ICD-10 Implementation Strategies

Dr. Fucinari says the intent with ICD-10 is to compensate quality, cost-effective care.

Risk Management

ICD-10 Implementation Strategies

On October 1, 2015, we entered into a new phase of ICD-10, leading companies to retool their policies, reprogram their software and increase audit scrutiny. Therefore, now is the ideal time to familiarize yourself with updates in coding and documentation requirements, including those for federal programs, private payers, and standards of care regulated by your licensing board.

Since the implementation of ICD-10, each healthcare carrier’s interpretation of code usage and policies for billing procedures has become more evident. The increased description and specificity of ICD-10 has fueled program policies that shift toward quality care, rather than the number of services provided. The data accrued from the claim formswill generate statistical analysis. This becomes a means for healthcare insurance companies to control costs.

While some still debate where to list the subluxation complex—now referred to as the somatic and segmental dysfunction—in the diagnosis list, advanced payment modelchanges are being implemented throughout the healthcare profession. Payment for quality and cost-effective care is replacing the fee-for-service reimbursement model.

The Value-Based Modifier

Under the Affordable Care Act, Medicare has instituted a differential payment to physicians known as the value-based modifier. Hospital and group practices have already experienced the implementation of this new model. In 2017, the value-based modifier will be assigned to each provider in solo practice and groups of two or more eligible providers.

The intent is to reward providers with increased reimbursement for quality of care, decreased complications and decreased reoccurrences. Reimbursement in the past monetarily rewarded those who performed more services. This gave no incentive to control healthcare costs. Data provided with the increased specificity of the ICD-10 coding system will result in methods to measure a healthcare provider’s performance.

The ICD-10 coding system will yield data to determine which doctors are delivering high-quality care at a lower cost. Under the value-based reimbursement system, doctors who deliver high-quality, low-cost care will receive increased reimbursement, while those who deliver low-quality care and high costs will face reductions.

On January 1, 2019, we are scheduled to begin the Merit Incentive Payment System (MIPS) payment adjustment system under Medicare. Under MIPS, the Health and Human Services Secretary must develop a methodology to assess eligible a provider's performance and determine a performance score. The score will then be used to apply a payment adjustment factor for 2019 onward. The MIPS score will dovetail onto the value-based modifier, which initially was partially calculated by each provider’s participation in the Physician Quality Reporting System and the electronic health records meaningful use programs.

One may ask, what does this have to do with ICD-10? Unlike our European counterparts, utilization guidelines in the U.S. insurance system are largely based on the diagnosis codes, documentation to support the diagnosis and medical necessity for care. ICD-10 greatly expanded the number of possible codes from 17,000 to 70,000 codes. This was primarily due to the increased specificity of codes.

Medicare has also put in place mechanisms to report complicating factors. A complicating or comorbidity factor is determined by data gained from the examination and the past history. The complicating factor acts as a multiplier to calculate additional amounts of allowable treatments. Therefore, it is incumbent on the provider to properly diagnose the patient to the highest degree of specificity and to include complicating factors.

Impact on Quality Care

I believe this will ultimately lead to quality care that is consistent with evidence-based care. Merely picking a code from a list is not easy, nor is it a good practice. If a patient legitimately has a complex condition with complicating factors, it is reasonable that the doctor documenting these factors will be reimbursed more consistently. That is why I believe that a diagnosis of lumbalgia or cervicalgia should be used only after careful consideration. What is the true diagnosis? This will impact not only each provider but ultimately our entire profession.

Over the next year, each doctor must learn the coding system in-depth. This will then yield a more accurate diagnosis that will be used for reimbursement, data collection and changes in coverage for needed chiropractic care. Like learning a new language, now is the time to advance our level of understanding of the diagnosis codes to better influencechiropractic care in the future.

The information in the NCMIC Learning Center is offered solely for general information and educational purposes. It is not offered as, nor does it represent, legal or professional advice. Neither does this information constitute a guideline, practice parameter or standard of care. You should not act or rely upon this information without seeking the advice of an attorney familiar with the specific legal requirements of the state(s) in which you practice. If there is a discrepancy between the site and an insurance policy you have with NCMIC, the policy will prevail.