CHICAGO – September 21, 2017 – Recent shifts in healthcare reimbursement models have trended away from a fee-for-service payment system, and instead tied payments to the quality of care provided. These shifts provide opportunities for health information management (HIM) professionals to help physicians code more completely and precisely to meet requirements under the new reimbursement models.
The article, “Money Troubles: Changing Reimbursement Models Shake Up Physician and Outpatient Healthcare Industry,” in the September issue of the Journal of AHIMA, addresses the reimbursement system changes facing physicians and outpatient facilities and the impact on physician and outpatient coding. It also discusses how newly introduced legislation, such as the Medicare Access and CHIP Reauthorization Act (MACRA), affects coding protocols in these specific settings by requiring more intricate coding, and increasing the need for programs that improve documentation.
“HIM professionals continue to quickly adapt to the changing reimbursement models making their expertise in coding and documentation an invaluable resource to physicians and outpatient facilities during the transition process,” said AHIMA interim CEO Pamela Lane, MS, RHIA. “We have more opportunities than ever to extend our clinical documentation improvement (CDI) skills to the areas in healthcare that are most in need of updated training, and show that every organization needs to know and understand their data and how to improve it.”
The challenge for physicians and HIM professionals tasked with documentation lies within the new Hierarchal Condition Category (HCC) coding system, which is driven by diagnosis and derived from conditions that are monitored, assessed or treated. Although these codes were implemented in 2004, they were largely unused until the Affordable Care Act (ACA) and MACRA made them more important for assessing a patient’s acuity, helping to predict expenditures on a patient for a coverage year. Previously, reimbursement focused solely on the first listed diagnosis, or the condition that prompted the patients to see medical treatment, not on additional conditions.
Specific physician groups and outpatient facilities that are experiencing reimbursement system changes as outlined in the article include:
Physician practices: Reimbursement changes have put additional emphasis on showing evidence of medical necessity, which requires additional specificity in documentation. Smaller offices often lack resources that larger hospitals and healthcare systems have for CDI initiatives that will help this process.
