HERE WE GO AGAIN: THE LATEST ON ICD-10 AND MEDICARE AUDITS

Transcription

1 HERE WE GO AGAIN: THE LATEST ON ICD-10 AND MEDICARE AUDITS

2 TODAY S OBJECTIVES International Classification of Diseases (ICD )-10: Delay to 2015? Medicare Cost Report : Desk Review and Audit Findings 2

3 ICD-10 DELAY : HERE WE GO AGAIN! H.R Protecting Access to Medicare Act of 2014 ~ Section 212. Delay in transition from ICD 9 to ICD 10 code sets The Secretary of Health and Human Services may not, prior to October 1, 2015, adopt ICD 10 code sets as the standard for code sets under section 1173(c) of the Social Security Act (42 U.S.C. 1320d 2(c)) and section of title 45, Code of Federal Regulations. 3

4 CMS- REACTION TO DELAY CMS Website breaks the silence - With enactment of the Protecting Access to Medicare Act of 2014, CMS is examining the implications of the ICD-10 provision and will provide guidance to providers and stakeholders soon. This provision in the statute reads as follows: The Secretary of Health and Human Services may not, prior to October 1, 2015, adopt ICD-10 code sets as the standard for codes sets under section 1173 (c) of the Social Security Act (42 U.S.C. 1320d-2 (c)) and section of title 45, Code of Federal Regulations. AHIMA ICD-10 Summit - The delay is not a killer for ICD-10, the Centers for Medicare & Medicaid Services (CMS s) Denise Buenning told members of the American Health Information Management Association (AHIMA) during a Wednesday meeting. In responding to questions from the audience, Buenning said CMS has had multiple conversations on this (the delay) internally and that HHS will be making an announcement shortly. Buenning also said that CMS is keeping to its regular schedule with meetings and committees and that CMS is behind ICD-10. HIMSS - Interest in ICD-10 had been running high. A HIMSS webinar scheduled for April 2 on ICD-10 Preparedness featuring guidance from CMS representatives attracted more than 4,000 registered attendees. A CMS representative cancelled his appearance soon after the law passed. 4

5 WHAT ARE CMS OPTIONS Implement ICD-10 on October 1, 2015 (or sometime after that) Allow voluntary early adoption of ICD-10 Shift focus to ICD-11 ICD-11 has been put off by the WHO, until New code set is not likely to be issued before 2019 or

6 CHALLENGES PRESENTED BY DELAY Delay will increase the cost of the ICD-10 program Challenge moving forward is both technical and cultural How does the new deadline fit into other IT project schedules? Has ICD-10 been linked with other projects such as meaningful use stage 2? Project loses credibility with the deadline shifting, tough to convince physicians that ICD-10 will happen Need to keep attention and momentum up, then get it going again 6

7 OPPORTUNITIES PRESENTED BY THE DELAY Assessing areas for clinical documentation improvement Evaluate training opportunities (coders and physicians) Additional time for dual coding Opportunity to do more testing with payers Improve business office functions More time to develop contingency plan for potential cash flow issues and productivity for physicians and coders 7

8 FOR THOSE WHO WERE WELL ON THEIR WAY No Good Deed Goes Unpunished Keep the Momentum Finish as much of the project as you can before putting it on the shelf Slow Down Stretch your project time line from 6-18 months Be Pragmatic Be strategic and finish as much as possible reserving a small budget for next year Stop Not recommended - don t stop and restart the project 8

9 PLANNING PROCESS FOR ICD-10 Initiate, Plan, and Communicate Test and Train Transition Discovery, Inventory, and Assessment Plan and Implement Change Monitor 9

10 TIMING SUMMARY Project Steps: May Jun July Aug Sept Oct Nov Dec Jan Feb Mar April May Jun July Aug Sept Oct Initiate, Plan and Communicate Discovery, Inventory, and Assessment Plan and Implement Change Test and Train Compliance Deadline Short Term Monitoring Long Term Monitoring 10

11 ISSUES UNCOVERED - NOT EXCLUSIVE TO ICD-10 Need for clinical documentation improvement Better processes for denials management Education for coders Identification of Major Complications and Co-Morbidities 11

12 MEDICARE COST REPORT AUDIT FINDINGS 12

13 MEDICARE BAD DEBTS A debt must meet these criteria to be an allowable bad debt: 1. The debt must be related to covered services and derived from deductible and coinsurance amounts. 2. The provider must be able to establish that reasonable collection efforts were made. 3. The debt was actually uncollectible when claimed as worthless. 4. Sound business judgment established that there was no likelihood of recovery at any time in the future. 13

14 MEDICARE BAD DEBTS Indigent Or Medically Indigent Patients 1. The patient's indigence must be determined by the provider, not by the patient; i.e., a patient's signed declaration of his inability to pay his medical bills cannot be considered proof of indigency; 2. The provider should take into account a patient's total resources which would include, but are not limited to, an analysis of assets (only those convertible to cash, and unnecessary for the patient's daily living), liabilities, and income and expenses. In making this analysis the provider should take into account any extenuating circumstances that would affect the determination of the patient's indigence; 3. The provider must determine that no source other than the patient would be legally responsible for the patient's medical bill; e.g., title XIX, local welfare agency and guardian; and 4. The patient's file should contain documentation of the method by which indigence was determined in addition to all backup information to substantiate the determination. 14

15 TIME STUDIES Regulatory Requirements Selection of weeks Contemporaneous with the costs to be allocated Provider specific Provide education to staff Review and update your tools 15

16 TIME STUDIES Part A (provider/facility) costs which are allowable Meeting time Supervision time Availability time for ER physicians If no time study is available to prove Part A time, all time will be considered Part B and non-allowable. 16

17 BREAK OUT OF COST CENTERS Services should be set-up as separate cost center, segregating costs, revenues, and statistics applicable to services, in accordance with CMS Publication 15-1, Section CMS Publication 15-1, Section 2300 Providers receiving payment on the basis of reimbursable cost must provide adequate cost data based on financial and statistical records which can be verified by qualified auditors. The cost data must be based on an approved method of cost finding and on the accrual basis of accounting. 17

18 QUESTIONS? Lisa Trundy (207)