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Behavioral Health: DSM and ICD Challenges

Planned changes, this year and next, to key standards in Behavioral Health mean that AdvantEdge and our customers will need to work together in close partnership to avoid major disruptions in reimbursement. The challenge is particularly acute in 2013 since the DSM changes coming in May are not well understood by anyone in the industry, meaning that there will be a very compressed timeline to learn about the changes and make the appropriate system and workflow adjustments: both clinical and administrative. While physical healthcare practitioners rely upon the ICD (International Classification of Diseases) to diagnose health conditions, behavioral health clinicians in the United States rely upon the DSM (Diagnostic and Statistical Manual of Mental Disorders) to guide the diagnostic process. According to some estimates, over 500,000 mental health professionals in the U.S. use the DSM manual: 197,000 social workers; 115,000 mental health counselors; 54,000 marriage & family therapists; 93,000 psychologists; 75,000 psychiatric nurses; and 38,000 psychiatrists.[1] This article describes how upcoming changes to both DSM and to ICD are...

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Behavioral Health and Healthcare Reform

As the Affordable Care Act (ACA) kicks into high gear in 2014, Behavioral Health is likely to be impacted more than most sectors.  Special thanks to Lee Dalphonse, CAGS, LMHC, LCDS, ICCDP-D, Vice President of Seven Hills Behavioral Health for his consultative input on this article. There are at least two major ACA impacts on Behavioral Health. The first seems to get more attention: “Mental health and substance abuse parity”[1]. In simple terms, “parity” requires that, when an insurance plan covers Behavioral Health, it must do so on the same terms as for Physical Health. For example, co-pays and deductibles should be the same. Earlier laws required parity for large employer plans. The ACA expands that requirement to the individual and small group market. Note that “parity” does not require an insurer to offer Behavioral Health benefits; it only requires that, if they are offered, the terms and conditions are at parity. However, it is worth emphasizing that the just-published requirements for “essential health benefits” that must be offered...

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ASC ICD9/ICD10 Coding Comparison

Here are some very common upper respiratory diagnoses.  These codes have a direct cross-over from ICD-9 to ICD-10. ICD-9 Code(s) Listed Under:  Diseases of the Respiratory System (Codes 460-519), Other Diseases of the Upper Respiratory Tract (470-478) ICD-10 Code(s) Listed Under:  Diseases of the Respiratory System (Codes J00-J99), Other Diseases of the Upper Respiratory Tract (J30-J39); DIAGNOSIS – Deviated Nasal Septum ICD-9 ICD-9 Description ICD-10 ICD-10 Description 470   Deviated nasal septum  J34.2    Same as ICD-9 DIAGNOSIS – Nasal Polyps ICD-9 ICD-9 Description ICD-10 ICD-10 Description 471   Nasal polyps  J33   Same as ICD-9 471.0   Polyp of nasal cavity  J33.0   Same as ICD-9 471.1   Polypoid sinus degeneration  J33.1   Same as ICD-9 471.8   Other polyp of sinus  J33.8   Same as ICD-9 471.9   Unspecified nasal polyp  J33.9   Same as ICD-9 DIAGNOSIS – Chronic Sinusitis ICD-9 ICD-9 Description ICD-10 ICD-10 Description 473   Chronic sinusitis  J32   Same as ICD-9 473.0   Chronic maxillary sinusitis  J32.0   Same as ICD-9 473.1   Chronic frontal...

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88305 Reimbursement in 2013

  It is the end of March and the significant 2013 Medicare rate reduction for CPT code 88305 (“Level IV – Surgical pathology, gross and microscopic examination) is in effect. The health care reform law mandated that CMS focus on high-volume codes from all specialties as potentially overvalued services. Changes to overvalued codes were reflected in the 2013 Medicare Physician Fee Schedule (MPFS) and because 88305 is a high volume code that not been reviewed since 2000, it was ripe for revision. The result of the review, as most know, was that the technical component reimbursement was reduced by 52% for 2013.  The professional component rate was increased 2%, resulting in a global reimbursement reduction of 33%. The 33% cut to the Medicare global rate has been estimated as a $460 million revenue loss for pathology groups and labs this year.  The estimate is based on $1.378 billion of allowed charges for 2011 multiplied by the 33.4% reimbursement reduction.  The reductions in technical component reimbursement for surgical pathology will...

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New Customer Reports

  In February, we released a new set of “standard reports” for AdvantEdge customers. Based on input from a wide variety of customers and Client Managers, these reports show Charges, Payments, Adjustments, Volume (encounters, procedures, anesthesia case count), A/R and Payor Group information in both tabular and graphic form. The reports are currently available and being deployed to customers. Feedback from these reports will determine a next set of reports in the new format. Of course, all current reports remain available and scheduled for each customer based on their specific needs. Over time, it is expected that the new reports will replace many of the current ones. In addition, InfoEdgeBI can answer almost any ad-hoc information request or question. As a result, we expect to eventually see a set of standard reports that provide routine information (e.g. monthly) augmented by flexible BI-based reports that provide the precise, customized information needed by each customer. AdvantEdge customers with ideas and suggestions should discuss them with their Client Manager: input is always...

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Client First: SALEM, NH

  Samantha Anaya, Accounts Receivable Representative. As part of the AR team for one of our largest clients, Samantha wears many hats. In addition to recovering payment on denied claims, she also fields phone calls from patients, assists in the daily balancing of insurance payments and month end reconciliation, and fills in for me when I’m not available. Samantha puts our clients first every day with her perseverance and determination to ensure that every claim is paid, even if it requires keeping up the pressure for weeks or sometimes even months. Recognized by Ray Baker, AR Supervisor   Stephanie Cambria, Nancy Curtis, Heather Cunningham, Linda Frizzell, Batching Team. All four members of our batching team are being recognized for their teamwork, dedication and efficient workflow, ensuring all charges sent by our clients are readied for billing. The Batching Team, led by Nancy Curtis, receives our clients’ charges in many different forms: secure emails, UPS, fax and the US Postal service.  The team’s standard is to have the charges received, logged, sorted and...

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