Washington Watch

Author: Carter Alleman, J.D.

ICD – 10 Starts October 1

The 10th revision of the International Classification of Diseases (ICD-10) takes effect on October 1. The transition from ICD-9 to ICD-10 affects surgeons because it expands the selection of diagnosis codes to 68,000 from 13,000 codes. In addition, the inpatient procedure code set has been increased to bring the entire set of new codes to 141,000. Since most of the information coders will use comes from the medical record, accurate and thorough documentation is crucial to ensuring a smooth transition.

The Centers for Medicare & Medicaid Services (CMS) released guidance in early July that will allow for flexibility in the claims auditing and quality reporting process as the medical community gains experience using the new ICD-10 code set. Specifically, CMS contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code, as long as the practitioner used a valid code from the right family, during a one-year grace period. CMS has established an ICD-10 ombudsman to help triage physician and provider issues. In certain circumstances, CMS may also make advance payments to providers if challenges arise during the ICD-10 grace period.

2016 Payment Adjustment for Improper PQRS Reporting

The Centers for Medicare & Medicaid Services (CMS) will apply a negative payment adjustment in 2016 for providers who did not satisfactorily report in the 2014 Physician Quality Reporting System. The negative adjustment applies to individual eligible professionals (EPs), EPs who provide services at a Critical Access Hospital that uses an optional payment method, and group practices participating through the group practice reporting option.

The 2016 PQRS payment adjustment letter sent to individual EPs includes a Tax Identification Number (TIN)/National Provider Identifier (NPI) combination. The adjustment applies only to the individual EP associated with the TIN/NPI noted in the letter and not the clinic or facility.

Providers who believe they have been incorrectly assessed in the 2016 PQRS negative payment adjustment may submit an informal review request until November 9 asking CMS to investigate the incentive eligibility and/or payment adjustment determination. CMS will issue a final decision within 90 days of the review request. Requests must be submitted electronically via the Quality Reporting Communication Support Page, under the Related Links section of the Physician and Other Health Care Professionals Quality Reporting.

Insurance Mergers Will Have a Large Impact

Potential blockbuster mergers involving four of the country's largest insurance companies would create marketplaces in up to 97 metropolitan areas across 17 states that exceed federal antitrust guidelines designed to preserve competition, according to an analysis released today by the American Medical Association (AMA). The proposed Anthem-Cigna merger would consolidate market power in 85 metropolitan markets in 13 states, including California, while the Aetna-Humana deal would significantly reduce competition in 15 cities across seven states, according to the AMA's analysis. Health care consolidation will be getting significant scrutiny on Capitol Hill in the coming months

Medicaid Expansion States See Biggest Dips in Uninsured

Arkansas and Kentucky continue to show the steepest drops in the uninsured rate in the country, according to the latest polling data from Gallup. The share of uninsured adults in Arkansas is down to 9.1 percent, compared to 22.5 percent prior to the full implementation of the Patient Protection and Affordable Care Act (PPACA). In Kentucky, the uninsured rate has fallen from 20.4 percent to 9 percent during the same time period. Three other states - Oregon, Rhode Island, and Washington - have seen decreases of more than 10 percentage points. All of those states have implemented the PPACA’s Medicaid expansion.

Possible Delay to Bundled Payments Program

House Committee on the Budget Chairman Tom Price is circulating a letter to colleagues asking CMS to delay the Jan. 1 start of the bundled payment program for hip and knee surgeries. The Comprehensive Care for Joint Replacements program, which is CMS' first mandatory bundled payment initiative, will involve more than 800 hospitals.

In his letter, Rep. Price asks CMS to respond to its rationale for the rulemaking. He states, “Given the fact that the proposed rule will not be finalized until almost the year's end, it will give physicians, hospitals and post-acute providers little or no time to prepare for this abrupt shift in payment for these high-volume procedures and the changes in care delivery that they will require.”

CMS proposed the Comprehensive Care for Joint Replacement Model (CCJR), a new episode-based payment model for lower extremity joint replacement (LEJR) that would apply to 75 Metropolitan Statistical Areas (MSA’s) for five years. The CCJR proposed payment model represents a significant change for beneficiaries and providers because it constitutes the first mandatory Medicare episode payment model promulgated under CMS’ Center for Medicare & Medicaid Innovation which was established under section 3021 of the PPACA.

The letter has bipartisan support and currently has more than 30 signatures.

Diagnostic Errors – IOM Report Released

The National Academies of Science, Engineering, and Medicine Institute of Medicine (IOM) released its follow up report to its 1999 report, "To Err is Human,” which launched the contemporary patient safety movement and quality measurement initiatives. IOM found that there are millions of diagnostic errors which could be prevented each year. The report is expected to become a hotly contentious issue with the development of new quality measurements.

IOM is recommending comprehensive malpractice reform, involving new efforts to come up with alternative dispute resolution and potential safe harbors for providers that adhere to clinical guidelines. The report also outlines the need for Medicare as well as private payers to overhaul compensation, so that physicians and other providers are adequately paid for the time and tasks it takes to get an accurate diagnosis, such as a thorough clinical history, interview and physical exam. Reforms might also include new reimbursement mechanisms for the time that pathologists and radiologists spend advising physicians or testing specific patients.

Repeal Restrictions on Savings Accounts

The House Committee on Ways and Means approved H.R. 1270, the “Restoring Access to Medication Act of 2015,” by voice vote on September 17. The bill, introduced by Representative Lynn Jenkins, R-Kansas and Ron Kind, D-Wisconsin, would repeal a provision in the PPACA that requires patients to obtain a prescription for over-the-counter medications in order to purchase them with a flexible spending account or a health savings account. Senators Pat Roberts, R-Kansas and Heidi Heitkamp, D-North Dakota, introduced companion legislation in the U.S. Senate. It is not yet known when the full House will consider this bill.