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Medical Coding Expert Doug Palmer Talks About the Future: Computer-Assisted Coding, and ICD-10

Doug Palmer is a practice management, billing and coding and revenue cycle consultant with over 17 years of experience in the industry. He was nice enough to answer some questions for our readers about his experiences and where he sees coding going in the future.

Medical Records

 MMP: How did you get started in coding?

Doug:  I started in the industry as a medical biller with a billing company in NY City. In a rather short period of time, I became familiar with the coding systems (COT, ICD-9, and HCPCS) and began to want to know more. I also wanted to know more about the overall Revenue Cycle Process. That starting point in billing led me to coding for several reasons. Aside from personal and professional development, I realized that I would be more marketable with that skill set. I was right. As I learned more and more about coding…more and more opportunities seemed to come my way.

MMP: What type of coding education and certification do you have?

Doug: I have gotten most of my education in coding “on the job”. I have attended many seminars, CEU courses, internal education opportunities with employers, etc., however, I have never matriculated into any formal or long term courses of study in coding other than a BS in Health Administration which did not specifically focus on coding. At the same time, with my CCS-P Certification through AHIMA, I have taught coding and related courses both in a formal classroom environment in several adult education schools as well as providing on site education as well as web based instruction to other coders as well as medical providers across the country.

MMP: What was your first coding consultant position and how did it come about?

Doug: After a very bad employment experience where I had to stand up for being compliant against a manager that had no regard for regulations nor the impact it had on the organization we worked for, I sought a different environment. A company based in California contacted me about a travel consulting position and it felt right and seemed to be just what I needed, and indeed it was. I have been consulting ever since. It has afforded me growth I do not think possible remaining in one environment. It has exposed me to countless organizations giving me the opportunity to see what works well, what doesn’t, and has made me a better coder, manager, and consultant.

MMP: What tools do you use to assist you in your day-to-day coding?

Doug: Of course, the basics are the CPT, ICD-9, and HCPCS publications which are the cornerstone of coding. There are a wide variety of resources out there that help you think outside of the your environment and open up a more global perspective. Some examples are Coding Alerts from The Coding Institute which are published in a number of specialties, Coding Clinic, and  Medicare NCDs and LCDs. These resources provide great insight, clarification, and education on a broad range of coding scenarios.

MMP: What do you find interesting about coding?

Doug: This is a tough question to answer only because there are so many fascinating aspects to coding. To be a part of the health field and know that coding goes beyond mere reimbursement, is one of the elements that I find both intriguing and satisfying. When a news report states a statistic such as a higher or lower incidence of a particular condition in a particular area, I know that those statistics are captured in large part from the coding that goes on.

MMP: What have you seen change about coding over the years?

Doug: I began in healthcare at a time when E&M Codes were assigned by the provider in essentially an arbitrary fashion based on what they believed the services they rendered were worth on an ascending scale. Largely, government programs such as Medicare and Medicaid with their dual role as payor and regulator of health services have led the way in changing, shaping, defining, and standardizing coding. E&M codes in particular, at least on the professional services side, have become much more standardized and in theory are more equitably assigned then they were prior to the 1990’s. Payment methodologies such as fee-for-service, DRG (Diagnosis Related Groups), capitation, HCC (Hierarchical Condition Categories), and CRG (clinical risk groups) all influence or depend on the core of coding and thus depend on complete and accurate coding to be optimal.

MMP: Would you encourage people to go into medical coding as a career? Why or why not?

Doug: Well, as an educator in this field, I would encourage people to explore it and find out enough about it to make a sound decision for them. While I find this field fascinating, rewarding, fulfilling, and have made a successful career of it, it may not be for everyone. There can be long arduous hours in front of a computer screen, with the requirement to think critically and analytically. This may not appeal to everyone. Reading some records may make some people squeamish or depressed. The many rules, which change regularly, may not necessarily be for everyone to digest. However, for those that are looking for not just a job, but a career with so many opportunities, a career where one can feel that they play a valuable role in a process and can learn so much, I would highly encourage coding as a possibility. It really is a wonderful field to work in.

MMP: Do you think computer-assisted coding (CAC) will ever take the place of coders?

Doug: Absolutely not. At least not as long as the coding methodology is as it is now. I have actually worked with a number of these systems, and there are too many areas where context is involved and these systems are yet to be able to accurately and reliably handle context. If that hurdle is ever solved, then perhaps. But, until then, I can not envision this being nearly as reliable as the human element.

MMP: Do you think the change to ICD-10 is being underrated as a healthcare-wide change in the US, or do you think people are making more fuss over it than is really necessary?

Doug: I view the transition to ICD-10 as a positive step forward. It offers a much more accurate and precise means of reporting conditions, circumstances, anatomical locations, and other important and relevant information. Of course, change is always disruptive and polarizing. The issue is still being deliberated at many different levels and lobbied by many different organizations based on so many different agendas. I think that is to be expected when a change of this magnitude is proposed and initiated.

MMP: What has been the most interesting or unusual coding job you’ve ever had?

Doug: I have been so many places, performed so many functions in such a wide variety of roles and specialties, this is difficult to choose only one. However, I believe that a project for a large health organization in Northern California would have to be the one I choose. In this capacity, I supported the transition to physicians, PAs, and NPs being responsible for assigning their own Evaluation and Management codes. This was all new to these providers and a task that they did not wish to be responsible for. It was a great challenge to go in and not only teach them a topic that they were not embracing, but to accomplish this in a very short period of time, and ALSO to achieve proficiency while changing a mind set. I got to do this over and over at each location and in the end did so successfully to the satisfaction of not only the organization but to the reluctant providers as well. I have to choose this over many equally interesting accomplishments based on my passion for providing education to new and veteran coders as well as health care providers.

Doug Palmer, Medical Coding Consultant

Douglas B. Palmer, BS Health Administration, CCS-P has over 17 years of Practice Management, Revenue Cycle Management, HIM and Consulting experience. He has worked with medical practices of all sizes, been on the management team of some of the countries leading healthcare facilities, and has consulted with prominent insurance carriers. He is expert in all reimbursement methodologies, revenue cycle issues, EMR implementation and HIM management. He has overseen and managed the recovery of millions of dollars in revenue for clients and past employers. As the principal at Phys Assist Consulting, he prides himself on being personally involved and connected with each end every client and exceeding clients expectations as the minimum acceptable outcome.

He can be contacted at d.palmer@phys-assist.com or at (888) 873-0735.

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ICD-10 Implementation Strategies for Physicians – My Notes from the CMS Provider Call

 

The new winner of my ongoing competition for the CMS Employee Speaker contest is Dr. Daniel Duvall, Medical Officer, Hospital and Ambulatory Policy Group Center for Medicare! During a recent ICD-10 call, Dr. Duvall spoke clearly, was easy to understand and kept my attention.

Why are we moving to ICD-10?

ICD-9 has deficiencies, such as:

  • Not enough detail for analyzing diseases
  • Not enough detail for payment
  • Insufficient attention to:
    • Medical encounters for reasons other than death
    • Non-lethal manifestations
  • Out of room for new codes
  • Obsolete family groups
  • Unable to address 30 years of medical knowledge of etiology
  • Inadequate attention to continuum of disease and clinically relevant subsets

ICD-10 brings to the table:

  • Appropriate payment via stratification of morbidity (“My patients are sicker”)
  • Specificity needed for episodes of care, Affordable Care Organizations, Hierarchical
    Condition Categories, and quality monitoring
  • Better quality in research/clinical trials
  • Identification of consistent cohorts
  • Improved outcomes from population analysis
  • Targeting resources to diseases: specialty, county, environment
  • 2010 computational power cannot use 1980’s information

The detail is demanded not by government nor by payers but by specialty societies.

What exactly is ICD-10?

  • Stands for International Classification of Diseases
  • Developed by World Health Organization (WHO)
  • The order of chapters is just like ICD-9
  • Was originally released in 1993 and adopted by other countries
  • Approximately 2000 diseases (families)
  • Approximately 70,000 specific codes
  • ICD-10-CM (diagnoses) will be used by all providers in every health care setting
  • ICD-10-PCS (procedures) will be used only for hospital claims for inpatient hospital procedures
  • ICD-10-PCS will not be used on physician claims, even those for inpatient visits (procedure coding system)

Will ICD-10 change the use of CPT and HCPCS?

There will be no impact on Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes – CPT and HCPCS will continue to be used for physician and ambulatory services including physician visits to inpatient.

How much of a headache will ICD-10 really be?

Dr. Duvall characterized how difficult the transition to ICD-10 will be for each stakeholder group, by assigning them stars and headache types. The more stars, the more head-pounding the transition will be!

  • Government, CMS & CDC will have 5-star headaches (encephalitis)
  • Health Insurance Plans will have four-star headaches (migraine)
  • Hospitals will have three-star headaches (cluster)
  • Billing Agencies will have two-star headaches (sinus)
  • Physicians will have one-star headaches (tension)

What should practices be doing now to prepare?

  • Create a new job aid (cheat sheet) or superbill
  • Update proprietary software or contact billing software vendor to discuss changes
  • Train your coders and billers
  • Train your physicians and providers
  • Purchase new coding books and forms
  • Develop a conversion plan –
    • Paper Charts
    • EMR
    • For some small conversion projects it may well be quicker and more accurate to use ICD-10 code books instead of GEMs (crosswalks)

When will the change to ICD-10 happen?

  • Single implementation date of October 1, 2013 for all users
  • Ambulatory and physician services provided on or after 10-1-2013 will use ICD-10-CM diagnosis codes
  • Inpatient discharges occurring on or after 10-1-2013 will use ICD-10-CM and ICD-10-PCS code
  • ICD-9-CM codes will not be accepted for services provided on or after October 1, 2013
  • ICD-10 codes will not be accepted for services prior to October 1, 2013
  • Last regular, annual updates to both ICD-9-CM and ICD-10 will be made on October 1, 2011
  • On October 1, 2012 there will be only limited code updates to both ICD-9-CM & ICD-10 code sets to
    capture new technology and new diseases
  • On October 1, 2013 there will be only limited code updates to ICD-10 code sets to capture new
    technology and new diseases
  • There will be no updates to ICD-9-CM on October 1, 2013 as the system will no longer be a HIPAA
    standard
  • On October 1, 2014 regular updates to ICD-10 will begin

Q & A (my favorite!)

Q: What will the financial impact be for a small practice to implement ICD-10?

A: This is dependent on how claims are being submitted and if the practice is responsible for paying for the system upgrade to handle ICD-10. If you are using free electronic billing, there should be minimal financial impact.

Q: Is the cost to the American public worth the value ICD-10 is supposed to create? Also, will offices be required to “prove” the new codes by sending medical records to payers?

A: Dr. Duvall answers “Yes” to the first question. As to the next question, that process is related to new codes moving from experimental to actual, not the process of moving from ICD-9 to ICD-10. Payers will not be requesting mass medical records since the change is global.

Q: With 2 years to go, when should we start training the staff?

A: You should start training 6-9 months before October 2013.

Q: There will be a tremendous impact on practices where physicians have not been documenting appropriately as there will not be enough information to choose a code. You are minimizing the physician’s time and effort needed to make this change.

A: Anyone who has been documenting correctly will have a relatively easy time choosing an ICD-10 code. Anyone who has been documenting minimally will have a hard time.

Q: What format will the new codes be released in?

A: They are in pdfs now, and they are also available in text and html formats.

Q: What will commercial payers be using for ICD-10?

A: Payers might be using GEMS (General Equivalence Mappings) to map from ICD-10 to ICD-9 if they are not ready.

 

Resources

General Equivalence Mappings (GEMs) assist in converting data from ICD-9-CM to ICD-10
Forward and backward mappings – Information on GEMs and their use – (click on ICD-10-CM or ICD-10- PCS to find most recent GEMs)

The CMS Sponsored ICD-10 Teleconferences web page provides information on upcoming and previous CMS ICD-10 National Provider Calls, including registration, presentation materials, podcasts, video slideshow presentations, written transcripts, and audio recordings http://www.cms.gov/ICD10/Tel10/list.asp

Provider Resources (for all providers) http://www.cms.gov/ICD10/05a_ProviderResources.asp

 

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CMS Never Sleeps! Version 5010, ICD-10, an Education Call, Twitter and YouTube

I am fortunate to be serving on the North Carolina MGMA Medicare Committee this year.  When we met yesterday, the members were asked why we wanted to be on the committee.  I said I couldn’t believe any practice manager wouldn’t want to be on the Medicare Committee!  I want to be on the front lines, asking questions and trying to understand the massive changes hitting our practices daily.  Don’t you? If you’re not a member of your local or state manager’s group and you’re not volunteering on one or more committees, why not?

Important Information and Reminders About the Upcoming Version 5010 and ICD-10 Transitions

CMS has resources for providers, vendors, and payers to prepare for the transition. Fact sheets available for educating staff and others about the transition include:

The ICD-10 Transition: An Introduction

Talking to Your Vendors About ICD-10 and Version 5010: Tips for Medical Practices

Talking to Your Customers About ICD-10 and Version 5010: Tips for Software Vendors

Compliance timelines, materials from CMS-sponsored calls and conferences, links to resources and sign up for email updates here

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Medicare FFS 5010 Program: Taking EDI to the Next Level- Ninth National Education Call on Medicare Fee-For-Service (FFS) Implementation of HIPAA Version 5010 and D.0 Transactions

August 25, 2010
2:00pm To 3:30pm EST

The Centers for Medicare & Medicaid Services (CMS) will host its ninth national education call regarding Medicare FFS’s implementation of HIPAA Version 5010 and D.0 transaction standards on August 25, 2010.  This session will focus on the 835 Electronic Remittance Advice transaction.  Subject matter experts will review Medicare FFS specific changes as well as general information to help the audience prepare for the transition; the presentation will be followed by a Q&A session.

Registration will close at 2:00 p.m. EST on August 24, 2010, or when available space has been filled.

Target Audience: Vendors, clearinghouses, and providers who will need to make Medicare FFS specific changes in compliance with HIPAA version 5010 requirements.

Subject: Medicare Fee-For-Service (FFS) Implementation of HIPAA Version 5010 835 Electronic Remittance Advice Transaction

Agenda:

* General Overview

* Medicare Specific Changes

* Timelines and Deadlines

* What you need to do to prepare

* Transaction Specific Issues

* Q & A

Conference call details:

Date: August 25, 2010

Conference Title: Ninth National Education Call on Medicare Fee-For-Service (FFS) Implementation of HIPAA Version 5010 and D.0 Transactions

Time: 2:00 p.m. – 3:30 p.m. ET

In order to receive the call-in information, you must register for the call. It is important to note that if you are planning to sit in with a group, only one person needs to register to receive the call-in data.  This registration is solely to reserve a phone line, NOT to allow participation.

Registration will close at 2:00 p.m. ET on August 24, 2010, or when available space has been filled.  No exceptions will be made, so please be sure to register prior to this time.

1. To register for the call participants click here.

2. Fill in all required data.

3. Verify your time zone is displayed correctly the drop down box.

4. Click “Register”.

5. You will be taken to the “Thank you for registering” page and will receive a confirmation email shortly thereafter.   Note: Please print and save this page, in the event that your server blocks the confirmation emails.  If you do not receive the confirmation email, please check your spam/junk mail filter as it may have been directed there.

6. If assistance for hearing impaired services is needed the request must be sent to medicare.ttt@palmettogba.com no later than 3 business day before the event.

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Social Media

The Centers for Medicare & Medicaid Services (CMS) continues to break new ground and to enhance their outreach efforts to the public. CMS is now using social media outlets to get information out to their audience as fast as possible.

Twitter: For CMS & Medicare Learning Network updates, click here.   You’ll need a Twitter account first if you don’t already have one – here are instructions:

  • Go to www.twitter.com and sign up for FREE (choose a name and a password)
  • You can use Twitter on the web or on your phone ”“ you can look at it once a day (you don’t have to look at it and respond to it instantly.)
  • Once you’re signed up, you can start “following” people and they can “follow” you.  I am following people who have interesting things to say about healthcare, and also people who are writing blogs like me.
  • Start by following me (@mpwhaley) and I’ll be glad to follow you.

YouTube:  Log on to the official CMS YouTube channel to view several videos currently available and more to come in the upcoming months.  See an example of a CMS video below.