Medical record compliance audits are looming

November 25, 2013

By Walt Whitley, O.D., Jason Miller, O.D., and Chuck Brownlow, O.D., AOAExcel™ medical & records consultants

Multiple Procedure Payment Reduction Policy (MPPR), Health Insurance Portability and Accountability Act (HIPAA), and International Classification of Diseases 10th edition (ICD-10) are all hot topics that will continue to impact our practices.

With the continuous efforts from Medicare and the offices of the Inspector General and Health & Human Services (HHS) to ensure compliance, practitioners must ensure their practices are both aware of and complying with these regulations. Medical record compliance audits are looming with many more to come. Here is a review of these issues.

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

The HIPAA Privacy and Security Rules are federal law. The Privacy Rule gives individuals rights over their health information and sets rules and limits on who can look at and receive health information. The Security Rule delineates safeguards to protect health information in electronic form and helps to ensure that electronic protected health information (PHI) is secure. Individuals, organizations, and agencies that meet the definition of a “covered entity” must comply with these regulations.

Optometrists are considered a “covered entity” if they transmit any information in electronic form in connection with a transaction for which the HHS has adopted a standard. For example, submitting an electronic claim to Medicare or another payer is such a transaction.

Several updates to HIPAA implemented this year include:

  • Marketing and Fundraising – The final rules address multiple privacy issues related to uses and disclosures of PHI, such as communication for marketing or fundraising, exchanging PHI for remuneration, disclosures of PHI to persons involved in a patient’s care or payment for care, and disclosures of student immunization records.
  • Notice of Privacy Practices(NPP) – Most covered entities are required to have a NPP, which describes uses and disclosures of protected health information a covered entity is allowed to make. This includes the covered entity’s legal duties and privacy practices with respect to protected health information and patients’ rights. 
  • Business Associate Agreements – HIPAA rules require covered entities and business associates to enter into contracts with their business associates to ensure the business associates will appropriately safeguard protected health information. This serves to clarify and limit the permissible uses and disclosures of protected health information by the business associate, based on the relationship between the parties and the activities or services being performed by the business associate. 
  • Breaches of Protected Health Information – “Breach” is generally defined as the unauthorized acquisition, access, use, or disclosure of protected health information that compromises the security or privacy of such information. Health care practitioners (HCP) may be required to notify affected patients, the HHS, and even the media in the event of a breach of health information protected under the law. If the protected health information is secured by encryption, the security or privacy is generally not considered compromised. 
  • Patient Access to Health Records – Allows patients to request electronic copies of their PHI.
  • Patient Rights When Paying Out of Pocket for Services Rendered – Patients can prohibit their HCP from disclosing their health information to a health plan.

Although the deadline for HIPAA compliance has passed, optometrists should continuously prepare and monitor their practices for compliance. It is the responsibility of each individual in a health care environment to be diligent in following procedures and protocols necessary to accomplish this goal.

Multiple Procedure Payment Reductions (MPPR)

This Medicare policy, which went into effect Jan. 1, 2013, affects the technical component (TC) of several eye procedures. This policy was authorized under Section 3134 of the Affordable Care Act (ACA) and specifies the Secretary of Health & Human Services identify potentially misvalued codes by examining multiple codes frequently billed in conjunction with furnishing a single service.

This reduction mainly affects special ophthalmological diagnostic services such as fundus photography (92250), scanning computerized ophthalmic diagnostic imaging (92132, 92133, 92134), ophthalmic ultrasound, diagnostic (76514) and ophthalmic biometry by partial coherence interferometry with intraocular lens power calculation (92136). (A full list of procedures subject to MPPR can be found at http://go.cms.gov/15BGe1D). The MPPR will be applied when multiple services are furnished to the same patient on the same day. These reductions only apply to the technical component of global services and not the professional component (PC).

When multiple ophthalmic imaging services are provided on the same patient on the same day, the most expensive service will be paid at the normal Medicare physician fee schedule rate, while the TC of the other services will be paid at 80 percent of the fee schedule. Practitioners will receive a Claim Adjustment Reason Code of 59 on the remittance advice when these payments are reduced.

International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10)

ICD-10 will replace ICD-9 Oct. 1, 2014, for reporting medical conditions in patient records and on insurance claims in the U.S.

Although many practitioners are familiar with ICD-9, ICD-10 is completely different, which is why it is important for them to prepare. ICD-10 offers more than 70,000 potential choices for coding diagnoses, causes of medical conditions, etc., compared to about 17,000 choices in ICD-9. It is the complexity, though, that will make the preparation easier. The ICD-10 system is so complex that one will need to rely upon software to aid in the choices.

Electronic health records (EHRs) are the answer. The software, which already exists, makes the process simple. In the near future, one will be able to purchase subscriptions for ICD-10 calculators that take the guesswork out of the process.

Additionally, offices using EHR systems will likely have ICD-10 capability built right into the EHR, automatically choosing (or recommending) ICD-10 codes just as they currently recommend choices of ICD-9 codes, based on the content of the patient’s record for the day.

The choice of ICD-10 code will be an automatic, single-entry system, converting the words of the diagnoses into ICD-10 codes.

There is no better time than now for optometrists to start their preparations for ICD-10. Although there seems to be lots of information out there, the best resource to gain an understanding of ICD-10 is available at http://cms.gov/Medicare/Coding/ICD10/index.html. Another helpful tool is to identify the practice’s most common ophthalmologic codes used and “practice” the new conversions using ICD-10 calculators.

The views expressed are those of the authors and do not necessarily reflect the views of the AOA.

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