ICD-10 “Gut Check” and New Opportunities to Bring Case Management Audits and Appeals In-House


ICD-10 implementation and a recent CMS decision create significant compliance, quality, and revenue opportunities for healthcare systems and providers in 2015, according to Michael T. Dougherty, Founder and Chief Executive Officer of Provident Consulting. These accelerate the national trend towards pay for quality and outcomes, he adds.

Dougherty explains the impact of the looming ICD-10 implementation on documentation standards and the nexus to value-based purchasing and quality.
How can healthcare executives be sure they are ready to meet the ICD-10 challenge?

With one year to go, all healthcare CFOs and CEOs should have a good idea of where they stand. That said, now is the time for an honest “gut check”. Critical risk areas are payer readiness, IT system vendor readiness, and clinical documentation training. The first two require tough-minded evaluation of payer and vendor representations, very tight testing plans, and contingency planning in case things go wrong.

Have the payers agreed to test with you?
Are they willing to work through denials on a test basis before go-live? In IT the big wild card is workflow regarding documentation. When will ICD-10 compliant systems be ready? How much time will you have to test the workflows and influence design and customization? We have worked with over 300 IT applications nationally and readiness is still a big concern.

You have talked about executives being ready for October 2, 2015? What do you mean?
Clinical Documentation training for clinicians and CDI Specialists should be well along by now and executives should be asking themselves: How do I support clinicians with documentation tools at the point of care after 10/1/15, especially if I am not satisfied with the workflows in my electronic medical records? Will our training assist with documentation for quality and value-based purchasing in 2015 and beyond? To help our clients deal with this we built DocEdge™ ICD-10. We isolated the most common, most complex, and highest impact documentation and coding challenges, and built clinical flow charts to show documenters, CDI specialists, and coders ICD-10 documentation standards and the concepts they will need for future reimbursement models. DocEdge™ is delivered at the point of care through any mobile device.

In today’s highly regulated healthcare system, what do healthcare organizations overlook that they should not?
There are several areas, but I think the new CMS settlement offer to resolve Patient Status appeals in exchange for a timely partial payment (68 percent of the net payable amount) is an opportunity for high impact cost reduction and quality improvement. Every system needs to analyze this offer on the merits and we are helping several to do this. I think the real opportunity here is to start from a zero baseline of appeals and apply continuous improvement principles and tools to build an effective best practice program. To help clients with this, we built Patient StatusEdge™. It allows hospitals to bring the patient status audit and appeals process in-house with automated workflows facilitating the production of well written, accurate and comprehensive appeals, and key metric reporting for effective program management. It is especially useful for reducing future denials because Appeals Managers can use Patient StatusEdge™ to identify and push continuous improvement training examples to Case Managers, Providers, and Coding staff, while the medical documentation is being reviewed for audits and appeals. This training is tracked to identify high impact areas and to identify individuals requiring more attention.

Any final words of advice?
Adopt a continuous improvement methodology where every time someone touches a clinical record, be it revenue and compliance audits, CDI and Case Management queries and referrals, or Physician Advisor actions, it results in actionable metrics and interventional training delivered as close to the point of care as possible. That approach will reduce errors, improve compliance, and ensure appropriate claims for reimbursement. We do this through our DocEdge™ suite but there are many approaches.

Interview by Sarin Kouyoumdjian-Gurunlian, Press Manager, marcus evans
For more information, please contact Laurel Zevitz at l.zevitz@marcusevansch.com