes, your error rate should drop because, as Sue Bowman reasons, ICD-10 is “less ambiguous and more logically organized and detailed.” Your lower error rate means you’ll see less risk of a medical coding audit, and your accounts receivable will see more reimbursement, faster.

Coding to the highest level of specificity with ICD-10 should also help you establish the medical necessity of the services you provide. Because medical necessity correlates to a visit’s complexity and risk, the greater the documented necessity, the higher the complexity/risk score, and the more complex your medical decision-making. Therefore, for many visits, you could potentially, legitimately submit higher CPT® codes (assuming you have completed the appropriate physical and history and have documented such), confident you can support the accompanying ICD-10 codes’ specificity.

 

Strengthen Your Overall Documentation and Revenue with MDCodePro

For all that’s changed with U.S. adoption of ICD-10, one thing hasn’t: Accurate documentation is still key to better patient care and stronger physician reimbursement.

As mentioned earlier, MDCodePro focuses on the other codes your charts and claims need: the CPT® codes. But the documentation essentials we teach in the app’s video lecture series will also help you capture the data you need to support the diagnosis codes CMS and other payers look for.

By supporting and submitting the best possible ICD-10 and CPT® codes, you’ll be ensuring you are appropriately paid for the services you provide. And Ambrose Bierce’s quip notwithstanding, you’ll know you’re serving your patients as their “pulse,” not their “purse,” deserves.

For more information about how MDCodePro can help you improve your documentation and your revenue, contact us using this easy online form.

The post How CMS Diagnosis Codes Can Improve Your Documentation and Revenue appeared first on MDCodePro.

source https://mdcodepro.com/blog/cms-diagnosis-codes/