The Big
Misconception
On October 1, 2015, physicians transitioned to
ICD-10. Many systems are there offer a
system for mapping ICD-9 to ICD-10. Once
again, technology is wanting to assist on the conversion process, but :
ALERT:
The fact is : No true crosswalk' exists between ICD-9
and ICD-10
Providers are led to believe that there EHRs (Electronic
Health Record) performs and/ or captures the various quality measures: HEDIS / Meaningful USE / PQRS and so forth.
Coders , as well as physicians are shown to use the
mapping. However, when you look at the possibilities of some diagnosis: ICD-9
to ICD-10
·
One to Three Mapping
·
One to Sixteen Mapping
·
One to 2,530 Mapping
You can easily see that the structure used for the
mapping is incorrect and/or nonexistent.
The wording or condition changes.
It is this misconception that will cause providers to be flagged or audited.
The reality is that these systems may alert you to a
possible condition or capture data that might apply to one of the measures. The
question you the provider must ask:
·
Does the
information qualify?
·
Is it be
coded correctly?
·
Is the
level of service correct or is the system upcoding?
EHRs and the
ability to exchange health information electronically can help you provide higher
quality and safer care for patients while creating tangible enhancements for
your organization. EHRs help providers better manage care for patients and
provide better health care by:
- Providing accurate,
up-to-date, and complete information about patients at the point
of care
- Enabling quick access to patient
records for more coordinated, efficient care
- Securely sharing
electronic information with patients and other clinicians
- Helping providers more
effectively diagnose patients, reduce medical errors, and provide
safer care
- Improving patient and provider
interaction and communication, as well as health care convenience
- Enabling safer, more
reliable prescribing
- Helping promote legible,
complete documentation and accurate, streamlined coding and billing
- Enhancing privacy and
security of patient data
- Helping providers improve
productivity and work-life balance
- Enabling providers to improve
efficiency and meet their business goals
- Reducing costs through decreased paperwork,
improved safety, reduced duplication of testing, and improved health.
That being said, at the end of the day, providers are
ultimately responsible for submitting the charges.
The vendors have clauses in there agreements, that in the
event of an AUDIT or REVIEW, they
(the vendor) have no liability, since you the provider were the one that
released / billed the service, you are responsible and should have known. After
all, they have already collected their percentage and/or service fee, thus
leaving the provider to confront the audit.
For years, physicians have been trained to understand the
coding techniques of how to use the appropriate evaluation and management (E/M)
code and to qualify the level of service. How many times has CMS ( Medicare and
Medicaid ) performed random audits and
made the determination that level of service does justify services rendered ? Physicians must understand, nothing has changed with regards to the level of
service, medical necessity, and the
relation to clinical documentation.
The technology of the EHRs is valid and important one
designed to meet the needs of today’s healthcare. However, it cannot replace
the physician, nor should it be allowed to capture or code for the physician.
Providers should understand the ICD-10 and how it
applies to clinical documentation.
Doctors are consumed with meeting the various quality
measures, scoring the Stars Rating to
satisfy the plans requirements, understand the value-based model and yet they have no time to be physicians.
The medical community should evaluate the true and
correct functions of the EHRs, and the physician should determine what is
correct and appropriate to capture and submit as service provided.
Remember the terms Fraud
and Abuse, or Not Medically
Necessary have not disappeared , they are still valid.
Furthermore, the OIG has expanded review process for 2016. The provider will
NOT have the excuse that the EHRs did the coding.
The HPP
Management Group has represented physicians in over 500 Medicare and Medicaid
audits of overpayment assessments, has participated in more than 50 A L J
hearings and has recovered millions of dollars for our clients.
The
knowledge acquired in the audits served as the basis to develop the AccuChecker
Product Line, so we developed proven software that enables us to maximize
recovery amounts from Audits.
Our
success is measured on key factors we treat each AUDIT with a unique approach:
·
Working
directly with the audited physician and the key staff.
·
Our
forensic analysis experience permits us to view and closely analyze each
transaction denied or reduced in reimbursement by the carrier.
·
The
forensic analysis includes implementing software scrubbing claims techniques
that allow us to follow Medicare and Medicaid reimbursement guidelines and to
prepare undisputable rebuttals to the Carriers’ decisions. .
·
Preparing
a detailed rebuttal to each denial or reduction in reimbursement
·
Compiling
a summary rebuttal report that includes all transactions affected
We have
assisted many physicians affected with Prepayment Review situations with
Medicare and Medicaid. The Prepayment Review - a lengthy and painful process,
that requires continuous scrutiny and follow up. We have been able to
successfully correct every Prepayment Review with patience and creating a team
effort with the medical practice.
FOR MORE INFORMATION
HPP Management
Group, Corp.
5201 Blue Lagoon,
Suite 800
Miami, FL 33126
Phone: (305)
227-2383
Email: psilben@hppcorp.com
