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Guide to ICD-10 Transition: Steps for August


Physician practices have less than 75 days before the October 1 deadline to implement the ICD-10 code set. The AMA and CMS have put together a guide to ensure a seamless transition to ICD-10.

Still getting started?

If you’re still in the early stages of prepping your practice, spend the month testing your practice’s ICD-10 readiness and identify potential problems.

  • Perform content-based testing to assess your practice’s documentation and ability to code in ICD-10. In this type of testing, your practice uses documentation to code a clinical scenario in the new code set. The Healthcare Information and Management Systems Society offers resources to help your practice with this kind of testing.
  • Conduct internal testing to evaluate your practice’s ability to create and use ICD-10 codes throughout the patient work flow in place of when you currently use ICD-9 codes. This type of testing requires your practice to have system upgrades installed already and helps you follow the flow of a patient through a visit to identify the points at which codes are used. Use this testing to identify any gaps in your ICD-10 updates.
  • Do external testing to test your practice’s ability to send and receive transactions that use ICD-10 codes with your external trading partners, including your billing service, clearinghouse and payers. Check with these groups about their testing plans.

One type of external test is acknowledgement testing with Medicare, which simply acknowledges that a claim has been received. Physicians can perform acknowledgement testing with their Medicare Administrative Contractors and the Common Electronic Data Interchange contractor any time until the October 1 implementation date.

Already on your way?

Now is the time to prepare for possible disruptions in claims processing. While organized medicine (AMA, CMA, SFMS) have secured provisions and confirmed 1-year grace period from CMS to ease the transition to the new code set, physicians should still be ready, especially because private payers may not ease up their claims payment processes.

Make sure you have taken the most important steps to prevent cash flow interruptions. They are to ensure:

  • Your systems can accommodate the ICD-10 codes
  • Your staff is trained
  • You have tested thoroughly with your trading partners

If you’ve been following a solid transition plan, you should be well-prepared to handle any potential claims disruptions.

The provisions the AMA secured from CMS address claims denials, quality reporting penalties, payment disruptions and navigating transition problems. Click here to learn details of the agreement. 

Additional Resources

CMS will host a National Provider Call from on August 27, 2:30 pm to 4 pm EST (11:30 am to 1:00 pm PST). Experts will discuss coding guidance and tips, answer coding questions, and provide information about claims that span before and after the implementation date. Click here to register for the free call.

Click here to view CMS’ Road to 10 Guide implementation guide for solo/small group practices. 

CMS Increases Physician Payment by 0.5% in Medicare Physician Fee Schedule

The Centers for Medicare and Medicaid Services (CMS) recently released the 2016 proposed Medicare physician payment rule. The rule reflects the 0.5% increase in payment as of July 1, 2015, and the additional 0.5% increase in payment on January 1, 2016, recently adopted by Congress. Overall, Medicare will pay physicians nearly $700 million more in 2016 than they will have paid in 2015.

Most notable in the payment rule is CMS’ proposal to pay for advance care planning and end-of-life counseling. The fee schedule would establish two new codes to cover early conversations between patients and their physician about care options. These codes were recommended by the American Medical Association (AMA) Relative Value Scale Update Committee (RUC). The codes include discussion before an illness progresses and during the course of treatment so patients can make decisions about appropriate treatment for their personal situation. One code would cover the first 30 minutes and the other would cover additional 30-minute blocks of time. AMA, CMA, and SFMS have been pushing CMS to cover such services.

CMS is seeking comments on the 2019 implementation of the new Medicare payment systems recently adopted by Congress as part of the permanent repeal of the sustainable growth rate (SGR) formula. The agency also noted its strong support for promoting primary care services and is soliciting comments on potential coverage of collaborative care services and an expansion of the Comprehensive Primary Care initiative. The proposal also includes an expansion of payment for telehealth services mainly for in-home treatments for end-stage renal disease.

There are numerous changes to the relative values of services; many recommended by the AMA RUC. Most notably, payment for gastroenterology services will be reduced 5%, with colon and rectal surgery reduced by 1%. Organized medicine is fighting many of these changes.

Other notable provisions of the rule include:

  • Myriad changes to the Accountable Care Organization Shared-Savings program, the Physician Quality Reporting System (PQRS) and the value-based payment modifier, which will soon apply to all physicians who bill under a tax identification number.
  • CMS will no longer require physicians who opt out of the Medicare program to notify Medicare on an annual basis.
  • New appropriate use criteria for advanced diagnostic imaging mainly based on recommendations from the related specialty societies
  • Some new exceptions to physician self-referral laws.

The overall payment impact by specialty can be found on page 711 of the rule. Please note that these payments do not account for adjustments made by PQRS, the value-based payment modifier, or meaningful use.

CMS is also updating the Geographic Adjustment Factors for all localities nationwide. California will see increases of 0.1 to 0.3%. Please note that starting in 2017, California localities will move to Metropolitan Statistical Areas due to the CMA-sponsored geographic practice cost index legislation, with there will be larger payment increases to the urban counties currently within the "Rest of California" locality.

Physicians can use the Medicare Physician Fee Schedule (MPFS) look-up tool to find payment information for services covered by the MPFS.

Click here to access the MPFS look-up tool.

Click here to view the proposed rule.

Special Session on Medi-Cal Financing Underway in the Capitol

In June, Governor Jerry Brown convened a special legislative session on health care financing. Specifically, legislators will be working to come up with new funding for developmental disability services, in-home supportive services, and the Medi-Cal program, which is facing a shortfall of at least $1.1 billion through the loss of the managed care organization (MCO) tax.

Since 2005, the state has taxed MCOs and used the money to cover the costs of provider reimbursement. However, federal officials informed California in 2014 that its MCO tax structure was not compliant with new federal requirements. The loss of the MCO tax and the federal matching funds would mean the loss of over $2 billion for the Medi-Cal program.

The budget that Brown introduced in January proposed a new MCO tax that would conform to the new federal requirements, but health plans objected to the new tax and the legislature failed to adopt the proposal.

The special session will look at sources of funding, from another MCO tax to alternative sources. Legislators will also tackle other issues, including:

  • How to restore cuts made to Medi-Cal provider reimbursement rates.
  • How to finance the Medi-Cal program when the state must begin paying in 2017 for 10% of Medi-Cal enrollees who are “newly eligible” under the Affordable Care Act.
  • How to pay for a court-ordered restoration of a 7% cut in In-Home Supportive Service rates.

The special sessions began in June with informational hearings, but the hard work isn’t expected to begin until late August after the summer recess. SFMS and CMA continue to work with its legislative allies and coalitions to push the issue of reimbursement rates and patient access over the finish line.

Medi-Cal currently covers approximately one-third of the population of the state of California, 12.3 million people. California has ranked among the bottom three states in the nation for Medicaid reimbursements since 2011. Low reimbursement rates have forced many of California’s providers to stop seeing Medi-Cal patients. As a result, more than half of Medi-Cal patients report difficulty finding a doctor. SFMS and CMA, along with We Care for California coalition partners, are committed to ensuring that Medi-Cal is not a broken promise of access to care for millions of Californians.

SFGH to Host 50th Anniversary of Medicare and Medicaid Celebration

This summer, the Centers for Medicare & Medicaid Services (CMS) will recognize ways in which Medicare and Medicaid have transformed the nation’s health care system over the past five decades. As we mark the 50th anniversary of Medicare and Medicaid, we are reminded of the critical role these programs play in protecting the health and well-being of millions of families and improving America’s economic security. These are life changing programs that keep Americans healthy.

To commemorate the anniversary, CMS Region IX, Health and Human Services, and San Francisco General Hospital and Trauma Center are hosting an event from 10:00-11:30 am on July 30, exactly 50 years from the day President Johnson signed the Social Security Amendments of 1965 into law. The event will feature remarks from health care experts about how Medicare and Medicaid continue to build a health care system that is better, smarter, and healthier.

Keeping US Healthy for 50 Years
Thursday, July 30
10:00 am – 11:30 am
Carr Auditorium, San Francisco General Hospital

Roland Pickens, Director of the San Francisco Health Network, and Interim CEO of SFGH will make introductory remarks and Dr. Edgar Pierluissi, Medical Director of the hospital’s Acute Care for Elders Unit will be a panelist. The keynote speaker will be Dr. Sandra Hernandez, President and CEO of the California HealthCare Foundation and former SFDPH Director.

The event is open and free with advanced registration.

Click here to RSVP by July 23.

Join the medical community to celebrate this historic anniversary!

Package of Tobacco Bills Reintroduced to Raise Smoking Age, Regulate e-Cigarettes

California lawmakers reintroduced a package of six tobacco bills this week to fight the No. 1 cause of preventable death in California: tobacco use.

The bills will be taken up during the second extraordinary session, called by Governor Jerry Brown to address health care. The package of bills was introduced by Democratic lawmakers in both the Assembly and state Senate, and includes:

  • SB 5 (Leno) / AB 6 (Cooper) add e-cigarettes to existing tobacco products definition. This bill addresses growing public health concerns about the unregulated use of electronic cigarettes (e-cigarettes) in California. It includes e-cigarettes within the existing tobacco products definition, thereby restricting the use of e-cigarettes in the same locations as traditional cigarettes. It will also increase the penalties and enforcement options for selling e-cigarettes to minors and require e-cigarette retailers to be licensed.
  • SB 6 (Monning) / AB 7 (Stone) close loopholes in smoke-free workplace laws, including hotel lobbies, small businesses, break rooms, and tobacco retailers.
  • SB 7 (Hernandez) / AB 8 (Wood) increase age of sale for tobacco products to 21. It is estimated that 90%  of tobacco users start prior to age 21, and 80% of lifetime users start before the age of 18. By increasing the minimum legal age to 21, this bill intends to prevent or severely restrict youth access to these highly addictive and deadly products.
  • SB 8 (Liu) / AB 9 (Thurmond and Nazarian) require all schools to be tobacco free. This bill is aimed at reducing smoking prevalence among youth in California schools. Currently, only school districts and county offices of education that receive Proposition 99 Tobacco tax funding are required to adopt and enforce a tobacco-free campus policy. This bill would close that gap by requiring that all districts adopt 100% tobacco-free policies.
  • SB 9 (McGuire) / AB 10 (Bloom) allow local jurisdictions to tax tobacco. This bill would allow counties to levy taxes on tobacco distributers.
  • SB 10 (Beall) / AB 11 (Nazarian) establish an annual Board of Equalization (BOE) tobacco licensing fee program.

SFMS and CMA join our Save Lives California coalition partners to applaud California legislators spearheading legislation to keep tobacco out of the hands of our youth and increase the overall health and wellness of Californians. Smoking contributes directly to heart disease and stroke, the number 1 and number 5 leading causes of death for Californians. The passage of this package of bills will have an immediate, life-saving impact by reducing the number one preventable cause of pre-mature death and disability.

Save Lives California is a coalition of doctors, dentists, health plans, labor, and non-profit health advocate organizations, including American Cancer Society Cancer Action Network, American Heart Association Western States Affiliate, American Lung Association, California Dental Association.

Click here for more information about Save Lives California.

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