Accounting Question 300 words
231
Information Systems Changes:
The Manager’s Challenge
20 C H A P T E R
OVERVIEW: THE MANAGER’S CHALLENGE
Information systems changes are both a challenge and an opportunity for the manager. Chapter 19 described the overall healthcare system changes that are occurring right now. This chapter follows up by discussing the tech- nical aspects of both ICD-10, e-prescribing, and what you need to know about implementing them. These changes are expected to transition over a period of years (see Fig- ure 19-1 in the preceding chapter for an overview of compliance dates). During this transition period a man- ager who understands the underlying technology issues can develop and/or strengthen needed skills. Then, he or she is in a position to support the implementation plan and work to assist change within the organization.
SYSTEMS AND APPLICATIONS AFFECTED BY THE ICD-10 CHANGE
The ICD-10 technology changes that we will discuss in the following section impact a broad variety of systems and applications. It is important for the manager to fully understand the breadth and depth of change that is re- quired by the technological transition from ICD-9 to ICD-10. Figure 20-1 illustrates the types of systems and applications that must change.
Twenty-five different examples of various systems and applications are contained in Figure 20-1, divided into three categories as follows:
1. Necessary revisions to vendor software and systems 2. Systems used to model or calculate that are impacted 3. Specifications that will need to be revised1
After completing this chapter, you should be able to
1. Understand why the change to ICD-10 codes is a technology problem.
2. Compute ICD-10 training costs.
3. Define lost productivity costs. 4. Understand the three
categories of “eligible professionals” within the e-prescribing incentive program.
5. Understand the five requirements for a qualified e-prescribing system.
6. Understand why claim form inputs are required to receive e-prescribing incentive payments.
P r o g r e s s N o t e s
ICD-10 TECHNOLOGY CHANGE DETAILS
Examining the details of ICD-10 code set changes will help you more fully understand the technological problems that manage- ment will face in this transition.
Understand Technology Issues and Problems
The scope of change is illustrated in the next three exhibits as follows.
Comparison of ICD-9-CM and ICD-10-CM Diagnosis Codes
There were approximately 13,000 ICD-9-CM diagnosis codes; now ICD-10-CM has ap- proximately 68,000 diagnosis codes, or more than a five hundred percent increase. ICD-9-CM diagnosis codes had three to five characters in length, while ICD-10-CM’s characters are three to seven characters in length. This generally means input fields have to be lengthened in order to accom- modate seven characters. In addition, ICD- 9-CM’s first digit may be alpha (E or V) or numeric, and digits two to five are numeric, while ICD-10-CM’s first digit is alpha, digits two and three are numeric, and digits four to seven are either alpha or numeric. This change means reprogramming will be re- quired for many applications. Exhibit 20-1 sets out a comparison of ICD-9-CM versus ICD-10-CM diagnosis codes. The exhibit in- cludes six benefits of the new code set in ad- dition to the three differentials previously discussed in this paragraph.
Comparison of ICD-9-CM and ICD-10-CM Procedure Codes
There were approximately 3,000 ICD-9-CM procedure codes; now ICD-10-CM has ap-
proximately 87,000 available procedure codes, or 29 times as many available codes. ICD-9- CM procedure codes had three to four numbers in length, while ICD-10-CM’s characters
232 CHAPTER 20 Information Systems Changes: The Manager’s Challenge
Necessary Revisions to Vendor Software and Systems for Transition from ICD-9 to ICD-10 include:
Ambulatory systems Billing systems Patient accounting systems Physician office systems Practice management systems Quality measurement systems
Emergency department software Contract management programs Reimbursement modeling programs
Financial functions such as- Code assignment Medical records abstraction Claims submission Other financial functions
Systems used to model or calculate are also impacted by the use of ICD-10 code sets:
Acuity systems Decision support systems and content Patient care systems Patient risk systems Staffing needs systems Selection criteria within electronic medical records Presentation of clinical content for support of plans of care
Specifications that will need to be revised for ICD-10 use include specifications for:
Data file extracts Reporting programs and external interfaces Analytic software that performs business analysis Analytic software that provides decision support analytics for financial and clinical management Business rules guided by patient condition or procedure
Figure 20–1 Systems and Applications Affected by the ICD-10 Change. Source: 74 Federal Register 3348-9 (January 16, 2009).
are alpha-numeric and seven characters in length. This generally means input fields have to be lengthened in order to accommodate seven characters and possibly reprogrammed to accept alpha characters. Exhibit 20-2 sets out a comparison of ICD-9-CM versus ICD-10- CM procedure codes. The exhibit includes seven benefits of the new code set in addition to the two differentials previously discussed in this paragraph.
An Example: Comparison of Old and New Angioplasty Codes
Exhibit 20-3 sets out one example of the proliferation of codes. In the ICD-9-CM, angio- plasty had one code (39.50). In the ICD-10-PCS, angioplasty has 1,170 codes.2 The Wall Street Journal even used this example in a headline: “Why We Need 1,170 Angioplasty Codes.”3
The Manager’s Role
You the manager need to identify tasks required during the transition period and perform them. These tasks could involve aspects of planning, creating, evaluating, testing, or even
ICD-10 Technology Change Details 233
Exhibit 20–1 Comparison of ICD-9-CM and ICD-10-CM Diagnosis Codes
ICD-9-CM Diagnosis Codes ICD-10-CM Diagnosis Codes
3-5 characters in length
Approximately 13,000 codes
First digit may be alpha (E or V) or numeric; digits 2-5 are numeric
Limited space for adding new codes
Lacks detail
Lacks laterality
Difficult to analyze data due to non-specific codes
Codes are non-specific and do not adequately define diagnoses needed for medical research
Does not support interoperability because it is not used by other countries
Source: 73 Federal Register 49803 (August 22, 2008).
3-7 characters in length
Approximately 68,000 available codes
Digit 1 is alpha; digits 2 and 3 are numeric; digits 4-7 are alpha or numeric
Flexible for adding new codes
Very specific
Has laterality
Specificity improves coding accuracy and richness of data for analysis
Detail improves the accuracy of data used for medical research
Supports interoperability and the exchange of health data between other countries and the United States
234 CHAPTER 20 Information Systems Changes: The Manager’s Challenge
all of the above. In other words, you as an observant manager can work to support aspects of the implementation plan that fall within your areas of responsibility, whether it involves, for example, information technology or the training plans.
ICD-10 TRAINING AND LOST PRODUCTIVITY COSTS
This section describes training and lost productivity costs for the ICD-10 transition.
Who Gets Trained on ICD-10?
CMS identified three types of individuals who would require varying levels of training on ICD-10. These included coders, code users, and physicians.
Coders
It is vital that coders receive adequate training on the ICD-10 coding changes. CMS, there- fore, estimated training costs for both full-time and part-time coders. In producing cost es-
Exhibit 20–2 Comparison of ICD-9-CM and ICD-10-CM Procedure Codes
ICD-9-CM Procedure Codes ICD-10-CM Procedure Codes
3-4 numbers in length
Approximately 3,000 codes
Based upon outdated technology
Limited space for adding new codes
Lacks detail
Lacks laterality
Generic terms for body parts
Lacks description of methodology and approach for procedures
Limits DRG assignment
Lacks precision to adequately define procedures
Source: 73 Federal Register 49803 (August 22, 2008).
7 alpha-numeric characters in length
Approximately 87,000 available codes
Reflects current usage of medical terminology and devices
Flexible for adding new codes
Very specific
Has laterality
Detailed descriptions for body parts
Provides detailed descriptions of methodology and approach for procedures
Allows DRG definitions to better recognize new technologies and devices
Precisely defines procedures with detail regarding body part, approach, any device used, and qualifying information
timates, CMS assumed that full-time coders were primarily dedicated to hospital inpatient coding and that part-time coders worked in outpatient ambulatory settings. The difference is based on the job setting for a reason. CMS further assumed that all coders will need to learn ICD-10-CM, while the coders who work in the hospital inpatient job setting will also need to learn ICD-10-PCS.4
Code Users
CMS refers to the American Health Information Management Association (AHIMA) defi- nition of code users as “anyone who needs to have some level of understanding of the cod- ing system, because they review coded data, rely on reports that contain coded data, etc., but are not people who actually assign codes.”5 These users can be people who are outside of healthcare facilities: individuals such as researchers, consultants, or auditors, for exam- ple. Or these users might actually be inside the healthcare facility but are not coders. Such facility users might include upper-level management, business office and accounting per- sonnel, clinicians and clinical departments, or corporate compliance personnel.6
ICD-10 Training and Lost Productivity Costs 235
Exhibit 20–3 Comparison of Old and New Angioplasty Codes
Old Code:
ICD-9-CM Angioplasty
1 code (39.50)
New Code: ICD-10-PCS
Angioplasty Codes 1,170 codes
Specifying body part, approach, and device, including:
047K04Z Dilation of right femoral artery with drug-eluting intraluminal device, open approach
047KODZ Dilation of right femoral artery with intraluminal device, open approach
047KOZZ Dilation of right femoral artery, open approach
047K24Z Dilation of right femoral artery with drug-eluting intraluminal device, open endoscopic approach
047K2DZ Dilation of right femoral artery with intraluminal device, open endoscopic approach
Source: Centers for Medicare & Medicaid Services (CMS) ICD-10 Fact Sheet
236 CHAPTER 20 Information Systems Changes: The Manager’s Challenge
P h y s i c i a n s
CMS believed that the majority of physicians did not work with codes and thus would not need training. The initial assumption was that only one-in-ten physicians would require such knowledge. (CMS also believed that physicians would probably obtain the needed training through continuing professional education courses that they would attend anyway.)7
Costs of Training
ICD-10 training costs were estimated for each category described above: coders, code users, and physicians.
Coder Training Costs
CMS initially assumed the following:
1. There were 50,000 full-time hospital coders that would need 40 hours of training apiece on both ICD-10-CM and ICD-10-PCS. The 40 hours of training was estimated to cost $2,750 apiece, including lost work time of $2,200, plus $550 for the expenses of training, for a total of $2,750 per coder.
2. Training of full-time coders would start the year before ICD-10 implementation. It was further assumed that 15% of training costs would be expended in this initial year; 75% would be expended in the year of implementation; and the remaining 15% would be expended in the year after implementation.
3. There were approximately 179,000 part-time coders who would require training only on ICD-10-CM (and not on ICD-10-PCS). The part-time coders’ training expense would amount to $110 for the expenses of training, plus $440 for lost work time, for a total of $550.8
Code Users Training Costs
CMS estimated there were approximately 250,000 code users, of which 150,000 would work directly with codes. Each code user was estimated to need eight hours of training at $31.50 per hour or approximately $250 apiece.9
Physician Training Costs
CMS estimated there were approximately 1.5 million physicians in the United States, of which one in ten would require training. Each physician was estimated to need four hours of training at $137 per hour or approximately $548 apiece.10
Costs of Lost Productivity
CMS used a productivity loss definition as follows: “The cost resulting from a slow-down in coding bills and claims because of the need to learn the new coding systems.”11 Thus, the productivity loss slow-down reflects the extra staff hours that are needed to code the same number of claims per hour as prior to the ICD-10 conversion. (For instance, Jane normally
codes x claims per hour; during the first month learning the new system, she slows down to xx claims per hour.)
CMS estimated that inpatient coders would incur productivity losses for the first six months after ICD-10 implementation; and further, that productivity would increase (and losses thus decrease) month by month over the initial six-month period until by the end of six months, productivity has returned to its former level. It was estimated that inpatient coders would take an extra 1.7 minutes per inpatient claim in the first month. At $50 per hour, 1.7 minutes equates to $1.41 per claim.12 ($50.00 per hour divided by 60 minutes equals $0.8333 per minute times 1.7 minutes equals $1.41 per claim.)
CMS assumed the same six-month productivity loss period for outpatient coders. CMS further assumed that outpatient claims require much less time to code. In fact, the initial assumption was that outpatient claims would take one hundredth of the time for a hospital inpatient claim. Thus, one hundredth of the inpatient 1.7 minute productivity loss equals 0.017 minutes. At the same $50 per hour, one hundredth of the $1.41 inpatient loss equals 0.014 per claim, or about one and one half cents.13 (To compute one hundredth of $1.41, move the decimal to the left two places. Thus $1.41 becomes $0.014.) The reasoning for this small amount of coding time per claim is that physician offices “may use preprinted forms or touch-screens that require virtually no time to code.”14
E-PRESCRIBING FOR PHYSICIANS: OVERVIEW
This overview contains e-prescribing definitions and commentary about the traditionally low adoption rate.
Definitions
In the definitions that follow, be aware that over time the precise wording of such defini- tions may shift and/or expand for regulatory purposes.
• E-prescribing means “the transmission, using electronic media, of a prescription or prescription-related information, between a prescriber, dispenser, PBM, or health plan, either directly or through an intermediary, including an e-prescribing network.”
• Prescriber means “a physician, dentist, or other person licensed, registered, or other- wise permitted by the U.S. or the jurisdiction in which he or she practices, to issue pre- scriptions for drugs for human use.”
• Dispenser means “a person, or other legal entity, licensed, registered, or otherwise per- mitted by the jurisdiction in which the person practices or the entity is located, to pro- vide drug products for human use on prescription in the course of professional practice.”15
Generally speaking, transactions recognized as part of e-prescribing include:
• New prescription transaction • Prescription refill request and response • Prescription change request and response
E-Prescribing for Physicians: Overview 237
238 CHAPTER 20 Information Systems Changes: The Manager’s Challenge
• Cancel prescription request and response • Ancillary messaging and administrative transactions16
As to the definition for “prescriber” above, CMS has commented elsewhere about other individuals who “are permitted to issue prescriptions for drugs for human use. These non- physician providers could include certified registered nurse anesthetists (CRNAs), nurse practitioners, and others.”17 (Naturally, these individuals would have to be properly li- censed or registered in order to be a prescriber.)
Also note that this discussion is limited to the impact of e-prescribing on physicians and other eligible professionals who prescribe, because the technical aspects of other applica- tions of e-prescribing (such as the impact on pharmacies as dispensers) are not within the scope of this book.
Traditionally Low Adoption Rate
Electronic prescribing among physicians and other professionals who prescribe has tradi- tionally been low. A study published a few years ago estimated only five to eighteen percent of providers used e-prescribing at that time.18
As to a real-life example of the low adoption rate, several years ago a Massachusetts col- laborative project was partially funding the adoption of e-prescribing by physicians. While this project offered the technology to 21,000 physicians, it reported that only about 2,700, or thirteen percent, of the targeted physicians had adopted the technology.19
E-PRESCRIBING BENEFITS AND COSTS
This section describes both benefit and costs of e-prescribing.
Benefits
The benefits of e-prescribing can be administrative, financial, and/or clinical. CMS has listed the following benefits as potentially improving quality and efficiency, and reducing costs:
• Speeds up the process of renewing medication • Provides information about formulary-based drug coverage, including formulary al-
ternatives and co-pay information • Actively promotes appropriate drug usage, such as following a medication regimen
for a specific condition • Prevents medication errors, in that each prescription can be electronically checked at
the time of prescribing for dosage, interactions with other medications, and thera- peutic duplication
• Provides instant connectivity between the healthcare provider, the pharmacy, health plans/pharmacy benefit managers (PBMs), and other entities, improving the speed and accuracy of prescription dispensing, pharmacy callbacks, renewal requests, eligi- bility checks, and medication history20
Costs
The cost of implementation to a practice may vary widely, based on practice size, location, and the degree of electronic adoption already under way within the office. However, three types of costs associated with e-prescribing can be identified as follows:
1. The initial purchase of hardware and software 2. Costs associated with daily use and maintenance, including on-line connectivity 3. Education and training21
Because of the wide variability, no official estimate of e-prescribing costs exists at the time of this writing. An older estimate of implementation costs has been published as follows. As background, in the past some health plans have offered to install an e-prescribing system for physicians that participate in their plan. In that regard, several years ago a health plan responded with comments to a CMS proposed rule about e-prescribing. The health plan stated that:
. . . it had spent three million dollars to equip 700 physicians with hardware and installation, software and training in their e-prescribing initiative (an average of almost $4,300 per physician). To boost participation, the health plan [was] piloting a program to grant honoraria (between $600 and $2,000) to physicians who write electronic prescriptions. The commenter believed that without the financial hardware/software and support incentives, the average physicians’ practice would incur costs up to $2,500 per physician to adopt e-prescribing.22
In conclusion, at the time of this writing, adoption of e-prescribing by physicians is vol- untary. Therefore each physician can make an individual decision about the costs and ben- efits of e-prescribing.
A View of the Future
We anticipate that the near future will bring a stream of information about implementation costs as the e-prescribing incentives described later in this chapter begin to show results. But we already have one view of the future. As of the date of this writing, the Wall Street Jour- nal announced that Wal-Mart Stores, Inc. has formed a partnership with Dell, Inc. and a pri- vately held software maker to sell a medical records system through its Sam’s Club membership warehouse. According to the Journal story, a Wal-Mart spokesman stated “Whether it is a single physician or a physician’s group, we can offer a system that enables them to electronically prescribe medication, set appointments, track billings and keep records.”23 Note that the system is more comprehensive than just e-prescribing, as it in- cludes office and patient management and billing tracking. The Journal story quoted the cost of the first installed system as $25,000, plus $10,000 for each additional system, plus $4,000 to $5,000 a year in maintenance costs.24
The significance of this announcement is that a big-box store and a prominent computer firm have joined forces to offer an electronic package that can be obtained, complete with
E-Prescribing Benefits and Costs 239
240 CHAPTER 20 Information Systems Changes: The Manager’s Challenge
installation and maintenance, from a membership warehouse. It seems to us that with this announcement the adoption of electronic medical records, including e-prescribing, has en- tered the commercial mainstream and may even shortly become commonplace.
E-PRESCRIBING IMPLEMENTATION
Implementation barriers and successes are described below.
Barriers
Barriers to physicians’ implementation and increased usage of e-prescribing include:
• costs of buying and installing a system • training • time and workflow impact • lack of knowledge about the benefits related to quality care • lack of reimbursement for costs and resources25
At least the “lack of reimbursement” barrier is lessening somewhat with the physician in- centives that are now in place.
While the primary barrier to adoption of e-prescribing by physicians appears to be the cost of buying and installing the system, change is also a significant barrier, since imple- mentation of a new system involves at least three types of change:
1. changing the business practices of the physician’s office 2. changing record systems (from paper to electronic) 3. training staff for change26
Another change-related barrier is resistance to actually using the electronic system, both by staff and by the physicians themselves.
Anecdotal Successes
Certain physician practices that have provided anecdotal evidence of successful e-prescrib- ing implementation to CMS, are quoted as follows:
• A 53% reduction in calls to the pharmacy. • Time savings of one hour per nurse and 30 minutes per file clerk per day by stream-
lining medication management processes. • A large practice in Lexington, Kentucky, estimates that e-prescribing saves the group
$48,000 a year in decreased time spent handling prescription renewal requests. • Before implementation of e-prescribing, a large practice in Kokomo, Indiana, with 20
providers and 134,000 annual patient office visits was receiving 370 daily phone calls, 206 of which were related to prescriptions. Of the 206 prescription-related calls, 97 were prescription renewal requests. The remainder consisted of clarification calls from pharmacists or requests for new prescriptions. Staff time to process these calls in-
cluded 28 hours per day of nurse time and 4 hours per day of physician time. Chart pulls were required in order to process half of the renewal requests. Implementation of an e-prescribing system produced dramatic time savings that permitted reallocation of nursing and chart room staff.27
E-PRESCRIBING INCENTIVES AND PENALTIES FOR PHYSICIANS AND OTHER ELIGIBLE PRESCRIBERS
The E-Prescribing Incentive Program was authorized by the Medicare Improvements for Patients and Providers Act (MIPPA) which was enacted on July 15, 2008. The incentive pro- gram is for eligible professionals who are successful electronic prescribers (e-prescribers) as defined by MIPPA. It is separate from, and is in addition to, the Physician Quality Re- porting Initiative (PQRI).28 Only services paid under the Medicare Physician Fee Schedule (MPFS) are included in the E-Prescribing Incentive Program.29
Note an important difference: the AARA incentives described in the previous Chapter 19 are paid only to “physicians,” as defined by law. The E-Prescribing Incentive Program de- scribed in this section pays “eligible professionals,” which includes other eligible prescribers in addition to physicians.
The E-Prescribing Incentives Program
Components of the program are briefly described below. This is a general description for purposes of illustration only; for additional details refer to the relevant rules and regulations.
Eligible Pro f e s s i o n a l
An “eligible professional” includes the following individuals, divided into three categories: Medicare physicians, practitioners, and therapists.
1. Medicare physicians • Doctor of Medicine • Doctor of Osteopathy • Doctor of Podiatric Medicine • Doctor of Optometry • Doctor of Oral Surgery • Doctor of Dental Medicine • Doctor of Chiropractic
2. Practitioners • Physician Assistant • Nurse Practitioner • Clinical Nurse Specialist • Certified Registered Nurse Anesthetist (and Anesthesiologist Assistant) • Certified Nurse Midwife • Clinical Social Worker
E-Prescribing Incentives and Penalties for Physicians and Other Eligible Prescribers 241
242 CHAPTER 20 Information Systems Changes: The Manager’s Challenge
• Clinical Psychologist • Registered Dietician • Nutrition Professional • Audiologists
3. Therapists • Physical Therapist • Occupational Therapist • Qualified Speech-Language Therapist30
Note that some professionals who would otherwise be eligible are excluded from the pro- gram due to their billing methods.31 Also note that in order to participate, these individu- als must be “authorized by his or her respective state laws to prescribe medication and prescribing medications must fall within the individual eligible professional’s scope of practice.”32
Qualified E-Prescribing System
According to the CMS ERxIncentive brochure, a qualified e-prescribing system must be able to perform the following five tasks:
1. Generate a complete active medication list, using e-data received from applicable pharmacies and pharmacy benefit managers (PBMs) (if available).
2. Allow eligible professionals to select medications, print prescriptions, transmit pre- scriptions electronically, and conduct all alerts (including automated prompts).
3. Provide information on lower cost therapeutically appropriate alternatives, if any. 4. Provide information on formulary or tiered formulary medications, patient eligibil-
ity, and authorization requirements received electronically from the patient’s drug plan (if available).
5. Meet specifications for messaging.33
Successful Electronic E-Prescriber
At the time of this writing an eligible professional was considered to be a “successful elec- tronic e-prescriber” if “he or she reported the applicable e-prescribing quality measure in at least 50% of the cases in which such measure is reportable by the eligible professional dur- ing the reporting period.”34 (Note that this percentage may change over time.)
Program Incentives and Penalties
The program incentive payment for 2010 is 2% of “the total estimated allowed charges for all such MPFS covered professional services”35 that are furnished during the calendar year and received by CMS by February 28th of the following year. (The payment was also 2% in 2009.) The payments continue as follows: 1.0% for 2011 and for 2012, and 0.5% for 2013.36
Note, however, that the incentive does not apply if only a minimum percentage of covered professional services are reported to which the measure applies (for example, this mini- mum was 10% in 2009).37
If, however, the professional does not adopt e-prescribing, a percent reduction in the fee schedule amount paid will be imposed as follows: minus 1.0% in 2012; minus 1.5% in 2013; and minus 2.0% in 2014 and in each subsequent year.38 The program incentives and penal- ties are illustrated in Exhibit 20-4.
Manner of Reporting
Because this is a claims-based reporting program, specific claim form inputs are required in order to receive e-prescribing incentive payments. Quality data codes for the e-prescribing measure are submitted through the Medicare claims processing system. Thus, there is no need to enroll or register, because the entire program reporting is accomplished through the sub- mission of the data codes.39 As a manager you need to remember this, because if the data code isn’t entered properly (or isn’t there at all), then the opportunity for payment is lost.
Three G-codes represent the quality data codes that are used to report the e-prescribing measure. One of these three codes should be entered on the claim:
1. Report G8443 if all of the prescriptions generated for this patient during this visit were sent via a qualified e-prescribing system. (This code is used for the example on Exhibit 20-5.)
2. Report G8445 if no prescriptions were generated for this patient during this visit. 3. Report G8446 if some or all of the prescriptions generated for this patient during this
visit were printed or phoned in as required by state or federal law or regulations, due to patient request, or due to the pharmacy system being unable to receive electronic transmission; or because they were for narcotics or other controlled substances.40
A particular array of 33 professional service CPT or HCPCS codes represents the permissi- ble codes to enter on the claim form in order to qualify for the incentive.41 In other words,
E-Prescribing Incentives and Penalties for Physicians and Other Eligible Prescribers 243
Exhibit 20–4 E-Prescribing for Physicians and Other Eligible Prescribers: Incentives & Penalties
INCENTIVE PAYMENTS FINANCIAL PENALTIES for e-prescribers for non-e-prescribers
Additional % of allowed charges paid % Reduction in fee schedule amount paid
2010 �2.0 2010 0 2011 �1.0 2011 0 2012 �1.0 2012 �1.0 2013 �0.5 2013 �1.5 2014 0 2014 �2.0
Each subsequent year 0 Each subsequent year �2.0
Source: 73 Federal Register 69847-8 (November 19, 2008).
244 CHAPTER 20 Information Systems Changes: The Manager’s Challenge
Exhibit 20–5 Prescribing Claim Form Input Example
Diagnoses for the encounter are placed in Item 21
CMS-1500 Claim Form [adapted for Electronic Prescribing Example]
21 Diagnosis or Nature of Illness or Injury 1. 714.00 2. 250.00
24. A. Date(s) of Service 24.B. 24.D. F. I. J.
Place Procedures, Rendering From To of Services or $ ID Provider
Service Supplies Charges Qual. #
CPT/ HCPCS
01 12 09 01 12 09 11 99202 45.00 NPI 0123456789
01 12 09 01 12 09 11 G8443 0.00* NPI 0123456789
99202 = 24.D. Line 1 Code for a patient encounter during the reporting period shown in 24 A
G8443 = 24.D. Line 2 Code for “all prescriptions generated via qualified e-prescribing system”
0.0 = 24.F. Line 2 Is the line item indicator for the quality measure*
24.I. Indicates Type of Physician ID # (NPI)
24.J. Indicates the rendering NPI number of the individual EP who performed the service
*The field for the quality measure cannot be left blank. **A sole practitioner enters the NPI in a field not shown on this example. Note: Item 24 Columns C, E, G, and H not shown on this example because they would be blank. Source: Adopted from “Sample Electronic Prescribing Claim” available at www.cms.hhs.gov/ERxIncentive.
two codes will be present on an acceptable claim form: one of the 33 professional service codes, plus one of the three quality data codes (G8443, G8445, or G8446).
Remember, you are a successful electronic e-prescriber only if you report the quality data codes (the “applicable e-prescribing quality measure”) in at least 50% of the applicable cases (in other words, 50% of the claims where one of the 33 applicable professional service codes are present). Therefore, CMS suggests reporting one of the three G codes on all of the claims that contain one of the 33 applicable codes. That way you will be sure to meet the 50% reporting requirement.
E-PRESCRIBING TECHNICAL INPUT EXAMPLE
Exhibit 20-5 presents an example of the form input items for a claim that is eligible for the e-prescribing incentive. Only applicable fields (“items”) of the CMS-1500 claim form are shown in the exhibit. Inputs for an e-prescribing incentive encounter are described below as illustrated on Exhibit 20-5:
1. Diagnoses for the encounter are placed in item 21. 2. Dates of service are entered in item 24.A, on both the first line where the professional
service code appears, and again on the second line where the quality data code for the incentive program will appear.
3. The place of service code is entered on both lines in item 24.B. 4. The CPT code for the professional service is placed on the first line in item 24.D. A
particular array of 33 CPT or HCPCS codes representing professional services repre- sent the permissible codes to enter on the claim form in order to qualify for the in- centive. The example on Exhibit 20-5 uses 99202 for the professional service. CPT code 99202 is one of the 33 acceptable codes.
5. The quality data code for the e-prescribing measure is entered on the second line. The example on Exhibit 20-5 uses G8443, which indicates all of the prescriptions gen- erated for this patient during this visit were sent via a qualified e-prescribing system.
6. The charge for the professional service is placed on the first line in item 24.F. 7. Zeroes (0.00) are placed on the second line in item 24.F. It is important to make sure
the zeroes are there, because the quality data measure will not be recognized if this field (item) is left blank.
8. The acronym NPI (National Provider Identifier) is entered on both lines in item 24.I. This acronym indicates what type of identifier will be present in the next column (in item 24.J).
9. The National Provider Identifier (NPI) number of the individual eligible profes- sional providing, or “rendering,” the service is entered on both lines in item 24.J. (Item 24.J. is labeled “Rendering Provider #”). Note that if the eligible professional is a sole practitioner, the NPI is entered in a different field (item 33) that is not shown on this claim form example.
TECHNOLOGY IN HEALTHCARE MINI-CASE STUDY
Information systems changes are the manager’s challenge. But implementing such change is made much easier if the change will visibly ease the staff’s workload. Such was the case
Technology in Healthcare Mini-Case Study 245
246 CHAPTER 20 Information Systems Changes: The Manager’s Challenge
described in Mini-Case Study 4, entitled “Technology in Health Care: Automating Admis- sions Processes.” See the description of the mountains of paperwork in this case, and then see the number of hours saved by implementing an automated solution. This type of change to an information system is a win-win situation.
INFORMATION CHECKPOINT
What Is Needed? If possible, find an actual CMS-1500 claim form. (But be extremely careful to have the provider completely mark out or eliminate all privacy items.) You might have to print one out from an electronic system. Or, as an alter- native, locate a superbill that contains codes for profes- sional services.
Where Is It Found? In the administrative offices of an “eligible professional” How Is It Used? The claim form might be submitted, if eligible, to be counted
for the claim-based reporting of the e-prescribing incen- tive program.
KEY TERMS
Code Users Dispenser Eligible Professional Electronic Prescribing (E-Prescribing) Prescriber
DISCUSSION QUESTIONS
1. Do you believe your place of work will be affected by the ICD-10 transition? If so, how will your employer be affected? If not, why not?
2. Have you seen newsletters or other materials announcing ICD-10 training? If so, where and what have you seen? Do you think the materials adequately explain the necessity for the ICD-10 training?
3. Do you believe any individuals at your place of work are performing professional ser- vices that are eligible for the e-prescribing incentive program? If so, do you believe they are reporting the quality data measures?
4. Have you seen newsletters or other materials describing the e-prescribing incentive program? If so, where and what have you seen? Do you think the materials adequately explain how the incentive program works? (That is, that it is entirely claim-based reporting?)