Obamacare witnessed a big day in court on July 22nd, 2014 as two federal appeals courts issued contradictory rulings related to a major provision of the Affordable Care Act (ACA). In Halbig v Burwell, a three-judge panel in Washington, DC ruled that “ACA does not empower the US government to help people purchase health insurance coverage, only states can do that”.

The ruling concluded that the ACA explicitly restricts subsidies to insurance purchased through exchanges established by the state. This new ruling would gut Obamacare in those 36 states that chose not to participate and the residents in those places will lose the federal support they anticipate to get if the ruling stands.

Obamacare

The actual provisions of the Affordable Care Act says that only those people who happen to purchase health benefit plans via an exchange established by the state can consecutively qualify for the subsidies. Yet, about 36 states chose not to set up their own exchanges leaving the entire work to the federal government. In May 2013, IRS issued a clarification of the law that reported that even people in those states could qualify for the same. This clarification was issued in adherence to the spirit of the law, which is to get the maximum number of people covered in an affordable manner.

The federal appeals court ruling was a stunning blow for the Obama administration and the healthcare reform law. Let’s take a look at the potential impact of this ruling by the numbers –

  • As per the latest estimate from the U.S. Department of Health and Human Services, out of the 5.4 million people who happened to purchase the health insurance via the healthcare.gov this year, more than 87%, that is about 4.7 million people received premium tax credits in the federal market place. These are the proposed portion of people who would in turn lose their financial benefits under Obamacare (if the US appeals court ruling that invalidated the subsidies offered were to stand)
  • If the current enrollment pattern continues, about 14 million people are expected to receive federal subsidies by the end of 2017. As per the Congressional Budget Office estimates, the first year numbers minimize the impact since the total enrollment is expected to triple to 25 million in the next 3 years.
  • About 1.5 million people residing in Florida and Texas who happen to be the two biggest participants in the federal exchanges would lose subsidies. More than one third of these endowments offered to healthcare.gov enrollees went to people in Florida and Texas. Wellness care providers in these states would face the highest number on uninsured people. This may in turn drive-up-costs for hospitals as they need to provide emergency care regardless of patient’s ability to pay.
  • Any individual who earns up to $ 46, 680 per year – 4 times the federal poverty level is eligible for subsidies. Hence, for a family of four the income threshold is $95,400.

One major question that arises at this point of time is what would happen to those people who are already receiving these benefits? Would they have to repay it? There is no clear-cut answer to this prominent question. Experts in this field doubt that the ruling would be retroactive and it may entirely depend on the final ruling.

The latest ruling does not have an immediate effect on the law as the Obama administration is likely to appeal the decision to the full appellate court. Experts view that if the decision is upheld, more than 250,000 firms in those states (which have more than 57 million workers) would not be subject to the employer mandate being phased in next year. Employers (with 50 or more full-time workers) will be pushed to provide affordable health insurance or pay a fine.



Prostate CancerProstate Cancer is the second leading cause of death in American men. More than 910,000 cases of this syndrome were reported globally (in the year 2008) and this number is expected to increase to 1.7 million by the end of 2030. The American Cancer Society estimates that in the year 2014, more than 233,000 new cases of prostate cancer will be diagnosed and about 29,480 men will die of this ailment.

This condition occurs mainly in older men and is rarely found in men below the age of 40 years. More than 6 cases in 10 are diagnosed in men aged 65 years or above. Generally, the signs and symptoms are not apparent in the early stages of this disease and will differ from one person to another. The potential risk factors include old age, genetic conditions, alcohol consumption, vitamin or mineral interactions, and other dietary habits.

Importance of Routine Screening Tests

For early detection of cancer symptoms, urologists recommend screening tests. Regular and standard screening tests will not only help patients to better manage the disease symptoms but also improve patient function thereby enhancing their quality of life. The American Cancer Society recommends that men should take an informed decision with their physician whether to be tested for prostate cancer, beginning at the age of 50.

A routine and timely test facilitates early diagnosis and helps determine the correct treatment modality required. Even though there is no regular screening program for this form of cancer, physicians make a comprehensive diagnostic evaluation of the symptoms by conducting screening tests such as prostate-specific antigen (PSA) blood test and digital rectal exam (DRE).

Medicare provides coverage for an annual preventive prostate cancer screening PSA test and DRE once every 12 months for all male beneficiaries age 50 and older.

Healthcare providers should utilize accurate diagnostic codes to ensure correct reimbursement. V76.44 is the ICD-9 code to report screening for malignant neoplasms of the prostate.

Diagnosing Urologists Influence Treatment Decisions – New Study

A new study conducted by researchers at the University of Texas, MD Anderson Cancer Center in Houston shows that diagnosing physicians (particularly urologists) can significantly influence the decision making of those men having low risk prostate cancer and the type of treatment option selected. The study published online in JAMA Internal Medicine (July 14, 2014) examines the prominent reasons for active surveillance being underused in men with low-risk disease.

The study aimed to identify the unusual variation that exists in managing the ailment with the physician playing a more important role than accepted patient factors that affect surveillance use. As part of the survey, researchers analyzed 12,068 men (aged 66 years and older) diagnosed with low-risk prostate cancer from the year 2006 to 2009. They also wanted to identify the impact of the diagnosing urologist on treatment decisions, quantify the rate of surveillance versus treatment and identify urologist and patient factors associated with surveillance selection. Eighty percent of the men received treatment and 20% underwent surveillance. The observation rates showed significant variation across urologists (from 4.5% to 64.2%), and radiation oncologists (from 2% to 47%).

It was found that the diagnosing physician accounted for more than double the rate of difference seen in treatment vs. observation decisions (when compared against patient characteristics like age, PSA level and co morbidities). Patients diagnosed by urologists (who treated low-risk prostate cancer) had more chances of receiving the same treatment and therapy their diagnosing urologist used.

The study results emphasize the fact that physicians influence the treatment decisions including the type of treatment method selected. Researchers also point out various limitations related to the study such as shifting practice patterns affecting treatment decisions, and the failure to measure certain core factors such as family history and patient anxiety that may have an impact on treatment choices.



Use Modifier 24 Correctly

Posted by on October 29, 2014 3:54 am

Modifier 24Modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period) is to be used to report an unrelated E/M (evaluation and management) service during the global period of a previous procedure. The expression “same physician” includes other “same-specialty physicians”. This means that a surgeon covering post-operative patients for his/her partner does not bill for services provided. Physicians in the same group practice and in the same specialty must bill and be paid as though they were a single physician.

AMA and CMS differ as regards what is included in the global surgical package, which creates confusion for providers. To bill correctly, providers must clarify whether their payers follow CMS or AMA guidelines. For CMS’ Medicare payment, unless a return visit to the operating room is required, all medical and surgical post surgery complications are included in the global payment and cannot be separately billed. Treatment of wound infections and other complications cannot be reported. CPT defines the surgical package as “typical” post operative care.

Correct use of modifiers makes claims processing easy and providers receive the due reimbursement without any hassle. On the other hand, incorrect use of modifiers will result in payment denials and other complications.

A surgeon can report atypical post surgical care for medical complications using modifier 24 for E&M services. In this case, the complication diagnosis code has to be used first on the claim form. It is important to clarify with your payer that this is in keeping with its rules. If the patient is seen by other physicians during the global period, they need not use modifier 24. Only the surgeon who performs the operation, and his or her same specialty partners/covering surgeons need to use modifier 24.

Let us look at the correct and incorrect uses of modifier 24.

Correct Use

  • Use on an unrelated E/M service that starts the day after a procedure, when the E/M is provided by the same physician during the 10 or 90 day post-operative period.
  • Append it to the E&M procedure or eye exam.
  • Use modifier 24 on the E/M if documentation shows that the service was entirely for treatment of the underlying condition and not for post-operative care.
  • Use it on the E/M code when the same physician is managing immunosuppressant therapy during the post-surgery period of a transplant.
  • Use it when the same physician is managing chemotherapy during the post-operative period of a procedure.
  • Use it when the same physician provides unrelated critical care during the post surgery period.

Incorrect Use

  • Modifier 24 cannot be used for a surgical complication or injection because this treatment is considered part of the surgery package.
  • It cannot be used to document treatment of wound infection, consider this part of the post surgery care.
  • Cannot be used when the surgeon has the patient admitted to a skilled nursing facility for a condition that is related to the surgery.
  • Cannot be used when the medical record documentation does not clearly indicate that the E&M was unrelated to the surgery undergone.
  • Do not use modifier 24 outside of the post surgery period of a particular procedure.
  • Cannot be used on the same day as that of a procedure.



HCPCS ModifiersCMS is introducing four new HCPCS (Healthcare Common Procedure Coding System) modifiers to identify subsets of modifier 59 that is used to designate a “distinct procedural service”. The new subset modifiers are designed specifically to reduce the improper use of modifier 59 and improve claims processing for providers.

The most extensively used HCPCS modifier, modifier 59 can be used in a number of circumstances. It is infamous for widespread misuse and high levels of manual audit activity and has often resulted in appeals, civil fraud and abuse cases, and reviews. Often, this modifier is used inappropriately to evade NCCI (National Correct Coding Initiative) edits. It is hoped that the establishment of the subset modifiers will reduce the wrong use of modifier 59. The new subsets are also expected to improve claims processing for healthcare providers. The following are the new modifiers referred to together as -X {EPSU} modifiers and represent specific subsets of the -59 modifier.

  • XE Separate Encounter: A service that is distinct because it occurred during a separate encounter
  • XS Separate Structure: A service that is distinct because it was performed on a separate organ/structure
  • XP Separate Practitioner: A service that is distinct because it was performed by a different practitioner
  • XU Unusual Non-Overlapping Service: The use of a service that is distinct because it does not overlap usual components of the main service

CMS will continue to accept modifier 59 in many instances. However, according to CPT instructions, modifier -59 should not be used when a more specific and descriptive modifier is available for billing certain codes that are at high risk for inappropriate and erratic billing. Since the -X {EPSU} modifiers are more definitive versions of modifier -59, it would be incorrect to report both modifiers on the same line.

This change will be effective from January 5, 2015. Initially, either modifier 59 or an X {EPSU} modifier will be accepted. However, CMS requests providers to quickly start using the more selective modifiers.



Handling Prior Authorizations Effectively

Posted by on October 27, 2014 5:55 am

Prior AuthorizationDealing with prior authorizations effectively improves patient outcomes by ensuring that they receive the most appropriate medications, while reducing waste, error and unnecessary prescription drug use and cost. Efficient and effective use of health care resources can minimize overall medical costs, improve health plan member access to more affordable care and enhance quality of life.

Keys to Success with Pre-authorization

Here are success strategies recommended by experts to obtain the approvals from insurance companies:

  • Best practices to contact the insurance company – It is not easy for the physician or his staff to find the time to call the doctor appointed by the insurance company and discuss the need for the required service. Nevertheless such calls need to be made. Another more viable option is to go to the payer’s website to get prior authorizations whenever possible. This can generate a quicker response and avoid wastage of time on telephone calls, where you may be put on hold.
  • Assign the task to specialists – Putting one or two of your employees in charge of prior authorizations is a practical solution as these individuals will become experts in handling the process and develop smooth relationships with the payers. Alternatively, when you don’t have staff members to spare, you can assign the task to a medical billing company which would have a dedicated team to handle the process.
  • Minimize the number of prior authorization requests: For medications, see that you or whoever is handling the procedure is familiar with insurers’ formularies. Develop a list of drugs covered for common diseases. This will help you get into the practice of prescribing that drug, appropriate for the patient, which does not require a preauthorization request.
  • Have forms ready: Make sure the forms for the drugs and procedures that most commonly require a prior authorization are readily and easily available in your computers or as hard copies. This will save a lot of time when a prior authorization alert arrives.

Physicians are very busy people and insurance verification and prior authorization can take up a lot of time and resources. That’s why many doctors outsource the tasks to a professional medical billing company. With a team of experienced insurance verification specialists, a reliable company can assure in cleaner claims and improved practice efficiency. The health insurance verification and preauthorization services they provide lessens physician workload and helps them to focus on their core business of ensuring timely and appropriate care. Prior authorizations are unavoidable part of running a medical practice and support from a healthcare business process outsourcing company can help reduce the time and financial burdens associated with these activities.



Rheumatoid ArthritisAccurate documentation of any health condition is important from the point of view of patient care as well as timely and correct reimbursement. Rheumatoid arthritis (RA) coding is thus an important process in the provider’s office, just as medical coding for various other specialties. Physicians have to utilize the correct diagnostic and procedural codes for arthritis and its treatment. The following diagnostic codes are used to report RA –

  • ICD-9-CM – 714.0 – Rheumatoid arthritis
  • ICD-10-CM – M06.9 Rheumatoid arthritis, unspecified

Arthritis is one of the most common causes of disability in the United States. About 50 million people in the United States are diagnosed with some form of arthritis. Rheumatoid arthritis (RA) is an autoimmune disease that mainly affects the synovial tissues around the joints. More than 1.5 million people suffer from RA in the United States. Out of every 100,000 people, 41 are diagnosed with this condition every year. Reports suggest that by the end of 2030, the number of people with arthritis is expected to rise to 67 million.

Women are about two and a half times more likely to suffer from this syndrome than men. This disease begins between the ages of 30 – 60 in women and somewhat later in life in men. The lifetime risk for developing this condition is 4% in women and 3% in men. However, RA can occur at any age and even small children can get it. More than 3, 00,000 children in the US have the juvenile form of this disease.

Routine Tests and Diagnosis – Why is it Essential?

Rheumatoid arthritis is a systemic disease that can affect all body parts such as the heart, lungs, tissues, muscles, ligaments and cartilage. The signs and symptoms of this disease may vary in severity and may even come and go. It may also differ from one person to another. Some of the main symptoms include chronic pain, joint swelling and stiffness, fatigue, and weight loss. The potential risk factors associated with this syndrome include heredity, sex, age and lifestyle. Moreover, RA increases the risk of developing other conditions such as stroke, osteoporosis, heart and lung problems, and carpel tunnel syndrome.

Early diagnosis and treatment of rheumatoid arthritis can help control the disease symptoms and prevent disability. However, it is difficult to diagnose this condition in its early stages as the initial signs and the symptoms mimic those of many other diseases. There is no single blood test or other tests to verify the diagnosis. As part of the physical exam, rheumatologists will check your joints for swelling, redness, reflexes and muscle strength.

These specialists will perform a comprehensive diagnostic evaluation of the disease symptoms by conducting blood tests and X-rays and clearly documenting them. This helps them to better track the progress of this disease in the joints over time.

Anti-inflammatory Drugs Slow Down Bone Loss in Early RA Patients

A recent study found that aggressive anti-inflammatory treatment could reduce the intensity of bone loss in patients with early rheumatoid arthritis. The study results show that modern aggressive treatment can minimize osteoporosis in patients with RA.

About 92 patients (mean age – 50.9 years) suffering from RA participated in the research. Out of the total participants, two thirds were women and 80% of them had conducted their bone mineral density assessment at 10 years. These patients experienced disease symptoms for a mean of 12. 4 months. The key findings include –

  • Researchers found that about 18.5% of patients with this disease used biologic disease-modifying anti-rheumatic drugs during the first 2 years of the study.
  • On the other hand, 62.6% patients utilized the same drugs for the next 8 years and at the same time the average bone mineral density loss reduced substantially.
  • The average yearly rate of bone loss at 2 years and 10 years reduced from -1.00% to -0.56% for the femoral neck, from -0.96% to -0.41% for total spine, and from -0.42% to 0.00% for the L1-L4 vertebrae.



Medical Billing for HPV Vaccine Administration

Posted by on October 22, 2014 6:32 am

HPV VaccineVFC (Vaccines for Children) program is federally funded and provides vaccines free of cost to children who are enrolled in Medicaid, underinsured, uninsured, or an Alaska or American Indian Native through age 18. Facilitating access to vaccines and vaccine activities is among Medicaid’s top priorities. All ACIP (Advisory Committee on Immunization Practice) recommended vaccines are provided to children under the age of 21 who are eligible for the Early Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. Under the VFC program, the Centers for Disease Control and Prevention purchases vaccines at a discounted rate and distributes them to state health departments and local/territorial public health agencies that in turn distribute them at no cost to public health clinics and private physicians’ offices that are registered as VFC providers. Providers can bill for an administration fee for the cost they incur in administering the vaccine. Medicaid covers the vaccine administration fee for children enrolled in its program, whereas the uninsured and underinsured children enrolled in VFC program, the parents have to pay. This administration fee varies from one state to another.

HPV Vaccine to Ward off Varied Cancer Types

HPV or the human papilloma virus is known to cause several types of cancer such as those of the cervix and throat. HPV infection can be prevented with the administration of HPV vaccine. Medical billing for HPV vaccine should contain the following information:

  • Human Papilloma Virus Quadrivalent Vaccine (Gardisil®) CPT code 90649 (Human Papilloma Virus [HPV] vaccine, types 6, 11, 16, 18 [quadrivalent]). This code is billed with modifier SL for both sexes ages 9 through 26 of age, females who are not pregnant. The vaccine is to be administered as a 3-dose regimen at 0, 2 and 6 month intervals. Providers should keep a vaccination log, and clearly document in the patient’s medical records details such as vaccination dates, sites of vaccination, dosage given and the lot number of the vaccine administered.

The newly licensed Gardasil vaccine provides protection against cervical cancer caused by HPV. However, not all insurance plans cover this vaccine administration. Medicaid covers this vaccine for females 19 – 26 years old. Females in the age group 9 – 18 who are Medicaid eligible or have no insurance can obtain the vaccine from clinics enrolled in the VFC program or at local Health Departments.

  • Human Papilloma Virus Bivalent Vaccine (Cervarix®) CPT code 90650 (Human Papilloma virus [HPV vaccine], types 16, 18, bivalent, 3 dose schedule, for intramuscular use)

This is a VFC program benefit available for female recipients 9 – 18 years of age.

Providers have to verify the insurance information of those approaching for vaccine administration.

HPV Vaccines in Children – Safe to be Administered with Other Vaccines

Many parents are concerned about the safety and adverse reaction of HPV vaccination for children and think that it is not needed. Federal health officials have found that only few kids are getting HPV vaccines that protect them from a range of cancers, including cervical cancer and cancers of the throat and mouth.

A new study, published online by the Centers for Disease Control and Prevention notes that a HPV vaccine added to the child’s other immunizations does not affect the safety or efficacy of any of the vaccines involved. The review included 9 studies, 4 of quadrivalent HPV vaccine and 5 of bivalent HPV vaccine. 1 double-blind and 8 open-label, randomized controlled trials of multiple vaccine co-administration published between 2008 and 2012 were reviewed by the team. The studies demonstrated non-inferiority of immune response and an acceptable safety profile when HPV vaccine was co-administered with other vaccines. Co-administered vaccines included: meningococcal conjugate, hepatitis A, hepatitis B, combined hepatitis A and B, tetanus, diphtheria, acellular pertussis, and inactivated poliovirus vaccines.

Each study assessed immune response by measuring seroconversion or seroprotection that is the percentage of participants with antibody concentration or titers above a predetermined threshold.

To determine safety, the study participants were asked to report symptoms 30 minutes after vaccine administration and at various intervals thereafter. The most commonly reported symptoms were adverse events at the injection sites such as pain, swelling, and bruising. The authors concluded that the available data suggests [the] HPV vaccine is safe and effective when administered with other vaccines. The team also noted that the HPV vaccine coverage is below target levels in the United States.

HPV vaccination coverage indicated receipt of any HPV vaccine and does not distinguish between HPV2 and HPV4. Vaccination coverage was assessed for each dose of the HPV vaccination series. According to the CDC, if healthcare providers increase HPV vaccination coverage to 80%, it is estimated that an additional 53,000 cases of cervical cancer could be prevented during the lifetime of those younger than 12 years.

Most pediatricians recommend routine vaccination against HPV for girls, and to a lesser extent, for boys. It is important for healthcare providers to educate patients and parents of children in the target age range for HPV vaccination about HPV-related diseases and be prepared to respond to questions regarding HPV vaccination, including its benefits, limitations, and safety, as discussed earlier. If the patient is tested for HPV DNA and the results are positive, vaccination is still recommended because the chance that the patient has been exposed to all vaccine-preventable HPV genotypes is low.



ICD-10 – Myths and Facts

Posted by on October 20, 2014 5:55 am

ICD-10With the ICD-10 compliance date fast approaching, many providers and medical coders continue to be plagued by doubts and ambiguities related to the new coding system. It is important that they obtain a clear view regarding ICD-10 and the features that distinguish it, as well as the government’s stand regarding its implementation.

Successful ICD-10 implementation demands considerable training and education for clinicians, coders and others within the healthcare system associated with the revenue cycle. Flawless transition to the new coding system also requires specific and adequate documentation to ensure accurate medical coding. Many myths are rampant regarding ICD-10, and these must be worked out to ensure a smooth transition. Below are some of the major myths as well as the actual facts.

  • Myth: Medical record content will increase phenomenally.
    • Fact: It is true that ICD-10 requires more documentation. However, this will only amount to a few more words for each documented condition. For instance, if the condition is one such as asthma which has different stages, ICD-10 allows documenting and coding each of these stages.
  • Myth: ICD-10 codes are all highly complex and comprise 7 characters each.
    • Fact: The most common code length is 4 characters, and there are 3 character codes too. It is a more logical system than ICD-9, because the first character indicates the disease category. This enables anyone to understand which disease family the code falls under. Often, one ICD-10 code can signify what multiple ICD-9 codes do. The new coding system reduces possibilities of error while ensuring accurate reimbursement for healthcare providers.
  • Myth: Medicaid plans need not switch over to ICD-10.
    • Fact: All HIPAA-covered entities including state Medicaid plans will have to switch over to ICD-10. CMS is offering special assistance to help the states with this huge transition. Payers not covered by HIPAA such as Workers’ Compensation, auto and property insurance are also encouraged to become ICD-10 compliant but it is not required at this time. The more specific nature of the codes will only be of more significant value to non-covered entities.
  • Myth: The October 1, 2015 ICD-10 compliance date is likely to be extended.
    • Fact: All HIPAA covered entities must implement the new ICD-10 code set with dates of service, or date of inpatient discharge , that occur on or after October 1, 2015. HHS has no plans to extend this compliance date.
  • Myth: No clinical input is involved in the development of ICD-10.
    • Fact: There was a lot of clinical input involved in ICD-10 development and a number of medical specialty societies contributed to its development.
  • Myth: ICD-10 is probably out of date since it was developed many years ago.
    • Fact: ICD-10 codes have been updated annually since their original development to keep current with advancements in medicine, technology, and the changes in the healthcare environment prior to the implementation of the partial code freeze. As a result of the code freeze, the last regular annual updates were made to both ICD-9 and ICD-10 code sets on October 1, 2011. Limited code updates for new diseases and new technologies were made to both code sets on October 1, 2012; October 1, 2013 and October 1, 2014. On October 1, 2015 only limited code updates for new technologies and new diseases will be made to the ICD-10 code sets. On or after October 1, 2015, no further updates will be made to ICD-9 because it will no longer be used. Regular updates to ICD-10 will resume on October 1, 2016.
  • Myth: Super bills based on ICD-10 will not be very useful on account of being too complex/long.
    • Fact: ICD-10 based super bills will not necessarily be longer or more complex than ICD-9 based super bills. Both these types of super bills provide all possible code options for many conditions.
  • Myth: General Equivalency Mappings (GEMs) were developed to assist in coding medical records.
    • Fact: GEMs were not developed to assist in coding medical records. Mapping is not the same as coding. Mapping connects the concepts in two code sets without considering medical record information while medical coding involves assigning the most appropriate codes on the basis of medical record information and relevant coding guidelines and rules. GEMs is used to convert databases such as payment systems, payment and coverage edits, risk adjustment logic, quality measures and a variety of research applications involving trend data from ICD-9-CM to ICD-10-CM-PCS.
  • Myth: GEMs have been developed for Medicare use only. So each payer will have to develop their own mappings between the 2 code systems.
    • Fact: The GEMs was developed by CMS and CDC for the use of all providers, data users and payers. They are free of charge and available in the public domain.
  • Myth: Medically unnecessary diagnostic tests have to be performed to assign an ICD-10 code.
    • Fact: ICD-10-CM codes are assigned according to the medical record documentation. In both coding systems, the condition has to be coded to the highest degree of certainty if a diagnosis has not been established. ICD-10 contains many more codes for symptoms and signs than ICD-9. It is designed to better report ambulatory encounters when there is not a known definitive diagnoses. ICD-10 system also has non-specific codes to report conditions where more detailed clinical information is not available.
  • Myth: ICD-10-PCS will replace Current Procedural Terminology (CPT).
    • Fact: ICD-10-PCS will not replace CPT. It will be used only for facility reporting of hospital inpatient procedures.

You can access CMS’ fact sheet on the International Classification of Diseases, 10th Edition, Clinical Modification/Procedure Coding System (ICD-10-CM/PCS) at http://www.cms.gov/Medicare/Coding/ICD10/downloads/ICD-10MythsandFacts.pdf.



Outpatient Diagnostic ErrorsMisdiagnosis is proven to be a serious concern for hospitals and may lead to patient harm, incorrect or delayed treatment, wasted resources and malpractice lawsuits. A wrong diagnosis by a healthcare professional can also result in medical coding errors. Inaccurate codes in medical bills can lead to medical office financial problems such as delayed payments, reimbursement denials, costly fines and loss of revenue. Even though, patient misdiagnosis has always existed as a major problem in the medical field, the number of cases reporting misdiagnosis issue has increased significantly.

A recent population-based estimate reveals that around 12 million adults in the US who seek outpatient care are misdiagnosed annually. This figure amounts to at least 1 out of every 20 US adults and the study found that this could potentially lead to severe harm for the patient. The study was partially funded by the Agency for Healthcare Research and Quality (AHRQ) and the results were published online in the April 17, 2014 edition of the journal BMJ Quality and Safety.

In order to determine the frequency of diagnostic errors in US outpatient care every year, researchers combined inferences from three large observational studies involving U.S. adult populations. They used data from three previous studies of errors in general primary care diagnosis, lung cancer diagnosis and colorectal cancer diagnosis.

In all the three studies, a detailed review of all the medical records was done to check whether any diagnostic error had occurred and these errors were confirmed through rigorous chart review. To estimate the annual frequency of misdiagnoses, the proportion of errors found was directly applied to the large population of all outpatient visits and to the total US adult population. Researchers found that about half of the diagnostic errors they found could have severely harmed the patients.

The authors of the study reveal diagnostic errors can harm patients by delaying their treatment. Their findings should encourage new efforts to monitor and curb the numbers of misdiagnoses. For example, a possible delay or incorrect diagnosis could make the disease more complicated to treat or more deadly. The research found that more than 6 million patients a year in the US could come across instances when a misdiagnosis could possibly lead to a deadly delay in the treatment of cancer or other such serious disease.

While combining the estimates (taken from three previous studies), outpatient diagnostic errors was recorded at the rate of 5.08% or approximately 12 million US adults on a yearly basis.

Researchers expect that this study will provide a strong foundation for healthcare organizations, healthcare professionals and policy makers to build up their future efforts to reduce diagnostic errors.



Patient EngagementKeeping the patients engaged and loyal has become important to the long-term financial viability of a healthcare practice. The new health plans have increase the patient’s financial responsibility and they need to be well-informed about their healthcare options. They also have higher expectations about the quality of care. Better patient engagement can reduce the costs of healthcare, improve outcomes, and benefit your practice’s revenue cycle.

Strategies to Boost Patient Engagement

There are many ways to engage patients and provide improved service to boost practice revenue:

  • Patient Education – This is a vital patient engagement strategy. It is important that they are well-informed about their plan’s preventative opportunities, network choices, coverage, and medical billing strategies. Providing them with access to such information will make healthcare more patient-centered, and thereby, more value-based. Empowering patients and their families will ensure better adherence to treatment plans and prevent readmissions and complications which can end up costing your healthcare practice more money or cause payment delays if the costs are not covered by their plan.

    Provide them with information in a clear, accessible format through an online portal or by sending email newsletters to help them understand their health conditions better and ensure that they follow the treatment plan.

  • Improved Access to Care – It’s crucial that patients can access the care system quickly and well. Whether an existing patient who needs nursing services or a new patient who needs a physician referral and appointment, effective communication is the key to quicker and seamless access to care. A well-designed appointment system can help deliver timely and convenient access to medical services, and enhance patient satisfaction and physician efficiency.

    Phone calls, video chat, and online meetings will be ways patients and providers will engage for virtual doctor appointments. Experimenting with telemedicine options for the elderly is another choice. Patient portals could facilitate email and other electronic format communication in a secure and compliant way, which would benefit both the provider and the patient alike. Using medical mobile applications to deliver information at the right time can also improve patient satisfaction.

  • Introduction of Electronic Forms – Wait time complaints because of the need to fill up of pre-appointment forms is a major issue. If the patient can electronically receive and fill out the necessary forms before their appointment, wait times could be eliminated to some extent. Introducing electronic check-in processes allows immediate collection of co-pays and outstanding balances.
  • Healthcare Kiosks – Kiosks offer self-service abilities that help to reduce data entry, delays in the waiting room and ensure accuracy of the information. Patients can use them to view their billing statements. They also provide a quick way to inform patients of their balance and co-pay and can even collect the amount due prior to the visit.

Patient engagement can definitely drive down operating costs and promote better revenue cycle management.



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