One Symptom in New Medical Codes:Doctor Anxiety

By ROBERT PEAR SEPT. 13, 2015 - http://nyti.ms/1KMrMdq

TERRE HAUTE, Ind. — The nation’s health care providers are under orders to start using a new system of medical codes to describe illnesses and injuries in more detail than ever before. The codes will cover common ailments: Did a diabetic also have kidney disease? But also included are some that are far less common: whether the patient was crushed by a crocodile or sucked into a jet engine.

The more than 100,000 new codes, which will take effect on Oct. 1, have potential benefits, as they will require doctors to make a deeper assessment of many patients.

But the change is causing waves of anxiety among health care providers, who fear that claims will be denied and payments delayed if they do not use the new codes, or do not use them properly. Some doctors and hospitals are already obtaining lines of credit because they fear that the transition to the new system will cause cashflow problems.

“It’s a sea change for physicians,” said Dr. Pardeep Kumar, a 46yearold internist

here who is counting down to Oct. 1. “We will have to be very much more specific.”

Under the new coding regime, government programs and private insurers will require doctors, hospitals, clinics and nursing homes to report vastly more information about the care they provide. Dr. Kumar, who is in practice with his wife, and physicians across America will try to answer questions like these:Did a diabetic also have kidney disease, eye problems or nerve damage?Did a patient with high blood pressure also have signs of congestive heart failure? Was that broken finger on the left or right hand? Was the fracture in the top, bottom or middle of the finger?Was the patient bitten by a horse, a snake or a shark? Pecked by a turkey? Crushed by a crocodile? (Code W58.13.) Or sucked into a jet engine? (Code V97.33.)

The new catalog of codes includes more than 100 for gout and more than 200 for diabetes. In a sign of the times, the government lists more than 30 codes for injuries caused by acts of terrorism.

The codes, from the 10th revision of the International Classification of Diseases, or ICD10, have significant implications for patients. For example, Dr. Kumar said, doctors may need to perform additional tests to help determine if a patient with high blood pressure has heart failure. ICD10 includes 68,000 diagnostic codes, compared with 14,000 in the current compendium. The number of codes for inpatient hospital procedures will expand to 87,000, from 4,000.

Consumers often need prior approval from insurers for expensive tests and medical procedures. To get approval, they need a valid diagnostic code.

Dr. Michael R. Marks, an orthopedic surgeon and coding expert in Connecticut, said that if doctors did not use the proper codes, insurers could delay approval. “The patient,” he said, “will get frustrated and ask: ‘Why has my M.R.I. not been authorized yet? Why has my surgery not been scheduled?’ ”

Professional coders play an invisible but indispensable role in the health care system, reading through medical records and assigning codes to describe patients’ conditions. Accurate coding helps ensure patients get the care they require. It is also a way to justify the services provided. The old codes, in use for more than 30 years, have not kept up with changes in medical technology and treatment. Health care providers are racing to hire coders as the deadline approaches.

Coders are “a hot commodity,” said Kevin M. Carpenter, director of health information management at Rush University Medical Center in Chicago, who estimated that his hospital had spent $5 million preparing for the new codes. That includes the cost of upgrading information technology and training 1,000 doctors and 30 fulltime coders.

The imminent shift dwarfs comparable changes. In 1983, Medicare started paying hospitals a fixed amount for each case, based on the diagnosis, but that was only for hospitals and Medicare patients. In 2014, under the Affordable Care Act, millions of people obtained Medicaid or subsidies for private insurance, but together those changes affected fewer than one in 10 Americans.

By contrast, the federal government says the new codes will be used by doctors and hospitals for virtually all patients. As people make the change, doctors and hospital executives say, it is inevitable that some claims will be denied for services that were provided but not properly coded. Patients may see the denials in statements they receive from insurers.

Many doctors and hospitals say they will step up efforts to collect the patient’s share of the bill, including deductibles and copayments, at the time of service. Doctors and hospitals can revise and resubmit claims to correct the codes. But that takes time and could delay reimbursement.

“We fully expect delays in payment from some insurers,” said Brenda L. Reetz, chief executive of Greene County General Hospital in Linton, Ind. “We don’t have the cash flow of larger hospitals. So we got a $3 million line of credit from a bank, based on the money we expect to receive from Medicaid, Medicare, commercial insurers and patients.”

The hospital has been training employees since November 2013, but Cathy Hadley, director of health information management at the county owned hospital, said, “It will take us 35 percent longer to do coding.”

On its website, Aetna says, “Medical claims will be denied if they don’t use the new ICD10 codes” for services provided on or after Oct. 1. Stacie Watson, an Aetna executive, said: “We are ready. Test results are encouraging. There should be very little disruption if providers and everyone else is ready.”

But Dr. Barbara L. McAneny, a cancer specialist in Albuquerque, expressed concerns. “I don’t think physicians are ready,” she said. “I don’t think health plans are ready.”

Dr. McAneny, a trustee of the American Medical Association, said she and her 17doctor group had taken out a $4 million line of credit to ensure they could pay expenses, including the cost of cancer drugs, if the new codes cause a delay in reimbursement.

Use of the new codes, originally scheduled for October 2013, was delayed a year by the Obama administration and then pushed back another year by Congress.

A Nashville bank, InsBank, is offering a special “ICD10 Line of Credit” to doctors in Tennessee. “Cash may come in slower than usual,” said Blake J. Wilson, a vice president of the bank, but doctors must still pay rent, electricity bills and wages.

Insurers, researchers and some doctors see many potential benefits in use of the new codes. Doctors will have to provide more information about the cause, severity and complications of an illness or injury.

“That will require deeper assessment of the patient.” Dr. Kumar said. The new codes will also make it easier for insurers and federal officials to measure the results of treatment and the quality of care — factors increasingly used in deciding how much to pay doctors and hospitals.

Public health officials say the new codes will help them identify outbreaks of disease, causes of death and community health needs. Researchers say the data will help them evaluate new treatments and procedures.

Dr. Robert W. Lash, a diabetes specialist who is chief of staff at the University of Michigan Health System, said: “ICD10 is a lot more work for many providers, with no obvious short term payoff. But in the long run, we should gain a better understanding of illnesses and injuries and how to treat them.”

Karen Zupko, a coding consultant in Chicago, said orthopedics would be affected more than other specialties because the codes for fractures and injuries are particularly complex. One code in the old system may be replaced by dozens of new options.

Dr. Marks, a former president of the Connecticut Orthopaedic Society, gave an example: A doctor will be asked to specify whether a fractured thigh bone is in the right or left leg; whether the bone protrudes through the skin; whether healing is routine or delayed; and whether the bone fragments rejoin at the wrong angle, leaving the patient with a deformed limb.

“The number of codes is exploding,” Dr. Marks said. “On Oct. 1, we will be speaking a new language. It’s like switching to German, after speaking English for 30 years.”

A version of this article appears in print on September 14, 2015, on page A1 of the New York edition with the headline: One Symptom in New Codes: Doctor Anxiety.

© 2015 The New York Times Company

EHRs Significantly Worsen Physician Job Satisfaction

Study Cites Lower Productivity, Reduced Patient Interaction, Poor Documentation Quality

JOHNSON CITY, TN -- A new study sponsored by the American Medical Association concludes that "EHR technology significantly worsened professional satisfaction in multiple ways". The study, conducted by the Rand Corporation, found that physicians expressed concern that current EHR technology "interferes with face-to-face discussions with patients, requires physicians to spend too much time performing clerical work, and degrades the accuracy of medical records by encouraging template-generated notes," according to a review of the report in Healthcare IT News.

This most recent study adds to the growing body of evidence documenting the problems with the EHR-driven clinical documentation workflow. Other recent studies include:

A physician survey at Riverside County Regional Medical Center presented at the annual meeting of the American Academy of Family Physicians in September of this year found that "the time it took to see a patient and chart the visit increased from 21 minutes to 37 minutes, the researchers found."

A September 2013 study published in the American Journal of Emergency Medicine found that emergency medicine physicians spend almost half their time entering data into EHRs.

The 2013 "Physician Sentiment Index" of 1,200 physicians showed that the percentage of physicians who perceive that the financial benefits of EHRs outweigh the cost fell from 53% in 2012 to 49% in 2013. A March 2013 study by the American College of Physicians demonstrated that physicians describing themselves as "very dissatisfied" with their EHR has risen from 19% in 2010 to 34% in 2012. MedScape's "EHR Report 2012" survey (access requires free MedScape registration, search on "EHR Report 2012") of over 21,000 physicians found that 30% of respondents reported EHRs had a negative impact on the doctor-patient relationship. Of those, 80% said it was due to less eye contact with patients and 75% said there was less conversational time.

Importance for Transcription Companies Many physicians prefer dictation and transcription, but have been told it's not an option once an EHR is implemented. In actuality virtually every EHR has the ability to interface transcribed patient notes; and, transcription does not necessarily prevent a physician from complying with Meaningful Use. For those physicians struggling with clinical documentation via their EHR, dictation and transcription clearly are the better alternative, and can offer a solution for the top three reasons for physician frustration (lowered productivity, reduced patient interaction, poor documentation quality).

CONS 1. The Promises and Challenges of EHR Adoption: EHRs promise to lower costs

resulting from inefficiency and inappropriate and/or redundant care while improving the coordination of care and exchange of information among healthcare enterprises. However, despite these promises and efforts to date, adoption rates among physicians still remain relatively low, with costs cited as a major deterrent. Other adoption concerns include complex organizational and system work flow issues and the increased documentation burdens on the part of physicians when they are asked to use direct text entry. Several studies have shown that practice productivity can decrease by at least 10% following EHR implementation.

2. No matter how advanced the technology and standard vocabularies become, clinical providers and documentation specialists entering data into electronic record keeping systems must be precise, specific, and accurate. Medical transcriptionists serve on the front line of risk management by creating accurate, reliable, and complete transcribed documents that help prevent medical errors, improve patient safety, and facilitate the coding and billing process for insurance programs. Without these knowledgeable professionals serving in this essential risk management role, there is greater potential for increased medical error rates as well as documentation fraud and abuse.

3. The Importance of Integrating People with Technology: New and emerging technologies can greatly enhance documentation processes but their successful implementation hinges on how they are used and integrated into practice. In a report released by the National Center for Research Resources, electronic clinical documentation systems enhance the value of EHRs by providing electronic capture of clinical notes, patient assessments, and clinical reports. Implementation of template-based data capture systems will further streamline the process and create greater efficiency in documentation for some patient encounters. However, the documentation of most encounters will not be readily facilitated by template solutions. To force complex data into a restricted template could greatly compromise both the scope and quality of the patient encounter record and has the potential for greater fraud and abuse in the system. Need a documentation specialist who monitors the quality and placement of the information.

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Professional Transcription Company7 Teleport Drive

Staten Island, NY 10311Tel: (877) 633 - 7652Fax: (718) 227 - 6347