Brief Summary of “Meaningful-Use” for eHRs

Posted on October 21, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

Objectives Listed

By Shahid N. Shah MS

www.BusinessofMedicalPractice.com

In 2009, the ARRA HITECH bill coined the term “meaningful use” and was a game-changer in the healthcare IT industry. In a series of regulations, the Recovery Act specifically required the following.

Summary of MU

Here are the substantive Meaningful Use objectives of the new ARRA HITECH bill:

  • Use Computer Provider Order Entry (CPOE).
  • Implement drug-drug, drug-allergy, drug-formulary checks.
  • Maintain an up-to-date problem list of current and active diagnoses based on ICD-9-CM or SNOMED CT®.
  • Maintain active medication list.
  • Maintain active medication allergy list.
  • Record demographics.
  • Record and chart changes in vital signs.
  • Record smoking status for patients 13 years and older.
  • Incorporate clinical lab-test results into EHR as structured data.
  • Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, and outreach. This is a common feature in EHRs.
  • Report ambulatory quality measures to CMS or the States.
  • Implement 5 clinical decision support rules relevant to specialty or high clinical priority, including diagnostic test ordering, along with the ability to track compliance with those rules.
  • Check insurance eligibility electronically from public and private payers.
  • Submit claims electronically to public and private payers.
  • Provide patients with an electronic copy of their health information upon request.
  • Capability to electronically exchange key clinical information among providers of care and patient-authorized entities.
  • Perform medication reconciliation at relevant encounters and each transition of care.
  • Provide summary care record for each transition of care and referral.
  • Capability to submit electronic data to immunization registries and actual submission where required and accepted.
  • Capability to provide electronic syndromic surveillance data to public health agencies and actual transmission according to applicable law and practice.
  • Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities
  • Generate and transmit permissible prescriptions electronically.
  • Send reminders to patients per patient preference for preventive/follow-up care.
  • Provide patients with timely electronic access to their health information within 96 hours of information being available to the EP.
  • Provide clinical summaries for patients for each office visit.

Conclusion

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Content Exchange and Vocabulary Standards for eMRs

Posted on October 14, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

Understanding Terms and Definitions

By Shahid N. Shah MS

As per the HHS rules, vocabulary standards are standardized nomenclatures and e-code sets used to describe clinical problems and procedures, medications, and allergies for eMRs. Some commons terms and definitions are listed below:

Terms and Definitions

  • ASTM’s CCR – for most of your basic patient summary exchange needs the CCR will meet your needs. If you’re moving from low or no interoperability today to some interoperable capabilities then CCR is your best starting place.
  • International Classification of Diseases, 9th Revision, Clinical Modifications (ICD-9- CM) or SNOMED CT® should populate a problem list. If you’re not familiar with both standards and are unsure where to start, go with ICD-9 for problem lists. SNOMED is not commonly supported in the broad EMR industry but ICD-9 support is quite common so start there.
  • Health Level Seven (HL7) Clinical Document Architecture (CDA) Release 2 (R2) Level 2 CCD – for more advanced patient summary exchange needs the HL7 CDA is recommended. If you’re already supporting CCR exchange and it’s not meeting your needs then HL7 CDA is the next logical place to go.
  • For patient summary exchanges, HHS expect the following fields to be populated: problem list; medication list; medication allergy list; procedures; vital signs; units of measure; lab orders and results; and, where appropriate, discharge summary.
  • ICD-9-CM [ACD-10] or American Medical Association (AMA) Current Procedural Terminology (CPT®) Fourth Edition (CPT–4) to populate information related to procedures. Both of these standards are support broadly by most existing vendors so going with either or both is good.
  • For medication lists, HHS requires the use of codes from a drug vocabulary the National Library of Medicine has identified as an RxNorm drug data source provider with a complete data set integrated within RxNorm.
  • For lab results, HHS requires the use of LOINC® to populate information in a patient summary record related to lab orders and results when LOINC® codes have been received from a laboratory and are retained and subsequently available in your EMR. HHS states that in instances where LOINC® codes have not been received from a laboratory, the use of any local or proprietary code is permitted. HHS does not require these local or proprietary codes to be converted to LOINC® codes in order to populate a patient summary record.
  • For the purposes of electronic prescribing, your vendor must be capable of using NCPDP SCRIPT 8.1 or NCPDP SCRIPT 8.1 and 10.6. With respect to a vocabulary standard, your vendor must use codes from a drug vocabulary currently integrated into the NLM’s RxNorm. For the purposes of performing a drug formulary check, your vendor must be capable of using NCPDP Formulary & Benefits Standard 1.0 adopted by HHS (73 FR 18918).
  • There are standards required for insurance data like eligibility checking and submissions of claims. ASC X12N and NCPDP standards (Versions 4010/4010A and 5010 and Versions 5.1 and D.0, respectively) should be used for these transactions. It’s important to realize that Version 4010 is being phased out in favor of Version 5010 so your vendors need to support both at this time and must be able to move exclusively to Version 5010 in the future.
  • For the purposes of electronically submitting calculated quality measures required by CMS or by States, your vendor must be capable of using the CMS PQRI 2008 Registry XML Specification. Going forward, HL7 Quality Reporting Document Architecture (QRDA) Implementation Guide based on HL7 CDA Release 2 may be allowed but for now focus on the CMS PQRI requirements until HHS provides more guidance in the future.
  • For the purposes of submitting lab results to public health agencies, your vendor must be capable of using HL7 2.5.1.
  • For the purposes of electronically submitting information to public health agencies for surveillance and reporting, your vendor must be capable of using HL7 2.3.1 or HL7 2.5.1 as a content exchange standard. At this time HHS not required adverse event reporting nor have they adopted a specific vocabulary standard for submitting information to public health agencies for surveillance and reporting.
  • For the purposes of electronically submitting information to immunization registries your vendor must be capable of using HL7 2.3.1 or HL7 2.5.1 as a content exchange standard and the CDC maintained HL7 standard code set CVX -Vaccines Administered18 as the vocabulary standard.

Assessment

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Conclusion

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More on the Meaningful Use of eMRs

Posted on September 3, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

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Final Meaningful Use Rules Released by HHS on July 13, 2010.

[By Shahid N. Shah MS]

Link: http://shahid.shah.org

For ambulatory care practices and physicians there are about 25 objectives and measures that must be met to become a “meaningful user”. Keep in mind that meaningful use is not tied to a certified EHR alone; in fact, unless you use the EHR properly and in all the ways the government wants you to, you will not be a “meaningful user”. Don’t be fooled by EHR vendors guaranteeing that they will make you a “meaningful user” – no vendor’s software, no matter how nice, can get your staff to use the software in the way the government wants. You, as the CIO of your practice, are the only one that can guarantee that. In fact, you don’t even need an EHR from a vendor to meet the requirements – you can even roll your own, use open source, or find any other means. But, in general, as long as you can attest and send data to the government that they require you can do it in any way that you want. Be aware that some unscrupulous vendors are scaring practices and making promises that they cannot keep.

Final MU Rules

The final Meaningful Use (MU) Rule was published by HHS on July 13, 2010. It defines 24 objectives for and measures eligible hospitals that could be met to become a meaningful user and qualify for incentive funding. There is a “core set” that must be met by all institutions and a “menu set” of from which organizations must implement at least 5 objectives.

Core Set Objectives

These are the “core set” of 14 objectives that must be met by all institutions and a “menu set” of 10 from which organizations must implement at least 5 objectives (at least 1 public health objective must be chosen from that set).

  1. Use Computer Provider Order Entry (CPOE).
  2. Implement drug-drug, drug-allergy, and drug-formulary checks.
  3. Record demographics.
  4. Implement one clinical decision support rule.
  5. Maintain a problem list of current and active Dxs based on ICD-9-CM or SNOMED CT.
  6. Maintain active medication list.
  7. Maintain active medication allergy list.
  8. Record and chart changes in vital signs.
  9. Record smoking status for patients 13 years or older.
  10. Report hospital clinical quality measures to CMS or States.
  11. Provide patients with an electronic copy of their health information, upon request.
  12. Provide patients an e-copy of discharge instructions at time of discharge, upon request.
  13. Exchange key clinical e-information among providers and patient-authorized entities.
  14. Protect electronic health information.

Menu Set Objectives

These are the “menu set” of 10 objectives from which organizations must implement at least 5. At least one public health objective must be chosen from this set as well (numbers 8, 9, or 10).

  1. Drug-formulary checks.
  2. Record advanced directives for patients 65 years or older.
  3. Incorporate clinical lab test results as structured data.
  4. Generate lists of patients by specific conditions.
  5. Use certified eHR technology to identify patient-specific education resources and provide to patient, if appropriate.
  6. Medication reconciliation.
  7. Summary of care record for each transition of care/referrals.
  8. Capability to submit electronic data to immunization registries/systems.
  9. Capability to provide electronic submission of reportable lab results to public health agencies.
  10. Capability to provide electronic syndromic surveillance data to public health agencies.

Assessment

As can be seen in the link below, the Office of the National Coordinator for Healthcare IT (ONCHIT) is a component of the Department of Health and Human Services (HHS). ONCHIT, usually abbreviated just ONC, is the principal policy group of the Federal Government that defines and manages NHIN.

  • ONC is responsible for coordinating with the Department of Commerce’s National Institute of Standards and Technology (NIST) on the specifications for the NHIN standards.
  • The HIT Policy and HIT Standards Committees are the working groups that advise ONC on what to put in the standards.
  • NIST is responsible for coming up with the test materials (assertions, procedures, methods, tools, data, and so on) that will be used to certify working systems.

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Health Insurance Prospective Payment System [HIPPS] Grouper Software and Documentation Codes

Posted on October 13, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Enter the CMPs

Understanding Home Health Prospective Payment System (HH PPS) Case-Mix Refinement Changes

[By Staff Reporters]

AdvocacyA few operational changes were made to the V-Code Table in the updated version of the ICD-9-CM Official Guidelines for Coding and Reporting, including:

  • HH PPS grouper software and documentation (effective October 1, 2006): Contains Version 1.06 of the home health PPS case mix grouper software codes, which accommodates changes in OASIS reporting requirements effective 10/1/2006.  Also includes the grouper coding logic (pseudo-code), test records, and demonstration programs.
  • HH Consolidated Billing Master Code List: An Excel workbook file containing complete lists of all codes ever subject to consolidated billing provision of HH PPS.  A master list worksheet shows the dates each code included and excluded from consolidated billing editing on claims, with associated CMS transmittal references.  The master list also associates each code with any related predecessor and successor codes.  Supplemental worksheets show the list of included codes for each CMS transmittal to date.

Example:

The national unadjusted (wage index) per-visit rate payments paid per code were: [a] home health aide $44.37; [b] medical social service $153.55; [c] occupational therapy $105.44; [d] skilled nursing care $95.79 and [e] speech pathology $113.81.

Assessment

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Understanding the Medicare Prospective Payment System

Posted on September 17, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

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Origins of Diagnostic Related Groups

By Dr. David Edward Marcinko; MBA, CMP™

[Editor-in-Chief]dem21

The Medicare Prospective Payment System (PPS) was introduced by the federal government in October, 1 1983, as a way to change hospital behavior through financial incentives that encourage more cost-efficient management of medical care. Under PPS, hospitals are paid a pre-determined rate for each Medicare admission. Each patient was classified into a diagnosis-related group (DRG) on the basis of clinical information. Except for certain patients with exceptionally high costs (“outliers”), the hospital is paid a flat rate for the DRG, regardless of the actual services provided.

Enter the DRGs

Each Medicare patient is classified into a DRG according to information from the medical record that appears on the bill:

  • principal diagnosis (why the patient was admitted);
  • complications and co-morbidities (other secondary diagnoses);
  • surgical procedures;
  • age and patient gender; and
  • discharge disposition (routine, transferred, or expired).

Medical Records DocumentationMedical Records

Diagnoses and procedures must be documented by the attending physician in the patient’s medical record. They are then coded by hospital personnel using ICD-9-CM nomenclature. This is a numerical coding scheme of over 13,000 diagnoses and more than 5,000 procedures. The coding process is extremely important since it essentially determines what DRG will be assigned for a patient. Coding an incorrect principal diagnosis or failing to code a significant secondary diagnosis can dramatically affect reimbursement.

DRG Categories

Originally, there were more than 490 DRG categories defined by the Centers for Medicare and Medicaid Services (CMS, formerly known as the Health Care Financing Administration [HCFA]). Each category was designed to be “clinically coherent.” In other words, all patients assigned to a DRG are deemed to have a similar clinical condition. The PPS is based on paying the average cost for treating patients in the same DRG.  Each year CMS makes technical adjustments to the DRG classification system that incorporates new technologies (e.g., laparoscopic procedures) and refines its use as a payment methodology. CMS also initiates changes to the ICD-9-CM coding scheme. The DRG assignment process is computerized in a program called the “grouper” that is used by hospitals and fiscal intermediaries. It was last significantly updated by CMS in 2006.

Assessment

Each year CMS also assigns a relative weight to each DRG. These weights indicate the relative costs for treating patients during the prior year.  The national average charge for each DRG is compared to the overall average. This ratio is published annually in the Federal Register for each DRG. A DRG with a weight of 2.0000, for example, means that charges were historically twice the average; a DRG with a weight of 0.5000 was half the average; and so on.

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Understanding Deviations in Medical Billing

Posted on August 21, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

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Appreciating Normative Comparisons

[By Patricia A. Trites; MPA, CHBC, CPC, CHCC, CHCO ]

tritesDeviation in medical billing can be detected through utilization data that insurance companies produce on all providers that submit a claim for payment of services.

Insurance companies track utilization through a variety of parameters, including CPT codes, ICD-9-CM, or number of referrals. Different programs utilize certain benchmarks to trigger a review.

Example

For example, a physician who sees patients in the office from 8:00 a.m. until 8:00 p.m., seven days a week and has the highest billing amounts in the region can be subjected to a review. This doctor’s activities would be scrutinized. The utilization review department would probably flag this doctor’s provider number and request more information on a sampling of his or her claims, based on the volume.

Utilization Review

Some utilization review activities may occur due to the type of services that a doctor may offer. For example, if a cardiologist should suddenly start billing for a large number of incision and drainages of abscesses, this might trigger a review, since that might not be a typical scope of service for this doctor in this locality. The same could be said for a pathologist, triggering a review due to the high volume of wound care or ulcer debridement.

Audit Trigger Thresholds Vary

Thresholds vary from locale to locale regarding what triggers an audit. There are consultants who have suggested querying the local carrier for provider specific information regarding utilization activity to compare against community performance. Some Carrier Advisory Committee (CAC) representatives have indicated that this may bring undesirable attention from the Medicare program and trigger an audit. Consult professional associations. and, if possible; local CAC representatives to obtain most current information in your area.

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