The AAFP is fighting to protect family physicians from untended consequences that could occur when the ICD-10 code set for outpatient diagnostic coding is implemented nationwide on Oct. 1.
Specifically, as spelled out in two separate letters, the AAFP expressed concern about ICD-10 fallout with regards to Physician Quality Reporting System (PQRS) claims-based reporting and the work of CMS' recovery audit contractors (RACs) to identify and recoup Medicare overpayments to physicians.
In a June 16 letter(1 page PDF) to CMS Deputy Administrator and Center for Medicare Director Sean Cavanaugh, the AAFP demanded assurances that Medicare administrative contractors (MACs) would be able to handle the coming tsunami of new diagnosis codes and that "no family physician will be penalized financially by a MAC's failure to do so."
ICD-10 increases the number of codes from about 13,000 to more than 68,000, and the deadline for the switchover falls smack in the middle of 2015 PQRS reporting, said AAFP Board Chair Reid Blackwelder, M.D., of Kingsport, Tenn. And claims-based reporting is the most common method employed by family physicians, he added.
- The AAFP recently fired off letters to HHS and CMS highlighting concerns about unintended consequences associated with the Oct. 1 implementation of ICD-10 that could unfairly penalize family physicians.
- In a June 16 letter to CMS, AAFP Board Chair Reid Blackwelder, M.D., asked for assurances that CMS' Medicare administrative contractors would be able to successfully aggregate physician claims associated with the Physician Quality Reporting System.
- A June 17 letter to HHS highlighted the AAFP's apprehension about the combined effect of a steep ICD-10 learning curve among physicians and efforts by CMS' recovery audit contractors to recoup Medicare overpayments.
Unfortunately, many of the PQRS measures on which family physicians will report use diagnosis codes to help identify patients who are included in the measures' denominators.
"For such measures, that means the diagnosis codes … will change during the course of the reporting period," said Blackwelder.
Concerned about this "midstream change," Blackwelder questioned MACs' ability to successfully aggregate claims with dates of service before and after Oct. 1 and to "accurately capture and reflect the totality of a physician's PQRS performance on the measures he or she has chosen."
The issue could hold significant financial consequences for physicians because if MACs fail in this task, CMS would penalize physicians with lower Medicare payments in 2017, said Blackwelder. And those penalties would be based on physicians' level of success in two separate programs: PQRS and the value-based payment modifier initiative that is largely dependent on PQRS.
The very next day, Blackwelder fired off another letter,(1 page PDF) this time to HHS Secretary Sylvia Burwell, highlighting the AAFP's "growing apprehension" about the combined effects of a long and steep ICD-10 learning curve among physicians and RACs' robust efforts to recoup overpayments made to Medicare-participating physicians and hospitals.
Blackwelder called the implementation of ICD-10 "a significant, large and technically challenging operation." Physicians will have their hands full selecting the most accurate codes and then documenting their choices, he said.
"We strongly urge CMS to specify for three years that the RACS not audit (or) seek recoupment for claims whose sole error is due to the transition to ICD-10," said Blackwelder.
"Medicare claims with the correct and appropriate corresponding diagnostic ICD-9 family code should not be penalized by the RACs," he continued.
Furthermore, said Blackwelder, CMS should instruct MACs to provide "targeted ICD-10 educational communications" to practices in need of additional help.
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