OASIS Alert

If you've been dreading the switch to ICD-10, you're not alone. The American Medical Association has been vocally opposed to adopting ICD-10 as the new diagnosis coding system. And now they're looking into a proposal that could leave ICD-10 in the dust.

Background: Not only did the AMA's House of Delegates vote last year to repeal ICD-10 (which the Centers for Medicare & Medicaid Services did not adopt), but the group also applauded the news earlier this year that ICD-10 may be delayed from its original implementation date of 2013.

Now the AMA has taken additional steps to express its disillusionment with ICD-10, announcing that its House of Delegates adopted a policy to evaluate ICD-11 as a potential "alternative" to replace ICD-9, an AMA news release noted.

"ICD-10 coding will create unnecessary and significant financial and administrative burdens for physicians," said AMA President-elect Dr. Ardis Dee Hoven in a June 19 statement. "It is critical to evaluate alternatives to ICD-9 that will make for a less cumbersome transition for physicians and allow physicians to focus on their primary priority -- patient care. AMA voted today to consider ICD-11 as a possible alternative. The policy also asks the AMA and other stakeholders, such as [CMS], to examine other options."

A home care consultant advocated considering this point in her recent comments on CMS's final rule delaying ICD-10. "Why not wait and do an update with the World Health Organization (WHO) ICD-11-CM?" asked Rose Kimball with home care billing company Med-Care Administrative Services in Dallas in her comments. "This would allow the United States to not always be so far behind the rest of the 'forward thinking' industrialized countries. This further reduces the costs associated with two (2) changes necessitated in order to be in sync with WHO."

Prepare for a Long Wait with ICD-11

But waiting for ICD-11 may not make as much sense as it seems at first glance. It took the U.S. eight years to adapt the WHO version of ICD-10 and create ICD-10-CM for use in this country," the American Health Information Management Association (AHIMA) points out in a recent article.

"Regardless of the benefits of ICD-11, the U.S. would need a national version to allow for the annual updating required by Congress and U.S. stakeholders. Assuming that the development timeline for a national version or clinical modification of ICD-11 could be cut in half down to four years, it would then take an additional two years to get through the HIPAA rulemaking process. As with ICD-10-CM/PCS, the industry would want at least a three-year period for converting systems to ICD-11," the AHIMA article says.

End result: "Assuming that ICD-11 becomes available on schedule from WHO in 2016, then the earliest the U.S. could move to ICD-11 would be 2025, or 13 years from now," the AHIMA article points out.

• Denials from the Comprehensive Error Rate Testing (CERT) project can confuse providers, but don't forget you can appeal.

Resource: If your HHH MAC is National Government Services, you can use its new CERT Denial Reason Finder self-service tool to locate the denial reason definition, understand why the claim was denied, view CERT reviewer comments, and learn how to correct the error, NGS says in a message to providers.

You can find the tool at www.ngsmedicare.com/wps/portal/ngsmedicare/certstatus. You just enter the CERT claim identification (CID) number in the tool's search form field then select "Submit." You can appeal the decision online at the MAC's NGSConnex.com online portal.

• Worried about receiving denials when teaching dementia patients with behavioral disturbances? Check out a new coverage article from HHH Medicare Administrative Contractor NHIC for tips on what your MAC will be looking for.

"Teaching and training activities ... in the case of the beneficiary population with dementia and behavioral disturbances, could be part of a unique beneficiary-centered care plan directed at teaching the family or caregiver how to manage the behavioral disturbances," NHIC explains.

But for teaching to be covered, clinicians should document the answers to a list of questions about the disturbance, ranging from "What is the frequency of the behavior" to "Are there other possible explanations for the behavior," NHIC instructs.

Remember: "In the home health setting, skilled education services are no longer needed if it becomes apparent, after a reasonable period of time, that the patient, family, or caregiver could not or would not be trained," the MAC tells providers.

The article, which includes example scenarios with interventions, is at www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=51856&ver=2&name=&ContrId=206&ContrVer=1.

• The Affordable Care Act appears to be doing its job when it comes to encouraging Medicaid use of home care. So suggests a new Government Accountability Office report.

The ACA established two new Medicaid home care programs with financial incentives: the Community First Choice and Balancing Incentive Program. And the health care reform law revised two existing programs -- Money Follows the Person and the 1915(i) state plan option.

As of this April, 13 more states had received $621 million in Money Follows the Person grants, the report notes. One state had applied for Community First Choice, four had applied for BIP, and three states received approval from the Centers for Medicare & Medicaid Services to offer the revised 1915(i) option.

Stay tuned: The U.S. Supreme Court has upheld the ACA. But you may still see some of the options available under the law dismantled if its political opponents are successful in their attempts at repeal or revision.

In the meantime, the HHS Office of Inspector General examined oversight of quality of care in Medicaid home care programs. In fiscal year 2010, Medicaid expenditures for home and community-based services (HCBS) waiver programs serving the disabled or elderly totaled an estimated $8.9 billion, the OIG says in a new report.

"Strong oversight of waiver programs is critical to ensuring the quality of care provided to HCBS beneficiaries," the OIG says. "The beneficiaries who rely on HCBS waiver programs are among Medicaid's most vulnerable, and the nature of these programs puts beneficiaries at particular risk of receiving inadequate care."

Problem: "Seven of the twenty-five states that we reviewed did not have adequate systems to ensure the quality of care provided to beneficiaries," the OIG found in its study.

Solution: The OIG wants CMS to provide more HCBS guidance to states; require plans of correction from states that don't meet quality oversight standards; require onsite visits of HCBS programs; and make quality information public. CMS agreed with the recommendations. However, "we believe that the efficacy of a site visit must be evaluated prior to any decision to conduct a site visit," the agency pointed out in its comments on the report. When a state meets all its quality standards, for example, "the agency reserves the discretion to determine that a site visit may not be required."

The GAO report is online at www.gao.gov/products/GAO-12-649 and the OIG report is at http://oig.hhs.gov/oei/reports/oei-02-08-00170.asp.