Guest post: Keep up with coding compliance for physicians facing MACRA changes

by James S. Kennedy, MD, CCS, CDIP

What’s a physician’s favorite radio station? When it comes to coding compliance and revenue cycle management of their practices, WII-FM, What’s In It For Me, is what physicians listen to.

Physician salaries have traditionally been based on CPT-driven relative value units in a fee-for-service environment, meaning the more that the physician did, the more he or she got paid. As a result, many physicians diminished their understanding or application of ICD-10-CM diagnosis coding because, most of the time, these don’t affect physician reimbursement unless it is to determine medical necessity for a procedure they want to perform.

That’s all different now with the ongoing implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), an AMA-sponsored act that will put 4% of a physician’s traditional Medicare fee schedule at risk in 2018 with gradual increases to 9% in 2022. Learn more about MACRA and its Quality Payment Program here.

When fully implemented, 30% of this 9% risk will be based on CMS’ determination of a physician’s cost efficiency based on the physician’s ICD-10-CM coding in his or her patient population for a designated period (usually a calendar year).

To give us some perspective, in the initial years of the CMS value-based payment modifier, only 4.5% were deemed to be cost-efficient, 7.2% were deemed to be cost-inefficient, and the rest (88.3%) were deemed to be average cost. You can bet that physicians want to know how to influence this calculation and not be penalized—and this, unwittingly, might lead to documentation and coding booby traps. As such, CDI professionals and those working in coding and compliance, must monitor and measure their approach to ensure compliant coding for them and our facilities.

Editor’s note: Dr. Kennedy is a general internist and certified coder, specializing in clinical effectiveness, medical informatics, and clinical documentation and coding improvement strategies. Contact him at 615-479-7021 or at jkennedy@cdimd.com. This article originally appeared in Briefings on Coding Compliance Strategies. Opinions expressed are that of the author and do not necessarily represent HCPro, ACDIS, or any of its subsidiaries.