Timothy Meakem, MD, the medical director of ProVation Medical, recently gave a webinar presentation titled "Utilizing Procedure Documentation to Overcome the Challenges of ICD-10 and RAC." ProVation Medical is a Wolters Kluwer Health documentation and clinical decision support solutions company serving the healthcare industry.
Dr. Meakem explained the importance of discussing documentation and coding in the current healthcare climate. "The bottom line of proper documentation and coding is retaining control of payment. Through proper documentation and coding, physicians can control the care given to their patients," he said. Dr. Meakem analyzed the challenges presented by ICD-10, Recovery Audit Programs and Medicare Administrative Contractors and illustrated the ways in which proper documentation and coding can help overcome these issues.
"The pressure is intensifying on physicians to deliver more comprehensive, tightly structured clinical documentation," said Dr. Meakem ICD-10, RAC and MACs are the three largest factors driving the focus on documentation. All of these things have the potential to have a negative impact on a surgery center's revenue cycle.
CMS has made it clear that the Oct. 1, 2014 deadline for ICD-10 implementation is here to stay. ICD-9 has 17,000 codes, while ICD-10 has nearly 155,000 codes, an 800 percent increase. It is clear that ICD-9 will seem ambiguous in comparison. Co-morbidities, manifestations, etiology/causation and complications will all have to be carefully documented. The key issue to master first is documentation. "If you don't have the right specificity in your documentation, you will never get the right code. Without the right documentation, even the best coders won't be able to do their jobs," said Dr. Meakem.
RAC has collected a total of $3.9 billion in overpayments since October 2009. The leading reason for this is insufficient documentation to support services. RAC is also expanding. MACs are building more and more focus on what is and is not appropriate. "The appropriate documentation is the bottom line. Without it, physicians won't get paid for the cases they are doing," said Dr. Meakem.
One of the most effective responses to these challenges is the leveraging of automation. Automation can effectively and efficiently help streamline the process of clinical documentation and by extension the process of coding. "Better clinical documentation leads to payment reliability and can make ICD-10, RAC and MACs non-issues," said Dr. Meakem.
Automation is important, but in order to be effective the right system must be selected. The optimal system will ensure that the specified medical findings correspond to the codes that are submitted, guide users through the documentation process, flag specific data for inclusion and provide updates as regulations change.
An effective system also offers surgery center administrators additional benefits. Duplicate data entry is eliminated. It improves productivity by allowing resources to be refocused on core responsibilities, rather than resubmitting information.
Once such a system is in place at a surgery center, there is little to do other than to review the system every one to three years to ensure that it continues to meet the center's needs. "You will spend time and money to get this system, but once you have it you won't have to worry about it again," Dr. Meakem indicated. He also discussed the alternative, "If you do not get an effective system you will be at risk for RAC and MAC audits and coding changes. You will have to manage all documentation changes and implement a system to capture the requirements. The net result is that you will be constantly concerned with these issues.”
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