By: Tammie Lunceford
December 8th, 2015 | Healthcare
As we finalize our newsletters for the year, it is important to review and look ahead at the impact 2015 can have in 2017. As we conduct regular practice management roundtables across our footprint, we hear managers from every specialty struggling to meet deadlines and keep the business of healthcare profitable.
The most recent deadline in 2015 was the implementation of ICD 10, it will be important to monitor clearinghouse reports, claim error rates and changes in aging by carrier. Managers and coders should continue to train providers on use of the most specific diagnosis code they can support in their documentation. A process to review coding and documentation prior to sending the claim can reduce denials and lead to enhanced training with improved documentation. We have one year of leniency related to the use of non-specific codes, but we should make every effort to improve specificity in the next few months.
ICD 10 is important as we move toward the Value Based Modifier. Groups of 10 or more will be subject to the VBM in 2016 and practices and 2-9 providers will be subject to VBM in 2017. The look back period for VBM is this year for practices with 2-9 providers so it is time to review related data. ICD 10 is important in the accuracy or risk adjustment. The risk adjustment is calculated for each patient through number of diagnosis and costs of treatment in a calendar year. Insurance carriers risk adjust the members to budget or prepare for the cost of care for each member. Physicians are judged by the least costly alternatives, accurate and specific diagnosis submission and other patterns to be considered cost efficient. Cost efficiency is one portion of the VBM’s calculation. It is important to point out that the value based modifier is applied at the tax identification level, not the provider level.
Another portion of the value based modifier is quality through participation in the Physician Quality Reporting System. This system has been in place since 2007 but it is no longer an incentive program. In 2017, practices not participating in PQRS will incur a 2 percent adjustment to Medicare reimbursement. Because PQRS is the other factor in the value based modifier, a non-participating practice will incur another 2 percent for VBM if the group size is 2-9 providers. Groups with 10 or more providers who are not participating in PQRS will take a 4 percent adjustment in Medicare reimbursement. A qualified registry is the easiest process to assure you are compliant with PQRS. Do not let 2015 end without participating in this program.
Many practices have struggled with Meaningful Use due to vendor issues or changes in ownership. If a practice does not demonstrate MU in 2015, each provider will incur a 3 percent adjustment to Medicare reimbursement. I assisted a provider last year who thought the hospital where she was employed during the first 9 months of the year had attested for her but they had not. Because she did not attest in her new practice or file a hardship, she incurred an adjustment of 1.5 percent this year, because our appeal was denied. Stage 2 meaningful use has been challenging but there have been several revisions in the last few weeks that may make it possible to attest this quarter:
The attestation period opens January 1, 2016 and ends February 29, 2016. There are hardships available for physicians encountering vendor issues or switching vendors.
It has been a busy year in healthcare and new challenges await in 2016. I am reminded of a motivational speaker from the 2015 National MGMA Conference who quoted from Nike’s marketing campaign…Just Do It.
Tammie Lunceford serves Warren Averett as a dental and healthcare consultant. Tammie is a Certified Professional Coder, CPC and registered with the American Society of Pathology as a medical laboratory technician, collectively bringing her clinical and administrative experience to more than 25 years.