No Penalties for PQRS ICD-10 in 2016 Reports

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No Penalties for PQRS ICD-10 in 2016 Reports

Good news for providers struggling with ICD-10: the Centers for Medicare & Medicaid Services will not apply 2017 or 2018 payment adjustments to any eligible professional or group practice that fails to satisfactorily report certain quality data to the Physician Quality Reporting System, because of the impact of the ICD-10 update.

“CMS has examined impact to quality measures and has determined that the ICD-10 code updates will impact CMS’s ability to process data reported on certain quality measures for the 4th quarter of CY 2016. Therefore, CMS will not apply the 2017 or 2018 PQRS payment adjustments, as applicable, to any EP or group practice that fails to satisfactorily report for CY 2016 solely as a result of the impact of ICD-10 code updates on quality data reported for the 4th quarter of CY 2016,” the CMS said in a statement.

Also, the Value Modifier program will consider solo practitioners and groups, who meet reporting requirements in order to avoid PQRS payment adjustment to be “Category 1,” which means they will not receive downward adjustment on under the Value Modifier Program.

Even though the penalties are being waived, optimizing clinical workflow for ICD-10 will prepare you for when penalties do apply. Let’s look at some best practices and see how PrognoCIS can aid you with ICD-10 coding.

Best Practices for ICD-10 Implementation

  1. Reexamine clinical processes related to ICD-10 codes: Look at all workflow associated with ICD-10 coding by reviewing reports on the top ICD-10 codes used, in particular, look at ones which may be unspecific and may cause penalties due later on. Analyze diagnosis codes by both clinician and biller to see if there are any trends in coding which may be ambiguous.Also, look at clinical documentation. Christine Lee of the American Health Information Management Association, points out it’s important to review documentation:
    • If more specific diagnosis codes can be assigned based on the documentation, provide education to the appropriate staff on proper code assignment
    • If documentation is not complete for desired level of diagnosis specificity, provide clinical documentation improvement education to clinicians.

    While it may be ok to enter unspecified ICD-10 CM codes now it may not be in the future. Practices who submit unspecified codes after 2018 may be subject to audits and penalties.

  2. Use an EHR that has claims processing in mind: A great EHR offers a user interface which allows you to search for ICD-10 codes easily, and save the most used codes. PrognoCIS is a Meaningful Use certified and ICD-10 compliant solution designed to help billers process claims quickly. An EHR must have internal scrubber checks, which “clean” your claims before they are sent to the clearinghouse. Scrubber checks are checkpoints a biller can create to ensure claims are processed correctly. Billers create a procedure where “checks” are created so information is valid before you can move on. I illustrate a simple example of a scrubber check in PrognoCIS which stops a biller from processing a claim unless it meets the requirements:

    PrognoCIS Scrubber Check
    PrognoCIS Scrubber Check
  3.  Use an integrated electronic health record (EHR) and practice management software (PMS) system: An integrated EMR/PMS system promotes interoperability and benefits everyone in the claims pipeline. Features like a toggle-able single-touch screen in PrognoCIS to switch between EMR/PMS, gives billers all the information required to process claims quickly and accurately. In addition, if the EHR has dedicated RCM staff to handle claims, it ensures that claims are as accurate as possible. Billers are then familiar with both the EHR and PMS side of the software, which equal zero time for training or implementation.  Read more about the benefits of an integrated EMR/PMS system here.

PrognoCIS and ICD-10 in the Future

The CMS will continue to regularly update ICD-10 coding, so it’s important to be prepared for what’s to come to ahead. Utilizing an EHR thoroughly prepared for ICD-10 updates may help you keep payment adjustments positive. Clients of PrognoCIS have seen great benefits with the new ICD-10 coding, as providers using PrognoCIS medical billing software and revenue cycle management are having fewer claims rejected and are able to quickly receive more payments. Many coding-specific factors of PrognoCIS have contributed to this improvement, including:

  • Well-designed improvement of the user interface to accommodate frequently used codes
  • Quick and accurate access to the new codes as provided by the “drill down” features
  • Preparation of customers through PrognoCIS training webinars
  • A thoroughly pre-tested EHR and related systems infrastructure

Quality reporting through PQRS will come to an end when MACRA and MIPS become the new standard. For the 2017 performance period, CMS will publish an addendum containing updates relevant to the ICD-10 value sets for eCQMs (electronic clinical quality measures) in the Merit-based Incentive Payment System Program (MIPS). CMS will provide additional information on the addendum later this year. Check out our ICD-10 Blog Archive, and stay tuned for more updates.