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Ordering Tests Without Using Words: Are ICD-10 and CPT Codes Bringing Precision or Dumbing Us Down?

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By HANS DUVEFELT, MD

The chest CT report was a bit worrisome. Henry had “pleural based masses” that had grown since his previous scan, which had been ordered by another doctor for unrelated reasons. But as Henry’s PCP, it had become my job to follow up on an emergency room doctor’s incidental finding. The radiologist recommended a PET scan to see if there was increased metabolic activity, which would mean the spots were likely cancerous.

So the head of radiology says this is needed. But I am the treating physician, so I have to put the order in. In my clunky EMR I search for an appropriate diagnostic code in situations like this. This software (Greenway) is not like Google; if you don’t search for exactly what the bureaucratic term is, but use clinical terms instead, it doesn’t suggest alternatives (unrelated everyday example – what a doctor calls a laceration is “open wound” in insurance speak but the computer doesn’t know they’re the same thing).

So here I am, trying to find the appropriate ICD-10 code to buy Henry a PET scan. Why can’t I find the diagnosis code I used to get the recent CT order in when I placed it, months ago? I cruise down the list of diagnoses in his EMR “chart”. There, I find every diagnosis that was ever entered. They are not listed alphabetically or chronologically. The list appears totally random, although perhaps the list is organized alphanumerically by ICD-10, although they are not not displayed in my search box, but that wouldn’t do me any good anyway since I don’t have more than five ICD-10 codes memorized.

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ICD-10: Rough Seas Ahead

By JAAN SIDOROV, MD

Have you heard of “ICD-10?”  In addition to the many requirements of the Affordable Care Act, this may turn out to be another big headache for insurers and providers.  According to CMS’ web site, under the authority granted to it under the 2003 Health Insurance Portability and Accountability Act (HIPAA), if you want to do business with Medicare or any other health insurer…

“ICD-10 codes must be used on all HIPAA transactions, including outpatient claims with dates of service, and inpatient claims with dates of discharge on and after October 1, 2013. Otherwise, your claims and other transactions may be rejected, and you will need to resubmit them with the ICD-10 codes. This could result in delays and may impact your reimbursements, so it is important to start now to prepare for the changeover to ICD-10 codes.”

Which is why the DMCB paid attention to this “Report from the Field” Health Affairs article “Coding Complexity: US Health Care Gets Ready For The Coming Of ICD-10.”

The Disease Management Care Blog was reminded that “International Classification of Disease” or “ICD” is an alphanumeric billing system used to specify and describe diseases and treatments.  Originally developed in 1763, it was adopted by the World Health Organization in 1948 for use in public health reporting.  It was later used by physicians, hospitals and health insurers to specify diagnosis coding and payment levels.  For example, persons with “diabetes” may think they saw a doctor for that particular disease, but as far as their insurer goes, they were really seen for “250.”Continue reading…

A Small EHR Vendor’s Emotional Open Letter to Users

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By HAYWARD ZWERLING, MD

flying cadeuciiOver the last few years, we have seen large EHR vendors purchase the moderate size EHR vendors, while moderate-size EHR vendors acquire smaller EHR vendors. We can expect to see a further decline in the number and diversity of EHRs as the IT mandates of Meaningful Use 2 and 3 are technically unachievable for all but the most well-endowed EHR vendors.

Along with the decreasing diversity of EHR options, an increasing number of physicians have lost the ability to choose the most important tool in their black-bag, their EHR, as many are now employed by large organizations which tell the physicians which EHR/HIT tools they are allowed to use.

If there was data that “Certified” EHRs, “Meaningful Use,” ICD10 and PQRS mandates had an impact on the cost or quality of healthcare which was commensurate with the IT costs and logistical disruptions, I would be the first to encourage physicians to use the new and proven technology. Unfortunately, we still do not know if “more” HIT is good for the healthcare system and society in general, or if it is only good for the IT industry.

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Death By Documentation

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DIKE DRUMMOND, MD

In my work with hundreds of over stressed and burned out physicians, one thing is constant. Documentation is always one of their biggest sources of stress.

In fact, if you ask the average working doctor to make a list of their top five stresses, documentation chores will take up three of the five slots.

1. EMR – especially if you use multiple EMR software programs that don’t talk to each other

2. Dealing with lab reports and refill requests

3. Returning patient and consultant calls and documenting them adequately and all the other places information streams have to be forced together by the sweat of your brow.

The average doc is walking the cliff edge of overload on a significant number of office days in any given month. Now comes ICD-10 and my biggest fear is the extra work of the new coding system will push many physicians over the edge into burnout.

How much more time will ICD-10 take?

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HIT Newser: Will Stage 3 Meaningful Use Be Delayed?

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By MICHELLE RONAN NOTEBOOM

CMS Releases Final Update to ACO Program

CMS releases a final rule updating the Medicare Shared Savings Program, which includes a new higher-risk, higher-reward Track 3 option; streamlines data sharing between CMS and ACOs; and adds a requirement that ACOs applying for the program describe how they will promote the use of health IT to boost care coordination.

Organizations Urge Stage 3 Delay

The AMA and MGMA join the AHA and CHIME in calling for a delay in finalizing Stage 3 Meaningful Use requirements. The current version is largely viewed as too burdensome for providers with the potential to impede the use of health IT to improve quality and efficiency.

Quite simply, Stage 3 will not be successful without provider buy-in. There have been delays before; look for another oneContinue reading…

HIT Newser: What’s the ICD-10 Contingency Plan?

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By MICHELLE RONAN NOTEBOOM

AMA: What’s the ICD-10 Contingency Plan?

The AMA and about 100 other physician groups urge CMS to develop an ICD-10 contingency plan in the event of a “catastrophic” backlog following the October 1 transition. The organizations want CMS to make public its plans to make advanced payments or reimbursements for services already rendered, work with ONC to ensure EHR systems are ICD-10 ready, and confirm contractors won’t audit for the correct code.

The silver lining here is that these organizations are (finally) not asking for a delay in implementing ICD-10. CMS apparently has drafted a contingency plan in the event of claims process disruptions but does not plan to make it public. In this age of more transparency, CMS needs to make the plan public – even though provider groups will surely find fault with the plan. But, isn’t it better to continue moving the conversation forward, just in case of there is a catastrophe?

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HIT Newser: The Not-So-Big Meaningful Use Stick

By MICHELLE RONAN NOTEBOOM

flying cadeuciiThis Year’s Meaningful Use “Sticks”: Not that Big

CMS reports that the majority of physicians who will be penalized this year for not having met MU requirements will lose less than $1,000 of their Medicare reimbursement; 34% of the penalties will be $250 or less, while 31% will exceed $2,000.

The adjustments will impact approximately 257,000 eligible providers. While no one likes losing money, the CMS penalty “stick” is pretty small compared to the overall cost of implementing an EHR.

Mayo Provides Dr. Google with 2nd Opinion

Google consults with the Mayo Clinic to expand its healthcare information for 400 medical conditions.

Given that 20% of all Google searches are related to health conditions, the change will no doubt shake up what Americans find when searching for medical information. The update includes the addition of illustrations for each condition, plus a full list of search results from sites such as WebMD and Wikipedia.

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HIT Newser: The CommonWell Alliance Gets More Common

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MICHELLE RONAN-NOTEBOOM

The CommonWell Alliance Gets More Common

Aprima and CareCloud join Allscripts, Cerner, McKesson, athenahealth, Greenway, and RelayHealth in the CommonWell Alliance, a nonprofit consortium of HIT vendors focused on fostering interoperability.

Coalition Says Stick to ICD-10 Schedule

CHIME, AHIMA, HFMA, and a dozen more industry organizations send a letter to Congressional leaders urging no further delays to the implementation of ICD-10.

CVS Health Ramps Up Digital Health Efforts

CVS Health will expand its efforts in digital healthcare with the opening of a 15,000 square foot innovation lab in Boston that will house up to 100 employees.

KLAS: NextGen Tops for RCM Services

KLAS names NextGen Healthcare the top provider of ambulatory 2014 RCM services in a report that ranks the best-performing HIT vendors for outsourced billing and RCM.

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Sometimes the Best Choice is the Simplest One

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By NICK VAN TERHEYDEN

Screen Shot 2014-09-07 at 7.53.02 PMCMS recently announced another change to health IT policy in order to offer healthcare providers greater flexibility. But what will the unintended consequences of this latest change be?

Over the Labor Day weekend, CMS announced that the Meaningful Use Stage 2 deadline will be extended through 2016 in order to offer more options and greater flexibility to providers for the certified use of EHRs.  In the interest of full disclosure, I found the timing to be strange— a rule published over a holiday weekend seems an odd choice, particularly when it is being touted as a benefit to the industry and the impact on healthcare provider organizations and clinicians, alike, is monumental.

Unfortunately, I think the additional flexibility allotted by this rule is the latest example of the unintended consequences of health IT regulations.  In an effort to make things easier and give healthcare providers more leeway, they have, in fact, made the situation unnecessarily more complex.

Agility is not healthcare’s strong suit

It seems at this point, too many options, or waffling between them (for instance the new ICD-10 transition deadline), can be more crippling than stringent regulations, particularly when there is so much on the line.  Healthcare organizations don’t have the wherewithal to vacillate with implementations; they are wrestling with string-tight budgets and constantly shifting rules require large cultural and behavioral changes.  As a result, as Dr. John Halamka noted, health IT agendas are being constantly hijacked by regulatory changes, such as Meaningful Use and ICD-10.

It now seems that hospital administrative teams and physicians again must endure constantly shifting rules that they’ve been coping with for years under Meaningful Use.  As Dr. Ben Kanter, former CMIO of Palomar Health, so astutely noted “A computer system is a tool, just as a scalpel is a tool.  What if a surgeon’s scalpel changed every few weeks?  How is it possible to deliver good care if the primary tool you are using keeps changing on an irregular basis?”Continue reading…

International Classification of Diseases Hampers the Use of Analytics to Improve Health Care

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By ANDY ORAM

andy oramThe health care field is in the grip of a standard that drains resources while infusing little back in return. Stuck in a paradigm that was defined in 1893 and never revised with regard for the promise offered by modern information processing, ICD symbolizes many of the fetters that keep the health industries from acting more intelligently and efficiently.

We are not going to escape the morass of ICD any time soon. As the “I” indicates in the title, the standard is an international one and the pace of change moves too slowly to be clocked.

In a period when hospitals are gasping to keep their heads above the surface of the water and need to invest in such improvements as analytics and standardized data exchange, the government has weighed them down with costs reaching hundreds of thousands of dollars, even millions just to upgrade from version 9 to 10 of ICD. An absurd appeal to Congress pushed the deadline back another year, penalizing the many institutions that had faithfully made the investment. But the problems of ICD will not be fixed by version 10, nor by version 11–they are fundamental to the committee’s disregard for the information needs of health institutions.

Disease is a multi-faceted and somewhat subjective topic. Among the aspects the health care providers must consider are these:

  • Disease may take years to pin down. At each visit, a person may be entering the doctor’s office with multiple competing diagnoses. Furthermore, each encounter may shift the balance of probability toward some diagnoses and away from others.
  • Disease evolves, sometimes in predictable ways. For instance, Parkinson’s and multiple sclerosis lead to various motor and speech problems that change over the decades.
  • Diseases are interrelated. For instance, obesity may be a factor in such different complaints as Type 2 diabetes and knee pain.

All these things have subtle impacts on treatment and–in the pay-for-value systems we are trying to institute in health care–should affect reimbursements. For instance, if we could run a program that tracked the shifting and coalescing interpretations that eventually lead to a patient’s definitive diagnosis, we might make the process take place much faster for future patients. But all a doctor can do currently is list conditions in a form such as:

E66.0 – Obesity due to excess calories

E11 – Type 2 diabetes mellitus

M25.562 – Pain in left knee

The tragedy is that today’s data analytics allow so much more sophistication in representing the ins and outs of disease.Take the issues of interrelations, for instance.

These are easy to visualize as graphs, a subject I covered recently.

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