Coders can expect to confront new challenges, including new payment models and HIPAA changes.

The new year brings new challenges for the healthcare industry. From new payment models to updates to the Health Insurance Portability and Accountability Act (HIPAA) to 21st Century Cures, hold on to your hats, because it is going to be a bumpy ride!

The Patient Driven Groupings Model (PDGM) will be implemented by the Centers for Medicare & Medicaid Services (CMS) on Oct. 1, 2019 for Skilled Nursing Facility (SNF) patients. The Health Insurance Prospective Payment System (HIPPS) code will still be reported, but the new system will not be based on Resource Utilization Group version IV. The principal diagnosis will determine the patient’s clinical category. The new groups are based on:

  1. Physical therapy (clinical category and functional score);
  2. Occupational therapy (clinical category and functional score);
  3. Speech and language (presence of acute neurological condition, SLP comorbidity or cognitive impairment, mechanically altered diet, and swallowing disorder);
  4. Non-therapy ancillary (comorbidities based on ICD-10-CM secondary diagnoses); and
  5. Nursing (same as RUG-IV).

There is also a variable per diem adjustment that changes the rate over the course of the patient’s stay. The Minimum Data Set (MDS) will continue to be used under the new methodology as well.

The Patient Driven Groupings Model (PDGM) will be implemented by CMS on Jan. 1, 2020 for home health patients. There are 432 possible case-mix adjusted payment groups for each 30-day period. The groups are based on:

  1. Timing (initial or subsequent);
  2. Admission source (community or institutional);
  3. Clinical grouping (based on principal diagnosis);
  4. Functional impairment (using specific OASIS items);
  5. Comorbidity adjustment (secondary diagnoses); and
  6. Additional payment adjustments based on cost and frequency of visits.

These two reimbursement methodologies will utilize ICD-10-CM diagnosis codes more than the previous methodologies. 

As health information management (HIM) coding professionals move forward into the ICD-10-CM/PCS world, we are still struggling with productivity and quality metrics. In the Journal of the American Health Information Management Association (AHIMA) are articles to assist in establishing your key performance indicators under ICD-10-CM/PCS. One is the articles is titled “New Study Illuminates the Ongoing Road to ICD-10 Productivity and Optimization.” 

HIPAA has been in place since 1996, when it was passed and adopted by Congress. The U.S. Department of Health and Human Services (HHS) is asking for input regarding how the HIPAA law can be amended to promote value-based healthcare. Currently, HIPAA has erected some barriers that have made it difficult to respond to the opioid crisis. The privacy laws are not the same across all states; that is one example of such a barrier. Another issue is patient matching and its impact on value-based reporting. If the patients are matched correctly, then value-based reporting or population health information may be incorrect. If you have any input with regard to changes to HIPAA, please direct your comments to Laura Riplinger, Senior Director of Federal Relations for AHIMA.

A second draft of the Trusted Exchange Framework and Common Agreement (TEFCA) is also upon us. The hope is that it will create a common set of principles for the exchange of data in a secure manner and promote interoperability. One complaint regarding the electronic health record (EHR) is the lack of interoperability outside of each facility. The exchange of data represents a need for value-based reporting.

The Healthcare Information and Management Systems Society (HIMSS) Quarterly Winter Interoperability and Health Information Exchange Community Roundtable will take place on Jan. 16, 2019 from 10:30 a.m.-noon CST. Their topic for this meeting is Community Information Exchange (CIE). 

The uses of ICD-10-CM/PCS continue to grow as we move into this new year. Happy new year, everyone! I hope that you are prepared.



Laurie M. Johnson, MS, RHIA, FAHIMA, AHIMA Approved ICD-10-CM/PCS Trainer

Laurie Johnson is currently a senior healthcare consultant for Revenue Cycle Solutions, based in Pittsburgh, Pa. Laurie is an AHIMA-approved ICD-10-CM/PCS trainer. She has more than 35 years of experience in health information management and specializes in coding and related functions. She has been a featured speaker in over 40 conferences. Laurie is a member of the ICD10monitor editorial board and is a permanent panelist on Talk Ten Tuesdays

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