Accountable Care Organizations (ACOs) allow providers to improve the coordination of care for patients by creating incentives for healthcare providers to work together to treat patients across various settings, including doctor’s offices, hospitals and long-term care facilities.

The incentives benefit those physicians, nurse practitioners and physician assistants who work together to mitigate the growth of healthcare costs while meeting performance standards on quality measures and patient outcomes.

Demonstrating the meeting of such standards requires significant infrastructure to manage reporting. Physicians, nurse practitioners and physician assistants first must learn the measures, take steps to identify patients within the ACO and properly document information in the medical record (and, perhaps, report the appropriate Category 2 CPT code).

Organizations must support physicians, nurse practitioners and physician assistants in this process by offering education on the measures, creating documentation templates, mapping the measures using reporting technology, and circling back to the users for reinforcement.

The tie-in of accountable care with ICD-10 exists at every level of managing care. ICD-10 codes provide precise information about patients’ conditions to the Centers for Medicare & Medicaid Services (CMS) without ever requiring the viewing a medical record. Physicians, nurse practitioners and physician assistants document their patients’ conditions with much more precision as become educated about ICD-10, so overall improvement in clinical documentation is achieved. Organizations are able to use technology along with people and processes to report progress on various measures and demonstrate their success in working collaboratively across the continuum of care to improve outcomes for the patients and communities they serve.

Organizations must demonstrate that they meet certain quality standards during each year of participation with ACOs. These standards are demonstrated through four key domains:

Patient/caregiver experience (seven measures)

Care coordination/patient safety (six measures)

Preventive health (eight measures)

At-risk population:

  • Diabetes (six measures)
  • Hypertension (one measure)
  • Ischemic vascular disease (two measures)
  • Heart failure (two measure)
  • Coronary artery disease (two measures)

ICD-10 will identify at-risk populations precisely. Consider the difference between using the ICD-9 codes 250.52 and 362.04 for the diagnoses of diabetes with ophthalmic manifestations and mild non-proliferative diabetic retinopathy versus the single ICD-10 code of E11.32 for same combination of diagnoses.

In the physician office setting, reimbursement will continue to be based primarily upon CPT coding of services. However, there are incentive programs that may adjust payments when high-acuity diagnosis codes are reported. Care for patients who have the high-acuity diagnoses can be correlated with hospitalizations, prescribing of medications, and services such as imaging, monitoring, laboratory testing and others.

Imagine a tale of two patients:

Patient A carries the diagnosis of diabetes, not stated as controlled or uncontrolled, but without manifestations. During a calendar year, this patient has six hospitalizations, each followed by care in a long-term, acute-care facility. This patient has encounters with multiple specialists, all of whom order testing, with many of those tests proving redundant. The patient does not have a primary care provider, and uses the local emergency department or urgent care facility as a healthcare hub.

Patient B also carries the diagnosis of diabetes with ophthalmic, vascular and renal manifestations, including mild diabetic proliferative retinopathy, peripheral angiopathy due to diabetes and Stage 3 chronic kidney disease due to diabetes. This patient sees a primary care provider who has engaged the patient in his or her own health conditions and encourages the patient to monitor blood sugar readings from home. The provider also has ordered home health services to deliver care and support for the patient’s diabetes-related conditions. Although the patient has required two hospitalizations within the year, the transition from hospital to home was managed by the primary care provider, with judicious use of specialists who have committed to collaborative care across the various settings within the system.

Cost for the care of Patient B is likely to be lower, by several orders of magnitude, than the cost for Patient A. Additionally, the quality of life for Patient B potentially could be significantly higher, along with the satisfaction of the physician caring for the patient. There is an improvement in the doctor-patient relationship that follows from close follow-up and collaboration, which leads to better care and improved outcomes for patients.

Technology is foundational for accountable care, and diagnosis coding at the highest possible level of specificity is one piece of the pie. Diagnosis accuracy is essential for managing populations of patients, especially at-risk populations with chronic illness. ICD-10, by design, provides high-specificity diagnoses that will allow risk stratification of patients so that our most vulnerable patients can be identified and proactively managed for optimum clinical outcomes.

About the Author

Lynn Myers, the physician champion of EMR at the Texas Health Physicians Group, and the Chief of EMR and Coding.

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