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

For the past few weeks, my inbox has been flooded with a wave of literature focused on the upcoming conversion to the ICD-10 coding system. In almost every instance, the subject line has an extremely serious message such as “don’t be left behind” or “avoid delays in claims processing.” While I am typically an advocate for preparation and being a “go to” person, I do not see the benefit in a health care practice’s extremely early study and implementation of the ICD-10 coding system. The CMS mandated conversion date is three years away (currently set for October 1, 2013) and the entire health care industry currently uses ICD-9.

To date claims processors, insurance carriers, billing and coding programs, electronic health records systems - not to mention Medicare and Medicaid - have not yet converted to ICD-10 and are not prepared to support, receive and/or process medical bills coded to ICD-10. Furthermore, a health care practice will be hard-pressed to find a billing and coding program or an EHR system that fully supports ICD-10. 

The alarm surrounding the conversion to ICD-10 is reminiscent of the alarm surrounding the health care industry’s conversion to electronic claims processing a few years back. The similarity exists in that whether or not a practice is ready to implement a new system, namely, electronic claims processing or ICD-10 coding, the practice’s unilateral implementation is useless until processors, carriers and payors are ready to interface with the new system. The lesson learned is that the health care industry, as a whole, needs to jump on board with this type of massive system overhaul. Once the industry is ready for conversion, there will be a plethora of information, training, demonstrations and hassle for the taking.

For more information on the implementation date, logistics and so forth, see the dedicated ICD-10 page on the CMS website.

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After a recent post discussing preparation and maintenance of medical records, I received several requests for further information regarding the 1995 and 1997 Documentation Guidelines for Evaluation and Management (“E/M”) Services that I briefly discussed.

The 1995 guidelines are applicable to: (a) all medical and surgical services and (b) in all settings. The 1997 guidelines, in addition to incorporating the 1995 guidelines, focus on specialists and outline each component of a typical E/M service. The following is an outline of the general principles that health care practices must adhere to when structuring medical records in accordance with the 1995 and 1997 guidelines.

1. The medical record should be complete and legible.

2. The documentation of each patient encounter should include:

·        reason for the encounter and relevant history, physical examination findings and prior diagnostic test results;

·        assessment, clinical impression or diagnosis;

·        plan for care; and

·        date and legible identity of the observer.

3. If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred.

4. Past and present diagnoses should be accessible to the treating and/or consulting physician.

5. Appropriate health risk factors should be identified.

6. The patient's progress, response to and changes in treatment, and revision of diagnosis should be documented.

7. The CPT and ICD-9-CM codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record.

The CMS website has further information regarding the 1995 (pdf) and 1997 (pdf) guidelines.

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