The long-anticipated proposed rule defining meaningful use finally was released by the Centers for Medicare and Medicaid Services (CMS) on Dec. 30. On the same day, we also received the interim final rule setting initial EHR technology standards, implementation specifications and certification criteria from the Office of the National Coordinator for Health Information Technology (ONC). You can view draft copies of both rules at www.federalregister.gov/inspection.aspx.

As it turns out, CMS will define meaningful use objectives in three distinct stages. Providers who meet the criteria in each of the three stages may be eligible for thousands of dollars in incentive bonuses through the American Recovery and Reinvestment Act (ARRA). In this proposal, however, CMS has only defined the requirements for Stage 1, which focuses on:

“…electronically capturing health information in a coded format; using that information to track key clinical conditions and communicating that information for care coordination purposes…implementing clinical decision support tools to facilitate disease and medication management; and reporting clinical quality measures and public health information.”

Stage 1 includes many of the recommendations that the HIT Policy Committee made last summer, although with modifications. Among them: use computerized provider order entry (CPOE); implement drug-drug, drug-allergy and drug-formulary checks; maintain up-to-date problem lists; use electronic prescribing; incorporate clinical lab-test results into EHR as structured data; and check insurance eligibility electronically from public and private payers.

Stage 2 criteria, to be proposed by the end of 2011, is expected to expand on Stage 1 criteria to more fully emphasize structured data exchange. Stage 3 will focus on “…decision support for national high priority conditions, patient access to self management tools, access to comprehensive patient data and improving population health.”

Look closely at this proposal. As you read, it becomes clear that interoperability is a major tenant of meaningful use. In fact, I would argue that saying this proposal defines meaningful use of “the EHR” falls short of the whole truth. Be careful not to limit your thinking to “medical record” technology alone. The reality is that the current definition requires interoperability across the entire HIT spectrum. CPOE, e-prescribing, clinical and outcomes data, insurance eligibility. You cannot achieve even these elements – which represent just the tip of the iceberg – unless interoperability is a criterion for every aspect of your HIT.

“‘Meaningful use’ is a term defined by CMS and describes the use of HIT that furthers the goals of information exchange among health care professionals.” That statement, found in the background section of the proposed rule, points to the undeniable standard toward which we are headed. It requires us to move data not only within our own organizations, but among myriad entities and applications. Does your HIT – across the board – possess the interoperability necessary to meet future requirements? That’s the question we all must examine.

It appears the American Medical Association (AMA) is unveiling a new strategy to help provide much-needed room for expansion. The association is calling it the CPT “resequencing initiative,” and explains it this way:

“Resequencing of CPT codes allows placement of related codes to an appropriate location regardless of the availability of code numbers for numerical placement. This initiative also allows the CPT code set to expand and grow as a HIPAA designated code set and demonstrates the capacity to respond to today’s health information technology (HIT) requirements.”

So, don’t let the name fool you; in this case, “resequencing” has nothing to do with the order in which you list codes on a claim. One example you’ll see is neck tumor excision code 21556. The AMA apparently wanted to revise it to designate tumors of varying sizes. But there was a problem: CPT already contains codes 21555-21557 in numeric order – no room to add another code to the family.

So, as part of the 2010 resequencing initiative, code 21556 will read, “Excision, tumor, soft tissue of neck or anterior thorax, deep, subfascial, (e.g., less than 5 cm).” Then, after it, you’ll see “#21554 – … 5 cm or greater.” After that, you’ll find radical resection code 21557. In other words, “available” code number 21554 will appear in the CPT manual – with the # symbol – between “already taken” code numbers 21556 and 21557.

To understand why CPT is breaking its long tradition of numerically sequenced code families, you must step all the way back to May 1998, when a Notice of Proposed Rule Making (NPRM) regarding Administrative Simplification criticized the CPT code set as “not always precise or unambiguous” and limited in its growth capacity due to its hierarchical structure. (You may remember that ICD-9-CM shared the same censure.)

With the benefit of hindsight, of course, we know that CPT nonetheless was chosen as the standard code set for electronic physician service claims. Still, those criticisms have driven some of the changes we’ve seen over the past several years – from the deletion of the phrase “with or without” from many code descriptors to the renumbering of entire code sections (for example, this year’s injection and pediatric E/M codes). Now, rather than delete and renumber code families that have “outgrown” their allotted space within the manual, the AMA is attempting a new way to work around CPT’s inherent size limitations.

This bill is one you may want to watch closely. The reason: it would allow payment delays of up to one year if the government suspects waste, fraud or abuse – essentially circumnavigating current prompt payment rules.

“Because of this prompt payment rule, the government puts itself in a position of having to pay and chase Medicare fraud, instead of working to prevent it in the first place,” Grassley says in a press release introducing the bill. So, Grassley proposes to “…give the Secretary of Health and Human Services authority to extend the time period in which payments must be made under the prompt payment rule if the Secretary determines there is a likelihood of fraud, waste or abuse. With this additional time, the Secretary would be required to conduct more detailed reviews of the claims in question to make sure they are supposed to be paid.”

Theoretically, of course, this bill makes perfect sense. Who can argue against proactively fighting Medicare fraud and waste, especially with some estimates saying it costs us $60 billion annually?

The devil, as always, is in the details. Few providers intentionally seek “wasteful” Medicare spending. But does a provider risk heightened scrutiny if he consistently bills level 4 office visits that government auditors believe warrant only a level 3? Where will the line be drawn in determining the “likelihood of fraud, waste or abuse”?  That’s what we don’t know, and need to watch.

If this bill were to be passed – which is far from a done deal at this very early stage – it would certainly intensify the importance of clean claims submission to your cash flow. Playing devil’s advocate, let’s say Medicare were to question some of your level 4 office visits. Consider the effect of payment potentially delayed as long as a year, with the government allowed “whatever time is necessary” to conduct its claims review.

Is it worthwhile to try to combat inappropriate and erroneous Medicare payments? Absolutely – no one would dispute it. Just be aware that prevention of unintended consequences rests in crucial details.

The good news, of course, is that you can be proactive. Whether or not this particular bill becomes law, there are many tools available that you can use right now to ensure each claim, to every payer, is scrubbed clean prior to submission. The immediate benefit to your denial and rejection rates is obvious – the future benefit to reducing any potential red flags may be every bit as profound.

Unfortunately, an important matter of semantics sometimes unwittingly leads us to heated debate or a dismissive, “They don’t know what they’re talking about!” attitude. It’s imperative to be aware that discussions of “interoperability” and “integration” can easily leave people talking apples and oranges without ever knowing it.

Here’s the reason: People from so many disparate backgrounds – technological, clinical, business, regulatory, governmental – all play a role in the current push to better automate healthcare. Everyone understands the generalities behind the idea of one HIT system “talking” to another, but most folks have no need to delve into nitty-gritty technical specifics. As a result, “interoperability” and “integration” have become broad-brush terms many of us use synonymously as a way to express the general concept of data connectivity.

However, these terms are not interchangeable at all to those deeply involved in the technical details necessary to bring about the transformation of HIT. Each term, in fact, has its own clearly distinct meaning.

Start with this carefully-wrought definition of interoperability created in 2005 by the Integration and Interoperability Steering Committee (I&I) of the Healthcare Information and Management Systems Society (HIMSS): “Interoperability means the ability of health information systems to work together within and across organizational boundaries in order to advance the effective delivery of healthcare for individuals and communities.”

HIMSS goes on to define six requisite dimensions for total interoperability, but this is the foundation. (From there, you should also understand that “semantic interoperability” drills down even further to describe when disparate systems not only share information, but allow receiving systems to understand/use incoming data while still preserving the data’s original “meaning.”)

Now take a look at the HIMSS definition of integration: “…arrangement of an organization’s information systems in way that allows them to communicate efficiently and effectively and brings together related parts into a single system.” As you can see, HIMSS differentiates between intra-organizational connectivity (interoperability) and inter-organizational connectivity (integration). Very different concepts.

So, when someone engages you in a serious discussion about interoperability or integration, it may be worthwhile to take a moment to be sure you’re both talking apples to apples. Are you speaking in generality, or in technical detail? Explain how you define the terms, and know how they define the terms as well.

Rather than contemplating an EMR purchase or PMS evaluation in the context of “what’s available,” consider how well these technologies will serve as your platform from which to custom-build, taking into account future needs as well as current.

It is similar to when, as a teenager, I went to buy my first stereo system. I saved up, went to the store, and there they helped me design my own system to suit my listening style. Two speakers or four? Turntable or tape player? Headphones? The stereo store catered to my taste, my music, my needs – and I ended up with a system that was perfect for me.

It’s the same concept with HIT. An interesting article posted on amednews.com addresses the fact that many organizations now are considering updating their PMSs just because they can get a “package deal” from an EMR vendor. That’s not necessarily a bad thing. However, you must be certain you won’t be limited by these systems. Think long-term. Don’t shackle future functionality with current system constraints.

One key point to consider: Are you investing in open systems that promote connectivity with a wide range of revenue cycle applications? Among other benefits, the ease of information exchange promoted by open systems fosters both increased efficiency and error reduction (because information doesn’t need to be re-entered into disparate systems).  

Be careful. While I definitely advocate analyzing your PMS and other systems in tandem with your EMR, make sure you don’t inadvertently short-change PMS or other functionality by tying your selection solely to an EMR vendor’s offerings. A vendor that limits the software packages you can pair with your PMS, for example, may force you to choose an application unable to support your mission-critical goals such as claims processing or revenue cycle management.

No two healthcare organizations are the same, so the “one-size-fits-all” technology approach simply isn’t feasible. You must have the flexibility to pick and choose among various technologies – perhaps using an EMR system from one vendor and a PM or lab reporting application from another. In fact, from my experience, I can say without reserve that this is one area where open systems are vital.

I urge you to keep this in mind as you consider which technologies will best position your organization for future prosperity. Be alert to attempts to hinder your selection of complementary software. Consider your EMR options. Consider your other technology options. Choose those you feel will best fit your unique requirements – resulting in “sound” decisions for today and tomorrow.

However, I’d like to offer one caveat: Please don’t allow confidence in technology to detract from the value of self-audits. Technological aids don’t render coding and billing audits obsolete. As advantageous as some coding tools are, ongoing self-evaluation remains the single best way to ensure optimal coding practices – those that garner appropriate reimbursement while also protecting against payer investigations.

Take, for instance, evaluation and management visits (otherwise known as E/M services). They are the lifeblood of many practices, yet they still account for a significant portion of the errors found in Medicare’s Comprehensive Error Rate Testing (CERT) audits. Perhaps that accounts for certain E/M services remaining on the Office of Inspector General (OIG) Work Plan for 2010.

Granted, a properly-constructed self-audit takes time and a degree of analytical savvy. But it is the most reliable way to pinpoint your compliance risks, as well as potential reimbursement opportunities. It serves two proactive functions: 1) identify and correct coding errors and 2) support justifiable outliers.

The provider who consistently bills 99213 for every patient “just to be safe,” for example, in reality may open your practice to risk of payer audit. Payers often evaluate bell-curve data, which places “flat-liners” in the crosshairs. (Not to mention, a self-audit may reveal the provider’s services truly warrant higher-level, higher-paying codes.)

Conversely, you may be able to solidly defend the seemly risky provider who often bills the highest level visit codes. Your self-audit may show that this particular provider sees only high-complexity patients.

A good self-audit requires you to review your standards and procedures, as well as your claims submissions.

• Medical necessity is the “overarching criterion” for payment of any service. It is a compulsory element, in addition to the specific requirements of any CPT code.
• The documentation itself – not the volume of documentation – supports the level of service reported.
• Documentation of established patient office visits only needs to contain two of the three “key components” of the applicable code. However, it still must provide evidence to support the medical necessity of the visit.

As you research your options, however, I’d suggest that one important place to begin is with a candid assessment of your organizational partnerships. The Herculean effort needed to successfully transition these two critical data sets at the same time will require close collaboration with trustworthy and responsive partners, each working within a well-defined area of expertise.

Consider the ways you can leverage current business relationships to accomplish the task at hand. Obviously, you best understand your business processes. HIT vendors, by contrast, may be better suited to navigate the technological waters. We don’t each need to reinvent the wheel; we need to work together.

The changeover to the HIPAA 5010 electronic transaction standard must be completed by January 2012. The move to the ICD-10 code set must be accomplished by October 2013. With precious little room for waste – of time or resources – practices must augment their internal strengths with the strengths outside vendors can provide.

There are many healthcare IT vendors with the requisite technical skills to master the new standards. Of course, some technologies are inherently more seamless than others. Web-based solutions, for instance, don’t require the software implementation necessary for other applications.

But regardless of the technology employed, I urge you not to overlook another crucial aspect of any business alliance: communication. I earlier stated the need to associate with enterprises that are trustworthy and responsive. Foster partnerships with those who listen and respond promptly to your unique organizational needs. A contract doesn’t necessarily equate to true collaboration.

Make sure your vendors talk with you about their plans for the coming transitions. Know their timelines. You have the right to make informed decisions regarding everything from necessary updates to overall process changes.

The reality is that most healthcare organizations have a limited IT staff – and most of them now are stretched to maximum capacity. Successful, seamless transition of these data sets, therefore, depends upon genuine teamwork with respected partners.

Some of the goals of this initiative, according to a HealthLeaders Media article posted online last week, include providing a physician’s staff the ability to:

• quickly verify patient eligibility;
• easily identify benefit information (e.g., co-pays, co-insurance, deductibles);
• handle real-time referrals and preauthorizations; and
• submit and manage claims online.

Take a moment to read the article yourself. As you do, you’ll no doubt see the wisdom in using the kinds of tools available through Web-based technology to tame the paperwork tiger.

You may even wonder why it has taken so long to put the inherent advantages of the Web to work in the healthcare arena. After all, the article notes our healthcare system could save up to $30 billion if we simply automate paperwork functions. That’s $30 billion – with a “b.”

So why has it taken so long? Well, the truth is – it hasn’t. Web-based solutions already exist that do most of the tasks being “tested” in the Ohio pilot program.

Applications are out there that allow real-time eligibility verification. Any physician practice that wants to can check coverage dates, benefit ceilings, co-pays, deductibles, etc., before patients ever receive services.

There are practices that now submit both their primary and secondary claims via the Web. Other practices currently use Web technology to automate the process of receiving and posting payments. In reality, the concept of applying Web-based solutions to streamline the entire revenue cycle and eliminate paperwork hassles is nothing terribly new.

The buzz surrounding the pilot program, in fact, is as much about who is involved as what. This particular initiative is being promoted by payers in collaboration with organized medicine – a partnership to be praised, most certainly.

But while the whole project focuses attention on the benefits Web-based technology can bring to the future of healthcare, it also underscores the many advantages Web-based solutions already provide today.

But perhaps not. Maybe there is something more we can garner from the release a few days ago of the Medical Group Management Association (MGMA) Cost Survey: 2009 Reports Based on 2008 Data.

According to the survey, multispecialty group practices saw a 1.9% decline in total medical revenue last year. Practices tried to counter the profit bleed by cutting overhead costs, but those reductions were not enough to cover shrinking revenue.

Other key survey indicators appear equally dismal:

• 9.9% drop in procedures performed;
• 11.3% decline in the number of patients seen over a two-year period;
• 13% rise in bad debt over that same two years.

You can read all of the details in the MGMA news release. But meanwhile, it’s imperative for us to ask what these numbers really indicate. What is the take-home message? That it is impossible to run a profitable medical practice in a bad economy?

No. This seemingly apparent conclusion completely overlooks a crucial nugget of strategic business intelligence: I believe this survey instead illuminates the importance of using all tools at your disposal to ensure effective collection of every dime your practice is owed.

The true take-home message: Financial success for any medical practice – especially in tough times – depends on efficient, reliable revenue cycle management. Nothing should slip through the cracks.

The president and CEO of MGMA, William F. Jessee, MD, FACMPE, said it well: “Even in a good economy, many of our member practices have trouble staying financially solvent, so now it’s more important than ever that practices look for ways to operate as efficiently and effectively as possible.”

That includes taking advantage of the benefits that automation offers all aspects of the revenue cycle. Tools exist to ensure timely receipt of all receivables, without the unproductive hassles of manual processes.

Take that 13% rise in bad debt as an example. One can only speculate how much that number would plummet if every practice conducted automated eligibility verification at check-in, with a resulting increase in appropriate co-pay and deductible collection. On the back end, essential strategies should center on proper and optimal coding, as well as reducing payer rejections and ensuring you submit claims to secondary payers rather than leaving those balances on the table.

Yes, times are tough. No one can afford to forego earned revenue. Respond to that challenge by making sure each stage of your revenue cycle operates at peak efficiency.