When I began writing articles for ICD-10monitor, ICD-10 itself was looming on the horizon – on Oct. 1, 2013, to be specific. Now, as we all know, ICD-10 is being delayed until Oct. 1, 2014, which is still more than two years away. While two years is very little time, considering the complexity of compliance, that reality does nothing to mitigate the simple truth that I’m not sufficiently creative to come up with a new ICD-10 article – especially one written in my particular style  – 24 more times! What to do?

As I lay in bed this morning – only half-asleep since my wife once again had to arise at 4 a.m. to catch a 7 a.m. flight to somewhere – it occurred to me that I had only two options:

  • Make this my last article; or
  • Broaden my subject area.

I chose the latter, so if your only interest is ICD-10, then you should move on to something else that will hold your attention. But if you are curious as to what else I can write that will:

  • Not jeopardize my work;
  • Be relatively easy to read; and
  • Have at least a tenuous link to ICD-10,

… then keep reading, and welcome to Volume 1 of “Outside the Scope.”


I believe the Centers for Medicare & Medicaid (CMS) staff does some amazing work – after all, they are tasked with implementing and managing provisions of some of the most poorly conceived legislation ever to come out of Washington. Furthermore, I believe that CMS management truly cares about the viability of Medicare and Medicaid, and really wants to protect individual medical privacy through HIPAA.

But are you familiar with the term “pig in a poke”? It means “something bad, but unseen,” and that pretty much describes a lot of the legislation that has come out of our “no leadership, no direction, do-nothing” Congress and administration. This is simply the most dysfunctional government I can recall since becoming a legal adult, although I can’t recall any that worked well…


The Patient Protection and Affordable Care Act of 2009 is merely the first of several pieces of legislation that, taken together, can be considered the “affordable care legislation.” Today, we don’t care about all those other laws or the bulk of the PPACA itself. We’re going to consider just one component of the PPACA: Section 3025.


Section 3025 is the primary section that defines the Readmission Reduction Program (RRP), which is a perfect example of something politicians do to garner votes. Let’s consider a few elements of the RRP versus what the government PR machine will tell the gullible masses.

“The RRP is intended to reduce avoidable readmissions.”

(Its intent is not in question, but what about the reality? If you do the math, the RRP will reduce Medicare payments, but its impact on “avoidable readmissions” is smoke and mirrors.)

“The RRP penalizes short-stay acute hospitals that have readmission rates higher than their peer group for similar conditions.”

(CMS has declared that approximately 64 percent of hospitals will be penalized for exceeding the readmission rates of their peer groups. But if you are being compared to a group large enough to be considered a “statistical population,” shouldn’t the number be more in the range of 50 percent? That is, half are better, half are worse than the peer group average?)

“The three monitored conditions in year one (which will have begun by the time you read this) are acute myocardial infarction, heart failure and pneumonia. Those cases will be identified by diagnosis code.” (You see, there IS an ICD tie-in!)

(The penalties assigned to each short-stay, acute-care hospital are determined by comparing their readmission rates for three years prior to those of their peer groups. For 2013, beginning Oct. 1, 2012, that means data from July 1, 2008 through June 30, 2011 was used. For 2015, the dates will be July 1, 2010 through June 30, 2013, which means beginning in that year (the 2015 fiscal year), hospitals will be evaluated based on ICD-9 claims but operating under ICD-10. And since GEM (the General Equivalency Mappings) are anything but accurate and complete, this appears problematic.)

“All readmissions are counted, with only two exceptions: PTCA and CABG (in most cases).”

(So this really is not a matter of reducing “avoidable” readmissions. If an individual is discharged from the hospital after a battle with pneumonia and is in a motor vehicle accident two weeks later, then gets readmitted to ANY acute-care hospital – except a CAH or a Maryland hospital – that readmission counts against the hospital that provided the pneumonia care!)

You can see the pattern here. The PPACA is not a law intended to protect patients or ensure affordable care (whatever that is). It is lip service, or a law designed to garner votes – like so many other laws – and I suspect it will succeed with providers footing much of the cost.

Until next time…

About the author

Billy K. Richburg, M.S., FHFMA is HFMA-Certified in Accounting and Finance, Patient Accounting and Managed Care. Bill graduated from the U. of Alaska, Anchorage and earned his M.S. in Health Care Administration from Trinity University, San Antonio, TX. Over a career spanning more than 40 years, Bill has held positions including CEO, COO, CFO, and CIO in hospitals ranging from 75 beds to over 300 beds, and in home health agencies, DME stores, and a home infusion company. Bill is a Board Member of the Lone Star Chapter, HFMA, and is Director of Government Programs for the Revenue Cycle Technologies business segment of MedAssets, Inc. His office is in Plano, Texas.

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