EHR Systems and ICD-10 Transition

Posted by on December 18, 2014 7:07 am

ICD-10 TransitionThe delay in transition to the next generation of medical coding, ICD-10-CM/PCS till October 1, 2015 has given both physicians and electronic health record (HER) vendors more time to prepare their systems for the change. ICD-10 offers better representation of disease severity and risk as well as better claim information that provides support to automated processing. In physician practices, a variety of systems such as EHR and billing and practice management need to be customized to support ICD-10. In fact, experts point out that updating their EHR for compliance with ICD-10 is one of the major challenges that physician practices face. Let’s take a look at some of the issues involved:

One main problem is that EHR applications differ in the way they store billing codes. While all systems are designed to capture ICD, CPT, and HCPCS codes to be used for claim submission and healthcare documentation, the methods they utilize to store these codes vary widely. An advanced EHR system would allow smooth transition to ICD-10, ICD-11, or any other required terminology without affecting the user much. Such superior systems use a reference terminology such as SNOMED CT – Systematized Nomenclature of Medicine, Clinical Terms – which can store clinical concepts centrally at a more accurate level than that enabled by ICD-9 and even ICD-10.

The US Department of Health and Human Services has allowed all federal and private developers of EHR systems to freely incorporate SNOMED CT. The vocabulary system offers a vast repository of synonyms that allows physicians to choose their patient’s problems faster and more accurately, and by doing so, improve compliance of their EHR system with clinical practice.

EHR Systems with such fully integrated reference terminology with maps from SNOMED CT to ICD-10 offers many advantages:

  • Allows physicians to send and receive medical data in an understandable and usable manner, speeding up care delivery and helping to minimize duplicate testing and prescribing
  • Comprehensive documentation which improves medical claim submission and reimbursement

These systems also enable the development of outcomes measures and other clinically relevant notes about the patient.

However, not all EHR systems offer such facilities to migrate to ICD-10. Some systems allow ICD-9 and other billing codes to be embedded within templates. In this case, these embedded codes will have to be updated to ICD-10 codes. Only expert medical coders with knowledge of ICD-10 billing requirements can do this. Many clinical conditions that were represented by one ICD-9 code now translate to multiple ICD-10-CM codes based on specific circumstances. For example, for bacterial infections, a secondary code may be necessary to identify the bacterial organism causing the infection.

Physicians with EHR systems that have a standardized core set of patient medical record information terminologies in place, local modifications to clinical content may not be needed. However, if the system is such that codes and supporting documentation in your locally developed or modified clinical content needs to be updated, the best option could be to seek help from a professional medical billing and coding company.



Hospital ReadmissionsThe Affordable Care Act (ACA) has introduced several new financial incentives and penalties in order to optimize the overall healthcare system performance. Policy makers are constantly searching for new ways to enhance the quality of patient care and reduce total health insurance spending. Reducing hospital readmissions is one such major initiative launched by the Centers for Medicare and Medicaid Services (CMS) to improve the healthcare quality in the United States. Hospital readmission is defined as a patient being readmitted within the initial 30 days of hospital stay.

In fact, avoidable readmissions are one of the main problems facing the US healthcare domain. Reports suggest that about one out of five elderly patients is readmitted to the medical center within 30 days of discharge. It is estimated that this costs about $15 billion per year and is causing more than double the cost of providing care to a patient.

In order to increase transparency of care, the Hospital Readmissions Reduction Program (HRRP) was established in the ACA that provides financial incentives to healthcare facilities to lower readmission rates. As part of this program, medical facilities with excess 30-day readmissions for patients with certain health conditions such as pneumonia, myocardial infarction and heart failure will be penalized.

Medicare Readmission Penalty Increased by 3 %

Healthcare facilities have recently begun ensuring that their patients don’t return soon after they are being discharged. Medicare penalties have been significantly increased and reached an all time high with its third round of fines imposed on establishments that have recorded a high rate of patient readmission.

As per the latest Federal records released, Medicare is fining about 2,610 hospitals for having patients return to the facility for taking additional or repeat treatment within one month of being discharged. This is the third year the industry faces these fines that were created as part of the HRRP established by the ACA. The potential penalties for this year are estimated to be the highest, up to 3% of Medicare bills.

In the year 2013, approximately 18% of patients with health benefit plans who had been hospitalized were readmitted within a month. Even though the re-hospitalization rate has dropped (when compared to 2012) about 1 in 5 patients with health insurance coverage returned within 30 days thereby costing tax payers an extra $26 billion. Below mentioned are some of the main details of the new Medicare penalties –

  • About three-quarters of health centers that come under the HRRP are being fined. This may result in lower payment (from October 1 through next September 30) for every patient stay – not just for those persons who are readmitted. Medicare estimates that the fines will total about $428 million over the course of the year.
  • About 1,400 facilities are exempted from these fines and this may include cancer hospitals, critical care facilities and other facilities offering psychiatry or rehabilitation services.
  • Half of the clinics in 29 states including California, Florida, Georgia, Illinois, Massachusetts, New York, Ohio, Pennsylvania, Tennessee and Texas, as well as the District of Columbia will be losing money.
  • About 39 hospitals including specialty surgical units, community centers and Pennsylvania hospital (a major teaching facility) will benefit from lowered payments by 3%.
  • Another 496 hospitals will lose 1 percent or more of their payments.

When compared to last year, heavy penalties were charged against 433 more hospitals this year. An average fine of 0.63 percent (from 0.38 percent last year) was recorded.

Another prominent reason for increased fines is that Medicare is tracking more conditions. Apart from health conditions such as pneumonia, myocardial infarction and heart failure, this year patients readmitted with elective hip and knee replacements and lung ailments such as chronic bronchitis are also analyzed. Hence, those facilities that have never faced fines before may have to pay it.

How Can Penalties Reduce Patient Readmission?

The penalties imposed by the federal government highlights the need for medical facilities to pay adequate attention to their patients and stay updated about their health status even after they are discharged. The initiative behind fines is that healthcare facilities will be motivated to provide adequate treatment to the patients to a point of wellness wherein they will have lower chance of returning for treatment.

Instead of giving perfunctory discharge plans such as paper typed instructions to patients, many facilities are taking up more active efforts that include conducting a detailed discussion with patients regarding discharge plans. This has proved to be an effective way to reduce the number of patients who return to the medical centre in less than a month. In addition, staffs are making sincere attempts to ensure whether the patient receives support from other doctors’ services outside, whether prescriptions are adhered to and whether recoveries are monitored closely. The officials in the healthcare domain assert that the threat of costly fines is certainly a good motivation for healthcare facilities to continue providing better quality services.



Medical Coding SystemThe U.S. is one of the developed nations which is still using ICD-9, many others already having implemented ICD-10 codes. The transition from ICD-9 to ICD-10 by October 1, 2015 is not easy as ICD-9 is deeply rooted in healthcare system and to upgrade the existing systems with the new codes is technically difficult.

Implementing ICD-10 will benefit physicians, patients, and the healthcare system in general as the new codes will result in a more accurate reporting system with better support for the clinical decision. It will also pave the way for advancements in diagnosis and treatment options as well as improved care for healthcare consumers. In addition to coding and documentation improvements, it will improve quality measurement, and has an increased ability to prevent and detect healthcare fraud and abuse.

In the U.S., the use of electronic health records (EHRs) has increased significantly. EHRs play an important role in ICD-10 as they are the primary diagnosis entry point, with diagnoses recorded in multiple places such as problem lists and also physician-patient encounters. Physicians who employ web-based EHRs and billing services stand to benefit more during the ICD-10 transition. Since mappings from ICD-9 to ICD-10 are not the same, electronic tools like EHRs help the physicians to use the appropriate ICD-10 diagnosis and, in some cases, automatically converts from one code-system to another. This helps to ensure that the physicians are selecting the most specific ICD-10 code for a particular diagnosis category which can be billed accurately.

One thing the physicians must consider is that SNOMED-CT (Systematized Nomenclature of Medicine-Clinical Terms) code is also required to record the entries in addition to the ICD-10 code in EHRs that are 2014 certified. The clinical data encoded in SNOMED-CT can be mapped to ICD-10 codes which results in better claims submission and reimbursement.

Failure to update the medical coding system will result in issues such as delayed payments or even non-payment, higher rejected, denied or pending claims, reduced cash flows and ultimately lost revenues for the health care providers. Claims that fail to use ICD-10 diagnosis and inpatient procedure codes will not get processed.

Transitioning to ICD-10 is a very complicated process and proper planning is crucial. Support from a professional medical coding company can prove invaluable for a smooth transition to the new system. These medical outsourcing companies have professional coders who are well versed in the new coding and billing practices. They can help healthcare practices review their existing systems, identify what needs to changed, and implement these changes and gain the benefits that the robust ICD-10 code set brings.



ICD-10The implementation of ICD-10 will dramatically impact the way coding is done.

In October 2015, the US health care system will transition to the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM). Proper attention to these codes is necessary to ensure accurate reimbursement in medical practices. ICD-10 code sets allow for greater specificity and exactness in medical diagnoses and inpatient procedures reporting. Providers will need to work more to document diagnoses as ICD-10 has 8 times more codes than ICD-9. Pediatrics, cardiology and nephrology are the medical specialties that will be more significantly impacted than others.

Specialties Facing the Most Documentation Challenges with ICD-10

  • Pediatrics – According to a study published earlier this year, pediatricians will have to pay special attention to specific codes in the transition to ICD-10. The researchers studied a data set from Illinois Medicaid specified for pediatricians. More than 2,700 ICD-10 codes were identified and divided into five categories: identity, class-to-subclass, subclass-to-class, convoluted and no translation. The study found that 26 percent of the codes were classified as convoluted and represented about 21 percent of all patient encounters and 16% of reimbursement. The diagnosis codes represented by information loss (3.6%), overlapping categories (3.2%), and inconsistent (1.2%) made up 8% of Medicaid pediatric reimbursement. It was therefore concluded that such potential for financial disruption and administrative errors would require pediatric practices to pay closer attention to these codes when transitioning to ICD-10.
  • Cardiology – The transition will also be particularly challenging for cardiology providers as more new cardiology-specific procedure codes are included under ICD-10. Here are some examples where miscoding can occur:
    • In ICD-10, the acute phase of myocardial infarction has changed to 4 weeks from eight weeks in ICD-9
    • The codes specifying the episode of care will cease to exist. For example, AMI of the anterolateral wall which is coded as 410.00 for an unspecified episode of care in ICD-9 will change to I21.09 in ICD-10, which has no relation at all to episode of care
    • Atherosclerotic heart disease of native coronary artery with angina pectoris takes only a single combination code (I25.11) in ICD-10, unlike ICD-9 where it takes two separate codes
    • Complication codes will also be much more specific in ICD-10-CM.

  • Nephrology – Nephrologists treat patients with Chronic Kidney Disorder (CKD). This disorder has only one code in ICD-9, but under ICD-10, five different codes will have to be applied correctly. Also hypertensive chronic kidney disease will take two codes – the first one will indicate both hypertension and CKD, and the second code will specify the level of CKD.

With these new challenges, diagnostic coding for these specialties will become extremely confusing, time consuming and complicated. Due to the ICD-10 transition, these specialists and others would need to pay greater attention to coding than providing care to their patients. In such a scenario, hiring the services of a expert medical billing and coding company which is ICD-10 ready could be the solution to minimizing the errors and ensuring proper reimbursement.



EpilepsyEpilepsy is a serious neurological disorder in which the central nerve cells in the brain work abnormally causing seizures. According to the World Health Organization (WHO), more than 65 million people suffer from this disease worldwide. Reports suggest that more than two million people in the United States have epilepsy. It is estimated that 1 out of 26 people will develop this condition at some time in their life. The average incidence of epilepsy in the United States each year is estimated at 150,000, with the rate of this disease being higher in young children and older adults.

Medical Coding for Seizure Disorder and Epilepsy

Epilepsy and seizure disorder are central nervous system disorders and are characterized by sudden onset of seizures and muscle contractions. The seizure disorders and recurrent seizures are coded to epilepsy. Convulsions, new-onset, and single, febrile/hysterical seizures are coded as non-epileptic.

ICD-9-CM code 345 signifies “Epilepsy and recurrent seizures”. Under this head, the medical codes 345.0 to 345.9 and their subsections describe different forms of epilepsy such as non-convulsive, convulsive etc. In the ICD-10 coding system, code G40 and its comprehensive subsections allow clearer representation of different types of epilepsy. Neurologists and their office staff should have in-depth understanding about the new guidelines or practices for medical billing and coding. Accurate diagnostic and procedural codes are to be reported on the claims to receive on-time and correct reimbursement.

For early and accurate diagnosis of the disease symptoms, neurologists recommend routine screening tests. Routine screening tests help patients manage the disease symptoms in a better manner thereby enhancing their quality of life. As part of the diagnosis, the neurologist will evaluate the patient’s medical history, analyze symptoms and perform a complete neurological exam. They may also recommend several tests such as blood tests, electroencephalogram (EEG), computed tomography (CT) or magnetic resonance imaging (MRI) to monitor the brain activity and determine the correct treatment modality required.

For more than 70% of people diagnosed with this disease, seizures can be controlled with medications which may depend on the specific type of seizures. On the other hand, if medications don’t treat the condition, doctors may propose surgery, electrical stimulation therapy, special diet or other suitable treatment.

Reporting EEG Monitoring

EEG monitoring is considered medically necessary in cases where a diagnosis cannot be made by neurological examination, standard EEG studies and ambulatory EEG monitoring, and the non-neurological causes of symptoms such as cardiac arrhythmias and syncope have been ruled out:

  • To differentiate epileptic events from psychogenic seizures Or
  • To establish the first diagnosis of a seizure disorder Or
  • To establish the specific type of epilepsy in poorly characterized seizure types in cases where such characterization is medically necessary to select the most appropriate therapeutic regimen

CPT code 95951 is used to report monitoring localization of cerebral seizure by radio or cable. It is combined EEG (electroencephalographic) that differentiates different types of epileptic events. Typically, the physician monitors the patient for 15 to 30 hours, not more than that. The EEG and video are intended to change an uncertain diagnosis for seizure surgery.

If the services are less than nine hours, an alternate code usually 95813 will be needed. This is an EEG extended monitoring code, which is more than one hour. For services lasting from 9 – 15 hours, code 95951 is to be reported with the modifier -52. This is a reduced services code, signifying that the physician reduced the services described by the CPT. Code 95951 is billed once each 24-hour period. Most payers allow full payment for CPT code 95951.

Importance of Early Diagnosis of Epilepsy

Having a single seizure (due to a high fever) does not necessarily indicate that the person is suffering from epilepsy. On the other hand, if a person suffers two or more seizures, then it is confirmed that he/she is suffering from this chronic neurological disorder. Early diagnosis and recognition of seizures is important to prevent further problems. Undiagnosed seizures can lead to learning disabilities, behavioral problems, sudden loss of awareness or consciousness, psychic symptoms, temporary confusion and other issues. Now, for some recent news.

Low Carbohydrate, High Fat Diets May Reduce Seizures

A new research review published in the medical journal of the “American Academy of Neurology” (October 29, 2014 issue) reports that diets rich in fat and low in carbohydrates (such as the ketogenic or modified Atkins diet), may reduce seizures in adults with tough-to-treat epilepsy. The ketogenic or modified Atkins diet may include food items such as eggs, heavy cream, fish, butter, green leafy vegetables and bacon.

As part of the study, researchers reviewed 5 studies each on the ketogenic diet and Atkins diet including a total of 47 people in the first analysis and 85 people in the second analysis. The major findings of the study include –

  • About 32% of people treated with the ketogenic diet and 29% of those treated with Atkins diet experienced more than 50% reduction in their seizures.
  • It was found that 9% of people in the ketogenic group and 5% of people in the modified Atkins group suffered more than 90% reduction in seizures.
  • People experienced long term positive results within days to weeks after following both the diets. However, the results did not continue in children after they stopped following the diet chart correctly.
  • Both the diets did not involve much serious side effects with the most common being weight loss.

The study results signify that following these diets correctly can prove to be very effective as another option to reduce seizures in people having severe or tough-to-treat epilepsy. However, 51% of the ketogenic diet group and 42% of Atkins diet group stopped the diet before the study was fully completed due to culinary and social restrictions.



Hospitalization ERA new study from the “UCLA Center for Health Policy Research” reports that the expansion of Medicaid under the Affordable Care Act (ACA) may lead to considerable increase in the use of emergency rooms (ER) and hospitalizations for previously uninsured people, but that increase will largely prove to be temporary and may not create a serious impact on state budgets. As part of the analysis, researchers evaluated two years of medical claims data for about 2,000 Californians (including patients who got enrolled in public health programs well in advance of last January’s expansion of Medi-Cal, the state’s version of Medicaid).

The primary objective behind the UCLA study (which was funded by the California Department of Health Care Services and Blue Shield of California Foundation) was to simplify the Medicaid expansion process by offering health insurance to those low-income people who were not eligible for Medi-Cal at that point but would become eligible when the health law’s expansion rule fully comes into effect. Researchers divided the group into 4 different categories (based on individual assessment of each specific category’s pent-up demand for health care).

It was found that people who were insured (after long periods of being uninsured) used hospital emergency departments three times more during the initial 3 months of coverage and later cut back significantly in the subsequent months. The hospitalization rate (for the “highest pent-up demand” group) was initially high and subsequently reduced by almost 80% within the two-year period 2011 – 2013. However, the emergency room and hospitalization rates reduction should have led to higher outpatient visits. But this was not the case as the rates of outpatient visits remained constant during the 2-year period.

Researchers point out that the Medicaid expansion could potentially lead to high-cost for the low-income group and this analysis would ease those problems. The findings indicate that the growing concerns about Medicaid expansion being financially unsustainable into the future are unfounded. Under the ACA, the federal government pays states 100% of the cost of newly eligible under the Medicaid expansion. But, it is expected that in 2017, that contribution will be phased down until it reaches 90% in 2020.

According to a tally from the Kaiser Family Foundation, out of the 27 states and a District of Columbia implementing a Medicaid expansion, 21 states have not yet implemented and in two states Indiana and Utah, the decision about health plan expansion is still an open discussion.

Medicaid officials say that the study results were quite consistent with what they planned to do by expanding health insurance access. Their next step would be healthcare homes to ensure that patients actually receive better care.

They feel that better coordination efforts for Medi-Cal beneficiaries is one of the prominent factors that helped to drive-down the higher rates of use.



Health InsuranceAccording to the preliminary data released by the Department of Health and Human Services, consumers will probably have wider choices while shopping for affordable coverage at the health insurance marketplace in 2015.

Reports suggest that there will be 25% increase in the total number of health insurers offering marketplace plans (from 252 insurers in 2014 to 316 in the upcoming 2015 enrollment period) over the previous years. It is estimated that a total of 77 new insurers will enter the marketplace in 2015 while 14 are dropping out.

The officials at the Health and Human Services (HHS) consider the sudden boost in the number of insurers willing to sell the new form of insurance (starting November 15) as a sign of the huge success of the Affordable Care Act (ACA). When considering the law on the grounds of access, affordability and quality, it can be clearly concluded that the ACA is working.

During the initial years of operation, many of the largest insurers in the nation followed a very careful approach to Obamacare by offering just a handful of plans in certain states. With more than 7.3 million people getting enrolled in these plans, many insurers see huge potential and profits on the exchanges.

The enrollment season begins on November 15 and ends towards mid- February 2015, for most Americans to shop for health insurance coverage and apply for tax credits (related to the cost of premiums). The HHS report evaluated the preliminary data from more than 36 states run or fully supported by the federal government (federal marketplace). In addition, it also looked at the data from 8 states operating state-based market places and finds that a bigger portion of issuers will be offering in the marketplaces in 2015. The key highlights of the report are mentioned below –

  • The federal marketplace reports 57 more number of issuers or insurance companies in 2015, a 30% net increase over this year.
  • Eight states running their own market places report an increase in insurer participation from 61 to 67 in 2015, a 10% net increase over this year.
  • 77 insurers will offer coverage in 2015 in 44 states (for which there is data),
  • Some insurers only offer plans in certain states. Four states namely Indiana, Missouri, New Hampshire and West Virginia out of 36 in the federal market place will have double the total number of issuers that they had in 2014. Further, 36 states nationally will have at least one new insurer.
  • On the other hand, California is the only state showing a decrease in the number of issuers from 12 to 10. Even amidst the decrease, California market is one of the most successful of the Obamacare exchanges (reporting the highest number of total enrollees of any state – 1.4 million and the second highest percentage of sign-ups among the eligible population at 42.7 percent).

Price plays a significant role in determining the total number of people who will get enrolled in health benefit plans this year or drop out of these plans. A new poll by the "Transamerica Center for Health Studies" found that about 22% of uninsured Americans did not obtain coverage this year as they were not fully aware about the individual mandate to obtain the same or pay a fine equivalent or up to 1% of their income. Another 43% of uninsured people had not even heard about Obamacare exchanges. This might create a hurry up and sign up for a new plan as soon as they can creating problems for physicians and hospitals as they go through their patient load and do insurance verifications, authorizations and proceed to medical billing.

The HHS report suggests that the number of insurers entering the marketplaces in 2015 has increased significantly. Further, some of the industry’s biggest players are also jumping in for the first time. The sheer increase in marketplace competitions may provide consumers with more number of options to choose from. However, the final question that remains is that whether the increased competition will help to keep premiums in check.



HealthcareFor long, the US Healthcare system has been predominantly based on the fee-for-service model wherein the patient receives quality care and the medical bill payment will be done by either the patient or a third party payer. This system has been the basic financial foundation on which all hospitals, physicians and healthcare organizations run their businesses. For the past 25 years, the healthcare spend per capita in the US has more than quadrupled. It has recorded a rise from $ 2,000 per person per year in 1988 to about $ 8,000 per person in the year 2013.

Increasing healthcare costs affect the nation on multiple fronts. For those families and senior citizens, the soaring medical cost means less money in their pockets. It becomes extremely difficult for small businesses and Fortune 500 employers to retain the employee retiree coverage. Rising healthcare costs lead to higher Medicare and Medicaid costs for federal and state governments.

Multiple reasons can be accounted for the increasing healthcare costs and spending in the US such as provider consolidation, paying for volume than value, new innovations in technologies and treatments (without considering their effectiveness), lack of transparency of information related to prices and quality, higher prices for medical services, defensive medicine and fraudulent medical billing. The common types of medical billing fraud include phantom billing, up coding, self referrals, double billing, cloning, inflated hospital bills and service unbundling.

Transition from Fee-for-service to Value-based Care Model

Research suggests that despite the extra money spent, the health outcomes in the US are not actually better than in other countries. While measuring the quality aspect, the life expectancy rates in the US are lower although our costs are literally high when compared to other developed nations.

Healthcare organizations and providers have now realized the importance of developing a unique method to provide services for the specific communities they serve at the same time covering their extra costs. "Population Health Management or Value-based Care" is a unique way of giving patients the adequate care they want and need. It is referred as "the value equation" - Quality over Cost over Time.

Value-based healthcare (often referred to as the value equation) is a healthcare management strategy focusing on Quality over Cost over Outcomes. Its main goal is to create a culture of health within the organization by eliminating all possible barriers and encouraging participants to lead a healthy lifestyle that eventually promote a healthy workforce. It helps to enhance patient experience and reduce preventable hospital admissions and emergency visits.

The transition from fee-for service to value-based care involves numerous changes for both patients and healthcare providers. For patients, value-based care means safe, proper and effective care at an affordable cost. For healthcare providers, this approach requires employing evidence-based medicine along with proven techniques and treatments that consider the patients’ preferences. With a shift to value-based system, any patient planning to undergo any specific procedure will be able to know key information from the physician about the total cost and the expected results of the procedure.



Open EnrollmentThe second Open Enrollment for Obamacare plans comes with a lot of changes from the first enrollment, which would require healthcare providers to improve their billing procedures and systems a little more. The enrollment started on November 15 and will end on February 15. Those who want their coverage beginning on January 1, 2015 should enroll by December 15. For the 2015 plan year, 27 federally facilitated Marketplace states, 7 state partnership Marketplaces, and 3 state based Marketplaces will use the federal site.

The other major changes with the second enrollment are as follows.

  • Additional Insurers – The number of insurance companies that offer Marketplace coverage will increase in 2015 for 35 states though the number will decline in two states.
  • Changes in Premium and Tax Credit – As per a preliminary analysis of premiums in 16 cities, the premium for the second lowest cost silver plan (the benchmark plan used for computing premium tax credit amounts) will drop by 0.8 percent on an average rate. Meanwhile, the benchmark premium among those cities will increase by as much as 8.7% and drop by as much as 15.6%. These changes will have an effect on the coverage cost for those consumers eligible for premium tax credits even if their own circumstances don’t change from 2014 to 2015. However, the cost of coverage will get affected by changes in an individual’s income, age, family status and the formula used for calculating premium tax credit eligibility.
  • Changes in Cost Sharing – The maximum out-of-pocket (deductibles, co-pays and coinsurance) cap amount for 2015 will be increased to $6,600 for an individual and $13,200 for a family policy compared to $6,350 and $12,700 respectively in 2014.
  • Changes in Individual Responsibility – For 2014, the tax penalty for not getting insured into a healthcare plan is $95 per adult or 1% of household income over the tax filing threshold. It will be increased to $325 per adult or 2% of household income over the tax filing threshold in 2015.
  • Medicaid Changes – Pennsylvania will adopt expanded Medicaid eligibility for adults from 2015, which will increase the number of expansion states to 28. The states that have not yet adopted the expansion may decide to expand Medicaid eligibility at any time in 2015.

Consumers who enroll into a Marketplace plan during the second enrollment period will be affected by these changes. Healthcare providers should thoroughly consider these changes when billing for services provided to the patients enrolled through Marketplace under ACA.

Let’s see how healthcare providers are affected by these changes and what preparation steps they should take.

  • We have already seen the out-of-pocket cap amount will be increased in 2015 and so healthcare providers should establish effective mechanisms to collect from patients up-front to ensure better revenue from Marketplace plans. Providers can offer some level of financial counseling as well as payment plans for patients. However, the most important thing is to have billing experts, right procedures and effective tools in place.
  • It is very important to perform patient eligibility verification before providing services. Since the requirements for 2015 plans will be different, healthcare facilities can surely benefit from the expert support of a medical billing company, which has a thorough understanding of the rules and requirements of the plans offered under ACA.

In short, the healthcare providers should either thoroughly train their staffs on the requirements of ACA or purchase an entirely new patient intake and billing system that supports billing requirements under the ACA. A more cost-effective and viable solution is to outsource billing procedures to a reliable medical billing and coding firm that keeps abreast of current developments in the healthcare field. With a reliable outsourcing partner, physicians and office staff need not spend their valuable time striving to accommodate the new changes, and can instead dedicate their time to providing quality care.



CodingCon 2014Medical billing and coding are two processes that are essential for the healthcare industry. The industry depends on billing and coding specialists to generate and maintain accurate medical billing and health insurance details. It is crucial that these specialists stay updated with coding changes and payer plan requirements that may change each year.

“CodingCon 2014 – The 7th Annual Medical Coding, Billing and Reimbursement National Conference” will be hosted by The Coding Institute, LLC in Orlando, Florida from December 5-7, 2014. The prime objective behind organizing this multi-specialty conference is to equip and educate medical billers, coders, practice managers and related healthcare professionals on important guidelines, updates, practices and new changes that are implemented each financial year.

The event focuses on dealing with the significant changes happening in the healthcare domain and avoiding the anticipated coding and billing confusions in 2015. The program will include practical specialty sessions focusing on the latest coding, reimbursement and compliance rules and pitfalls.

This year’s conference will include interactive sessions to make learning easy and effective. It will cover more than 50 sessions on a wide variety of topics such as practice management, billing, compliance, auditing, revenue cycle management and medical coding. The sessions will cover up-to-date insights and practical applications of 2015 code changes (ICD-10-CM, CPT, and HCPCS). In addition, it will provide attendees specialized networking sessions, opportunity to qualify for AAPC’s ICD-10 recertification test by attending ICD-10 track and earn up to 19.5 CEUs. This will make them eligible to track correct coding and reimbursement with the CPT® changes in 2015. In addition, attendees will have the unique option to switch from one specialty track to another at no additional charge.

The following sessions are included in the CodingCon 2014 conference:

  • 4 hour pre-conference workshops for coders on the prominent benefits of ICD-10 over ICD-9.
  • 9 specialty tracks – ICD-10 general/traditional ICD-10, general surgery, home health, Obstetrics & gynecology, orthopedics, pain management, pathology/lab, pediatrics, urology.
  • Information on ICD-10 coding system and tips on successful and smooth transition to the new coding system.
  • Discussions on new concepts for laterality, borderline diagnosis, 7th characters that change in meaning (based on ICD-10 chapter) and new “excludes” definitions.
  • Post conference workshops.

Apart from this, the conference will also include discussions on how to escape audits and steer clear of claim slow-down during the transition. Participants will have the unique opportunity to network with their peers and share their valuable experiences and ideas. It is expected that CodingCon 2014 will be attended by more than 800 physician practices, healthcare organizations and health insurance company decision makers across the United States and territories. More than 200 people have already registered at http://www.codingconferences.com/.



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