Health Care Compliance Watch : New York Health Care Compliance Lawyer & Attorney : Ilana Sable : NY Physician Representation Law

This post goes out to all those private medical practices that are under the impression that they are too small or too insignificant to draft and implement a comprehensive compliance program. You know who you are.

What are you doing to protect your patients medical records from inappropriate examination or theft? How do you ensure that your practice is consistently billing and coding “clean claims”? How will your prove that your employees are trained in handling protected health information?

Auditors, attorneys and inspectors will not be amused when they ask to see your compliance manual and you, in turn, point to the “employees only” sign on your wall.  Every single private medical practice is subject to the rules and regulations of powerhouses such as HIPAA, and is thereby encouraged to have a formal corporate compliance program. And I am not talking about a 1,000 page binder that would take an entire week to read. To the contrary, a comprehensive compliance program consists of seven fundamental elements:

1. Implement written policies, procedures and standards of conduct
2. Designate a compliance officer to be responsible for execution of the compliance program
3. Conduct effective and consistent employee training and education
4. Develop lines of communication for employees, patients and private citizens
5. Enforce compliance standards through well-publicized disciplinary guidelines
6. Conduct regular internal monitoring and auditing
7. Respond promptly to detected offenses and develop a strategy for corrective action

The trick is to take these seven elements, transform them into a simple set of written guidelines that are tailored to meet the needs of the individual practice, and then incorporate them into the practice's daily routine.

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Recently I have been getting an increasing number of questions regarding the conversion from ICD-9-CM to ICD-10-CM/PCS. I think it is important to have a general understanding of the educational and financial burden that the health care industry is about to tackle, so I put together the following overview in an effort to inform those of you that have not had a chance to research this subject further.

• The compliance date for conversion to the new coding system is October 1, 2013.
• The number of diagnoses codes will escalate from 14,025 (ICD-9) to 68, 069 (ICD-10). Yes, you read that right; there is going to be a 54,044 increase in the number of diagnoses codes under the new coding system.
• The number of procedure codes will escalate from 3,824 (ICD-9) to 72,589 (ICD-10); an increase of 68,765 in the number of procedure codes.
• Structural differences will include an increase from 3-5 digits in diagnoses codes (ICD-9) to 3-7 digits in diagnoses codes (ICD-10), and all ICD-10 codes will be alpha-numeric
• ICD-10-CM will replace ICD-9-CM Diagnoses and ICD-10-PCS will replace ICD-9-CM Procedures.

If you are wondering why the coding system is going through this exhaustive conversion, the answer is actually quite simple. ICD-9 is over thirty years old and it did not keep up with the evolution of the health care industry. ICD-9 is not exact enough to identify diagnoses and procedures precisely, and it is not flexible enough to incorporate emerging diagnoses and procedures.

CMS offers the following example in a CMS overview presentation on ICD-10 (pdf) to help illustrate the concept:

Example – fracture of wrist
Patient fractures left wrist. A month later, fractures right wrist.

ICD-9-CM does not identify left versus right.

However, ICD-10-CM describes:

• Left versus right
• Initial encounter, subsequent encounter
• Routine healing, delayed healing, nonunion, or malunion

While the road to conversion will likely be rough (I am recalling my first few experiences with Microsoft Vista), the result will be an accurate, accountable and measurable coding system that increases productivity, while decreasing audits, the need for supporting documentation and the delay in receiving reimbursement from health insurance companies.

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For those of you wondering whether the cost associated with implementing an e-prescribing software as early as calendar year 2009 outweighs the incentive payment offered under the 2009 Electronic Prescribing Incentive Program, a financial breakdown will be the most useful tool in the decision making process.

While we can agree that e-prescribing will enable prescription of the most medically appropriate and cost effective therapy by offering an exchange of information that includes a patient's medication history, insurance coverage information, drug interaction information, allergy alerts and so forth, the costs associated with incorporating an e-prescribing software may be an unreasonable financial burden for some providers.

Data currently available estimates that a standalone e-prescribing system can range from $50/month to $100/month, per physician (not per practice). To qualify for the incentives, the standalone system must meet the certification criteria established by the Certification Commission for Healthcare Information Technology through its Electronic Prescribing Work Group.  In addition to qualifying for incentives, certification will also ensure that standalone systems are interoperable with any future technology that a practice decides to adopt.

As an alternative, the more sophisticated electronic health records (“EHR”) systems available on the market offer an electronic prescription submission function. However, it may be too early for providers to commit to any particular EHR software because a national certification system for EHR software it yet to be named, and only providers using nationally certified EHR systems will be eligible for the financial incentives offered under the HITECH Act. And for those of you that have not begun testing the EHR systems available in your area, they generally have a purchase price of $25,000 to $45,000 per physician, or a lease price of $250/month to $500/month per physician.

On the incentive side, eligible professionals who are determined to be “successful prescribers,” as outlined on the Electronic Prescribing Incentive Fact Sheet (PDF) may earn an incentive payment equal to 2.0% of the total estimated allowed charges for all covered professional services for reporting year 2009-2010. Centers for Medicare & Medicaid Services (“CMS”) anticipates that the first e-prescribing incentive payments, for reporting year 2009-2010, will be paid as a lump sum in mid-2010.

It is important to note that being deemed a “successful e-prescribers” is no easy task. One e-prescribing measure must be reported in at least 50% of the cases where the measure is applicable during the reporting period, and where at least 10% of the providers Medicare Part B covered services are made up of CPT codes that appear in denominator of e-prescribing measures. The denominator codes are comprised mostly of office visits, consults, psychiatric evaluations, and generally center around diagnosis based visits rather than the course of treatment.

Therefore, the decision of whether to incorporate an e-prescribing software will likely hinge on the size of the providers practice, and whether a 2% incentive payment will result in a return equal to the amount spent on implementing the e-prescribing software into the practice. Providers that currently have billing software with a mechanism for reporting the number of certain procedure codes that were billed during a specific period of time can easily estimate what their 2% incentive return will amount to.

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