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Compliance Newsletter: Q1 2014

Compliance Newsletter: Q1 2014

ICD-10 Provider Training Outline

MedData is excited to announce the implementation of our 2014 provider ICD-10 training and want to motivate our clients to fully engage their providers in the training!

October 1, 2014, the ICD-9 code sets used to report medical diagnoses and inpatient procedures will be replaced by ICD-10 code sets. ICD-10 codes are more descriptive with a major focus on anatomy, physiology, and precise locations and causes of injuries and illnesses. In order to reduce the risk of a reduction in group revenue, every provider should undergo basic training that will ensure adequate preparation regarding documentation that will support the specificity required for the new ICD-10 code sets.

In response MedData has prepared comprehensive provider ICD-10 training material that will be relevant to all client specialty types and will be accessible utilizing a user name and password via our intranet website. The training material will address the following key aspects of ICD-10 as compared to ICD-9 coding and the specificity documentation requirements for optimum and compliant coding and billing:

  • ICD-10 Advantages
  • Differences between ICD-9 and ICD-10
  • ICD-10 Myths
  • ICD-10 Format, Structure, and Organization
  • Critical Provider Documentation Considerations
  • Top 20 ICD-10 Codes by Practice

Provider Documentation will become critical

The largest problems following the October 1, 2014 implementation date will be insufficient documentation to support the specificity required for the new ICD-10 code sets. The coding staff will be fully prepared for ICD-10, but if clinical documentation has not improved, accurate coding and proper payment will not be possible. We believe a behavioral change in documentation habits for most providers will be necessary—and now is the time to start preparing. Physicians, midlevels and residents will have to be more precise in their encounter notes and overall documentation. Come October 1, 2014, this specific responsibility will become even more necessary. Our provider training will commence in the 1st quarter of 2014 and your Client Service Directors will be sending instructional details in February on how to access our website and the ICD-10 training material!

Emergency Medicine (2012 Medicare Acuity) *latest data from CMS

The following table lists the percentage of Medicare emergency department visit levels 99281 through 99285 and critical care services (CPT 99291) nationally. This table includes allowed services as processed by Medicare for the emergency physician specialty 93, place of service 23, from January 1, 2012 to December 31, 2012. The information was obtained from CMS and is estimated to be 100% complete for 2012. This data is valuable for comparing your physician practice’s statistics to Medicare state and national percentages. Medicare may use this comparison to identify “outliers” and to determine which physicians and/or practices may be flagged for potential audits.


Documentation Requirements when “Scribes” are utilized

Physicians may on occasion utilize the services of scribes to assist with documentation during a clinical encounter between the physician and patient. The scribe is present during the encounter and records in real time the actions and words of the physician as they occur. Scribes may not interject their own observations or impressions into the medical record.

The physician is ultimately responsible for all documentation and must verify that the scribe’s note accurately reflect the service provided.

The scribe’s note should also include:

  • The name of the scribe and a legible signature (scribe identification)
  • The name of the physician providing the service
  • The date the service was provided
  • The name of the patient for whom the service was provided

The provider’s note should indicate:

  • Affirmation of that all the work was performed by the physician
  • Verification that he/she reviewed the information
  • Verification of the accuracy of the information
  • Any additional information needed

In a teaching facility setting attending physicians may employ scribes, but residents or fellows may not, since the creation of the medical record is inherent to the training programs (paid for under Graduate Medical Education [GME] program and to the medical care delivered by these residents.

More info»

CMS Issues Hospital Outpatient Department and Ambulatory Surgical Center Policy and Payment Changes for 2014

Collapsing Five E/M Levels of Visits to one; the final rule with comment period streamlines the current five levels of outpatient clinic visit codes, replacing them with a single Healthcare Common Procedure Coding System (HCPCS) code describing all clinic visits. The current five levels of outpatient visit codes are designed to distinguish differences in physician work. The final rule did not finalize the proposal to replace the current five levels of codes for each facility type of emergency department visits. CMS intends to consider options to improve the codes for these services in future rulemaking.

Physician Quality Reporting System (PQRS)

2014 is the last year a physician can qualify for an incentive payment of 0.5 percent under PQRS. Unfortunately, CMS is also making it harder for many physicians to avoid PQRS penalties, by increasing the number of measures that have to be reported, and limiting use of claims- based reporting, over the AMA’s strong objections. However, the final rule contains several improvements due largely to AMA efforts. For example, CMS has agreed to lower the reporting threshold from 80 to 50 %, and has decided not to increase the number of measures required in several areas, as further described below.

2014 PQRS Participation, Incentives, and Penalties

In addition to this being the last year physicians can receive incentives, 2014 will also serve as the performance year for the 2016 penalty adjustment of two percent. CMS finalized its proposal to lower the percentage of applicable patients a physician must report on from 80 % to 50 % in order to be considered a satisfactory reporter.

  • For individual incentive, CMS finalized plan increases the number of measures from 3 to 9 in 2014 at the 50% level for the 0.5% incentive. The measures must cover at least three of the National Quality Strategy (NQS) domains. This issue of 3 domains is challenging since in the past all our measures were in 1 domain (Effective Clinical Care).
  • To avoid the 2016 PQRS 2% penalty the provider has to report on 3 measures at the 50% level during 2014.

PQRS Measures to be reported by MedData, Inc. for 2014


Value Based Payment Modifier for 2014

2014 is the performance year for 2016 just like PQRS. This requires compliance with PQRS and self- nomination to participate in one of the Group Practice Reporting Options GPRO. Your Client Services Directors will be contacting you with the specific requirements.

CMS Sustainable Growth Rate (SGR) and Payment Update

The SGR is fixed for 3 months until March 31st. This is to allow time for the congress to eliminate the SGR that hangs over the physician’s necks every December. The proposal will only cost $116.5 billion, which is the lowest amount in years. The proposals go through 2017 and include an increase of 0.5% annually.

Breaking news: CCI Manual 2014 refines how to bill modifier 59, post-op E/M visits

Post-operative E/M services: You won’t be able to bill and be reimbursed for an E/M service during a global surgical period for any complication that arises from the surgery, even when the complication requires a return trip to the OR. This is a change for after 1-1-14. More info»

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