Quality Measures Resource Guide: Our New Future With ICD-10-CM

Well, after just a few weeks of living with ICD-10-CM, I’m sure some to most of us in the industry are befuddled, confused, irritated, and/or maligned due to the coding changes implemented Oct.1. As much as this is to be expected, I want to discuss how ICD-10 can help us in the future, even if we don’t want to go through the growing pains now.

With the death of ICD-9 here in the United States, we are now at even-par level with our colleagues around the world as far as diagnosis coding. Is it really that important for 99.9999 percent of us to know the ICD-10 code for “injury from manned spacecraft”? No, not really. However, it is important to know that E11.xxx might be the difference between payment for a diabetic foot ulcer and not getting payment. 

I alone have gone from about 72 diagnosis codes as a podiatrist wound care specialist in my own practice to about 300 codes. Obviously, the codes that affect me most are fracture, trauma, and sprain coding, which in essence is about 250 pages (I’m exaggerating of course) of the new ICD-10 manual.  As I went through the training courses and online tutorials, I actually gained a lot of respect for the coding system as a whole.

For example, under ICD-9, there was no anatomic relationship to tell the payers what part of the limb I was working on. It was generic. Providers can code “LT” or “RT,” but as far as telling them which specific anatomic area, we could not code the anatomic sites correctly. In essence, we have to perform numerous multilevel appeals and undergo extended wait times to be reimbursed for services performed. 

Now, under ICD-10, we as providers can at least tell “the story” of the patient encounter through the diagnosis code sets to explain everything.  This includes patients’ body mass index and other comorbidities that I (and we) did not previously have room to report under ICD-9. This new ability to tell the story of each encounter allows some leeway with the provider/insurer relationship that, in truth, is more open and terrifying at the same time.

Why do I think this is terrifying, you may wonder? Well, now the payer(s) get to see exactly as to how we code. There is no more justification as to maybe what we do anymore. It is definitive. Also, the payers get to see patterns of care and treatment per each provider. This will eventually lead to the Merit-Based Payment Incentive System (MIPS), a new program in the Medicare fee-for-service payment system that consolidates three existing programs — Meaningful Use, Physician Quality Reporting System (PQRS), and Value-Based Payment Modifier (VBPM) — into a single program.

MIPS will assess individual physician performance in four categories to generate a composite score on a point scale ranging from 0-100. The categories are:

1. quality,

2. resource use,

3. Meaningful use of certified electronic health record technology, and

4. clinical practice improvement activities.

Beginning in 2019, physicians participating in the MIPS will be eligible for positive or negative Medicare payment adjustments that start at four percent and gradually increase to nine percent for 2022.

The threshold for these payment adjustments will be the mean composite score for all MIPS-eligible professionals during the previous performance period. Distribution of payment adjustments will follow a bell-shaped curve:       

A. Physicians who score at the threshold (ie, earn the mean composite score) will receive no payment adjustment.

B. Physicians whose composite score is above the mean will receive a positive payment adjustment on each claim for the following year.

C. Physicians whose composite score is below the mean will receive a negative payment adjustment on each claim for the following year.

Physicians with high composite scores will be eligible for a positive payment adjustment that is up to three times the baseline positive payment adjustment for a given year. For example, the baseline positive payment adjustment for 2019 will be four percent. So, high performers will be eligible for a positive payment adjustment of up to 12 percent. For 2019-24, an additional positive payment adjustment of up to 10 percent will be available to exceptional performers. Beginning in 2026, all physicians participating in the MIPS will be eligible for a 0.25 percent increase in their payments each year. The Medicare Access of CHIP Reallocation Act of 2015 allocates $100 million for the U.S. Department of Health and Human Services to support organizations (eg, quality-improvement organizations, regional extension centers) that provide technical assistance to practices with 15 or fewer eligible professionals participating in an alternative payment model or the MIPS. Priority will be given to practices in rural areas, health professional shortage areas, and medically underserved areas, as well as to practices with low composite scores. The allocated money will not fund changes at the individual practice level.

So, in a nutshell, life gets more difficult. But it is not so burdensome that, as well-informed and educated providers, we can’t overcome all these new administrative and governmental regulations to still provide proper care for our patient populations.

This resource guide is made possible through the support of Hollister Inc., Libertyville, IL. The statements made within are not connected to any officials or providers affiliated with the company.

Eric J. Lullove is a staff physician at West Boca Center for Wound Healing, Boca Raton, FL; serves on the healthcare policy committee of the Association for the Advancement of Wound Care; and is the AAWC liaison to the Alliance for Wound Care Stakeholders. He also serves as a consultant for Hollister Wound Care, Medline Industries Inc., and ABL Medical.)