January 10, 2014 Home|Journals & Publications|  AGA AGA Quarterly: Practice
AGA Quarterly: Practice

ICD-10 | Practice Management | Coding | Policy | Coverage


Get Ready: ICD-10 is Y2K for Medical Practices

By Lawrence R. Kosinski, MD, MBA, AGAF, FACG

2014 will be a pivotal year as many EMR vendors will need to update their software to be ICD-10 and Meaningful Use Stage 2 compliant. This will be akin to Y2K as EMR vendors are taking this opportunity to enhance their interfaces. It also means implementation and training issues! AGA is here to help.

On Dec. 13, AGA hosted “The Impact of ICD-10: What’s In Store” webinar, presented by Rhonda Buckholtz, CPC, vice president of ICD-10 education and training at the American Association of Professional Coders. Ms. Buckholtz covered the changes in the transition to ICD-10, emphasizing where gastroenterologists should focus their immediate attention so that you will be compliant by the Oct. 1, 2014, deadline. You can watch the webinar on AGA's website and read an article in this newsletter about how to assess your readiness for the transition.

My practice recently assessed our situation and realized that, in addition to what we need to focus on for ICD-10, we will need to upgrade our EMR software and possibly hardware as well. Here's a gantt chart that details the timeline we have created at Illinois Gastroenterology Group for the ICD-10 implementation process. As you can see, there are hardware upgrades, software upgrades, license upgrades, and training and testing issues in order for our group to transition to ICD-10. Some are done in series, but others must be accomplished in parallel.

[click chart to download]

Oct. 1, 2014, will be upon us sooner than we anticipate. The time to prepare is now:

  • Speak with your EMR vendor and ask when the software will be available for implementation.
  • Find out if your current hardware is adequate for the upgrade.
  • Determine if other software applications, such as SLQ Server licenses, will need upgrading.
  • Prepare a timeline to make sure you are going to be ready to upgrade and prepare for the ICD-10 transition.

There will also be a session at DDW® 2014 on this transition — but you can’t wait. You have to begin the process now. Vist AGA’s ICD-10 Center for more information, including translation guides for the top 50 most used GI-related diagnostic codes.


Steps to Assess ICD-10 Readiness

By Rhonda Buckholtz, CPC, vice president of ICD-10 education and training, American Association of Professional Coders

With an ICD-10 implementation deadline of Oct. 1, 2014, GIs need to begin preparing now to be ready. Clinical documentation improvement is a crucial step in preparing for ICD-10. Providers will need help getting their chart documentation ready to support the new level of specificity in ICD-10. If you randomly pull charts and assess the diagnosis documentation, you could get multiple different diagnoses that cover multiple different guideline issues in ICD-10. Struggling to cover too many things at once would make it difficult and frustrating to discuss with a provider. Where do you start?

First, run a report in your computer system and sort it by diagnosis code. Next, start with your top 10 and run another report listing patients who had those diagnoses appended to them. Pull 10 to 20 charts with your most commonly used diagnosis code. Review the ICD-10-CM guidelines (if there are any) for the chapter in which the diagnosis is located. Then, review the notes for diagnosis ONLY. Look at the history and the assessment, and code them under ICD-10-CM. Put together a report based on the diagnosis:

  • How many notes could be coded under ICD-10-CM?
  • How many notes need more specific information to code?
  • How many notes had to be coded to an unspecified code?

Take these findings to each provider and review them to show the specificity in ICD-10-CM and what is needed in the documentation to support the diagnosis. Go through all of the notes and answer all questions. Depending on how well the provider did on the assessment, you may either perform another assessment on the same diagnosis, or move on to the next diagnosis on your "top 10" list. The facility/office should have a target percentage for the assessments that all providers should meet. Reports should be kept on each assessment to show progression of the providers.

Once the assessments begin, they should continue until the implementation date of Oct. 1, 2014. How often they occur depends on the number of providers you have, the number of different specialties, the type of specialties and how the providers perform. When we start to officially use the code set, these assessments should become part of the regular audit process.


How to Manage ACO Exclusivity Requirements

By Lawrence R. Kosinski, MD, MBA, AGAF, FACG

Does your GI group provide services at multiple hospitals? Do the hospitals belong to different Medicare accountable care organizations (ACOs)? Is your practice at risk from the exclusivity requirements of ACOs? What do you need to do to preserve participation in multiple ACOs, while preserving your Physician Quality Reporting System (PQRS) participation (and avoiding the Medicare withhold for non-participation)?

There is a common misconception that only primary care physicians (PCPs) are required to be exclusive to a single ACO. This is not true. A recent CMS update clarifies that if a group practice bills Medicare for services under any of the billing codes that fall within the definition of “primary care services,” the taxpayer identification number (TIN) of the group is not allowed to appear on the participant list for multiple ACOs. Since these services include all of the E&M codes, specialists and your midlevels will generally be precluded from participation in multiple ACOs if you are billing E&M codes.

In addition, ACO participation affects your PQRS participation. CMS has clarified that if a group operates under one TIN and any of the physicians in the group are contracted with an ACO, then your PQRS will be reported through the ACO rather than through your practice. This means that the ACO must qualify as an entity. As long as the ACO is compliant, all of the doctors in your group who participated in PQRS will get credit for participating, but the PQRS gets reported through the ACO. By participating in the ACO, you avoid the penalty for not reporting PQRS, but you still should participate in and report your PQRS on your own.

What should the GI group do if there are multiple hospital systems/multiple ACOs involving the physicians in your group?

CMS indicates that physicians and their practice entities have substantial flexibility to avoid the exclusivity restrictions by affiliating with ACOs as “other entities,” rather than as ACO participants. Rights and obligations of the “other entities” do not appear on lists of ACO participants, do not qualify for PQRS incentives and are not included in determining beneficiary assignment to ACOs, but are required to agree to comply with the Medicare Shared Savings Program (MSSP) rules and may be entitled to share in savings relating the ACO’s participation in the MSSP. This will likely require negotiation with the ACO as they will likely not initially want to allow you to participate under this option. Since all specialists should be in the same situation, you should be able to prevail if you act as a group.

Another option is for the group to report using multiple TINs. This may raise Stark issues in your practice depending upon how you are sharing revenue from sources such as pathology. It also raises significant operational issues. However, this may be your only option if your ACO does not allow for you to participate under “other entities.”

Save the Date!

Mark your calendar for GI Outlook 2014, the practice management conference, presented by ASGE and AGA. The meeting will take place Aug. 1–3, 2014, at the JW Marriott Washington, D.C.


CPT® Coding Changes for 2014

AGA, ACG and ASGE work closely together to ensure that members are made aware of, and prepared for, coding and reimbursement related changes occurring each year. For 2014, there were more than 50 changes to Current Procedural Terminology® (CPT) codes for gastroenterology services, impacting esophagoscopy, EGD, ERCP and esophageal dilation procedures. Changes for additional GI endoscopy services are anticipated in 2015.

The society advisors continuously work through the AMA process to revise and add new codes as appropriate. Please review the 2014 CPT Coding Updates Manual developed by the societies.

Additionally, AGA has developed a quick reference guide for upper GI endoscopy coding for 2014.

Revision to NCCI Manual

Effective Jan. 1, 2014, the National Correct Coding Initiative (NCCI) manual will allow reporting of CPT code 43247 (upper gastrointestinal endoscopic removal of foreign body) for removal of a foreign body, object or device which is entirely within the lumen of the gastrointestinal tract and cannot be removed except by endoscopic approach, such as an endoscopic luminal stent or a capsule endoscope that is retained in the stomach and unable to pass through the pyloris. Previously, the NCCI manual stated that 43247 should not be reported for routine removal of previously placed therapeutic devices. AGA, along with ACG and ASGE, requested the change to allow gastroenterologists to report 43247 in appropriate circumstances.

Coding Q&A

Answers by AGA’s coding and billing specialist Kathy Mueller, RN, CPC, CCS-P, CMSCS, PCS, CCC

Question 1: Is it true that colonoscopy cost sharing was eliminated for privately insured patients?

Answer 1: On Feb. 25, 2013, after pressure from AGA and other organizations, the federal government issued an important clarification regarding preventative screening benefits under the Affordable Care Act (ACA). Patients with private insurance will no longer be liable for cost sharing when a pre-cancerous colon polyp is removed during a screening colonoscopy. This ensures that colorectal cancer screening is available to privately insured patients at no additional cost, which was the intent of the new health-care law. Patients with Medicare coverage must still pay a co-insurance when a polyp is removed as a result of the screening colonoscopy, but their deductibles are waived. There are “grandfathered” plans that are exempt from the ACA. When performing preauthorization and eligibility/predetermination, it is recommended that staff members ask if this is a “grandfathered plan.” If so, the patient does need to be informed that there most likely will be “cost sharing” and potential patient responsibility should be discussed at the time of scheduling.

Question 2: What age does Medicare stop covering average risk screening colonoscopies?

Answer 2: Average risk screenings are limited to those between the ages of 50 and 75. This is reflected in the PQRS measure 113. High risk screenings do not have age limitations.

Question 3: My physician states that the submucosal injection code, 43236, has been unbundled. Is this true and how do I correctly bill?

Answer 3: Yes, there was a NCCI edit change on code 43236 (upper GI endoscopy with submucosal injection). It was bundled with any endoscopic procedure in the upper GI tract. Effective Oct. 1, 2013, 43236 can be billed in conjunction with 43251 (EGD with snare). The combination of submucosal injection and snare is often used for the excision of larger lesions. This change is retroactive to Jan. 1, 2013. Practices should run a report on code 43251 to see if 43236 could be billed. The ability to go back and bill this code will be dependent upon the payor’s timely filing limits.


How the PFS Final Rule Will Impact Your Practice

On Nov. 27, CMS released the calendar year (CY) 2014 Physician Fee Schedule (PFS) Final Rule, and the CY2014 Hospital Outpatient Prospective Payment System (HOPPS)/Ambulatory Surgical Center (ASC) Final Rule. AGA has drafted a brief summary of the rules for members.

AGA, ACG and ASGE were extremely disappointed in CMS’ reimbursement rates for GI endoscopy services in the final rule. The societies have prepared a payment analysis for GI codes and other procedures of interest to gastroenterologists under the Medicare physician fee schedule, which demonstrates the impact these drastic cuts may have on our practices and patients. In the coming weeks, the societies will be exploring all options to mitigate these cuts, including approaching CMS with our concerns regarding its final determination of RVUs for GI endoscopy procedures in the final rule.

Additional information on the final rule will be posted on our website. In the meantime, questions should be directed to Elizabeth Wolf, AGA's director of regulatory affairs, at 240-482-3223 or ewolf@gastro.org.

The Impact of Changing Policies on Physician Reimbursement

AGA is hosting a free webinar on Monday, Feb. 10, 2014, at noon ET, to keep members abreast of new health-care policies — PQRS, meaningful use, the value-based payment modifier — and their impact on physician reimbursement. The webinar will be led by Peter S. Margolis, MD, chair-elect of the AGA Regulatory Work Group. 

Register Now


Pharmacy Benefit Coverage Changes

As of Jan. 1, 2014, there are several prescribed medications that are no longer covered under UnitedHealthcare. Because of these changes, you may need to change prescriptions or switch to alternative medications.

The UnitedHealth Group National Pharmacy and Therapeutics Committee determined that select mesalamine, pancrealipase and H. pylori medications are therapeutically equivalent to medications they cover, meaning they provide essentially the same therapeutic outcome and adverse event profile.

For more information, please review the full notification letter and details

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