AMA letter to CMS: Repeal ICD-10

Written by Jill Raykovicz

On Wednesday, the American Medical Association wrote a letter to the US Department of Health and Human Services calling for a repeal of the ICD-10 implementation, slated to be required by all covered entities October 1st, 2014.  AMA Executive Vice President and CEO, Dr. James L. Madara, reasoned ICD-10  “is not expected to improve the care physicians provide their patients and, in fact, could disrupt efforts to transition to new delivery models.”

Financial Burdens and Vendor Readiness

Dr. Madara voiced particular concern for smaller sized practices, where some estimates of the ICD-10 price tag could reach over $225,000, which, he writes, merely compounds other financial hardships such as costs to comply with Stage 2 Meaningful Use, overcoming any impending ePrescribe and PQRS penalties, as well as mitigating the 2 percent across-the-board sequestration cuts now pushed into 2023.

The letter released the results of a report by Nachimson Advisors, which revealed fewer than half (47 percent) of physicians say their practice management system vendor plans on delivering an ICD-10 software upgrade. Of those who are expecting an upgrade, 26 percent expect to receive it before April, 24 percent before July, 13 percent before October, and 1 percent after the October 1st deadline.  These timelines, the AMA argues, is insufficient to perform the necessary testing to ensure the software is working as intended.

Dr Madara also implored Medicare to conduct true end-to-end testing with at least 100 different physician practices of varying size and specialties.  Dr. Madara writes, “We believe end-to-end testing is essential for ensuring the health industry will not suffer massive disruptions in claims and payment processing and ultimately risk physicians’ ability to care for their patients.”

Advance Payment

Dr. Madara also appeals for an “Advance Payment” policy for the more serious cases that would jeapordize a provider’s ability to treat Medicare patients due to non-payment of services. This would apply to those services that have been submitted but not yet paid for date of service after October 1st, 2014, where the provider has already tried unsuccessfully to recoup payment from their contractor but is still weeks or months away from receiving reimbursement.  Dr. Madara reminds CMS a similar policy went into effect after the implementation of the National Provider Identifier (NPI) in 2008, and proposed the following parameters where advance payment would be afforded to providers:

1. When a physician has submitted claims but is having problems getting the claim paid to reach the contractor due to problems on the contractor’s end
2. When a physician has not been paid for at least 90 days
3. When they attest that at least 25 percent of their patients are Medicare and;
4. When they attest that at least 25 percent of their reimbursements are from Medicare.

Two-Year Implementation Grace Period

To battle the learning curve physicians and coders will experience as they gain a better understanding of the specificity required for ICD-10, Dr Madara proposes a two-year “implementation period” during which Medicare will not be allowed to deny payment based on the specificity of the ICD-10 code, and provide feedback to the physician on any coding concerns.  Medicare would also agree not to recoup payment due to lack of ICD-10 specificity during this grace period.


While the AMA confirms their commitment to the successful transtion to new payment and delivery models, and the adoption of technology to promote care coordination,  the letter concludes that  ICD-10 is “unlikely to improve the care physician provide to their patients and takes valuable resources away from implementing delivery reforms and health information technology”.

42,000 Impacted by Insurance Hard Drive Breach

A Wisconsin health insurance group has notified nearly 42,000 of its members that their protected health information may have been compromised following a HIPAA privacy breach.

Back in December, Unity Health Plans Insurance Corporation, which serves some 140,000 members, discovered a unencrypted portable computer hard drive containing health records of 41,437 individuals was missing from the University of Wisconsin-Madison School of Pharmacy. Officials say the school had this information as part of a benefits program evaluation.

Member names, dates of birth, name of prescription drugs and dates of service were contained on the device.

“(We’re) reviewing all our policies and trying to reeducate employees,” Jennifer Woomer Dinehart, spokesperson for Unity Health, told Healthcare IT News. Woomer Dinehart would not confirm or clarify what the company-wide encryption policy was.

“We are sorry this happened and want to provide pertinent information concerning the occurrence along with the steps we are taking to minimize any potential impact,” read a Jan. 30 company notice.

To date, out of the more than 80,000 HIPAA breach cases OCR has received since 2003, only 17 of them have resulted in fines thus far.

Just this past December, the five-hospital Riverside Health System in southeast Virginia announced that the PHI of nearly 1,000 patients had been compromised in a privacy breach that continued for four years. From September 2009 through October 2013, a former Riverside employee inappropriately accessed the Social Security numbers and electronic medical records of 919 patients. The breach wasn’t discovered until Nov. 1 following a random company audit.


Originating Source

Skype With Patients? HIPAA Says “No Go”

Oklahoma medical board sanction against Thomas Trow, MD, sparked concern over the practices of telemedicine and telepsychiatry. Using Skype, Trow conducted online video appointments and prescribed controlled substances to a patient who ultimately succumbed to an overdose. Trow never saw the patient in person before prescribing the drugs. As a result, the Oklahoma medical board published a ruling on January 16 of this year, stating that telemedicine, “Technology must be HIPAA compliant.”

With growing excitement, doctors and patients are “seeing” each other online through a range of video chat technology platforms. In fact, healthcare innovation like telemedicine is vital to the changing landscape of patient demands and government-driven insurance. For many, the Oklahoma telemedicine ruling brings welcome clarification and an opportunity to educate providers about this new way of practicing HIPAA-compliant telemedicine.

“The last thing the U.S. healthcare system needs is to abandon the idea of telemedicine,” said Daniel Gilbert, president and CEO of CloudVisit Telemedicine. “The technology has tremendously positive implications for providers and patients. To lose out because of one platform — a platform that was never designed as a medical tool — would be real detriment.”

Since the Oklahoma ruling does not specifically cite any brand names, many physicians are left wondering, “Is Skype HIPAA compliant?” Skype’s privacy policy simply states that they, “will take appropriate organizational and technical measures to protect the personal data…” and owner, Microsoft Corp.’s Business Associate Agreement (BAA) explicitly omits Skype. To better understand Skype’s security, one must turn to the Health Insurance Portability and Accountability Act (HIPAA).

  • Telemedicine is a HIPAA-compliant method for patient appointments
  • Online video appointments must be conducted via a HIPAA-compliant telemedicine platform
  • Business Associate Agreement (BAA) must exist between the healthcare provider and the company responsible for the telemedicine technology
  • The BAA must guarantee the HIPAA compliance of all measures for security practices and data encryption
  • Providers must obtain informed patient consent prior to conducting online video appointments
  • In absence of a BAA and informed consent, Skype is not HIPAA compliant

“It’s important to keep in mind that Microsoft never intended Skype to be a medical tool,” reminds Gilbert. “Beyond significant HIPAA issues, Skype has many operational shortcomings. CloudVisit provides tools for scheduling and billing, plus treatment notes and more. Skype has none of these features.”

In fact, a search of the word “telemedicine” on the Skype website comes up empty. They do not claim to be HIPAA compliant, nor do they position themselves as a resource for the medical community.

As stated, healthcare practices and patients have a lot to gain from online video appointments. The right technology can be highly effective and appropriate for follow-up care, routine appointments, and mental health consultations once a provider-patient relationship is established in person.

CloudVisit Telemedicine provides a HIPAA-compliant telemedicine and telepsychiatry platform for scheduling, conducting, tracking, and billing online video appointments with patients. CloudVisit enters into a BAA with every client.


Originating Source

Independent Physicians Lag Behind with EHRs

Adoption and use of health IT increased significantly from 2009 to 2012, though there is a sizable gap between the adoption levels of large and small practices.

A study by The Commonwealth Fund measured changes in health IT use over that four-year period. The study found that the percentage of physicians able to electronically send prescriptions to pharmacies rose from 34% to 66% and electronic prescribing increased from 40% to 64% over that timeframe. Adoption of electronic records is where the difference between practice sizes was most pronounced: Only half of solo physicians use EMRs, while more than 90% of physicians in practices with 20 or more physicians do so.

A lack of resources is one explanation why independent physicians and smaller practices aren’t turning to health IT solutions at the same rate as larger ones. Independent physicians’ responses to an athenahealth Inc. survey reflected this sentiment. Fewer than half of independent physicians not associated with hospitals felt the financial and care benefits of EHRs exceeded the costs, while greater than half of their employed peers felt the same.

Independent physicians’ unwillingness to take on major business costs (including those associated with EHRs) is likely contributing to the shrinking number of independent doctors in the U.S. Statistics from Accenture show the percentage of independents sunk from 57% in 2000 to just 39% in 2012. A large majority (87%) of doctors cited business costs and expenses as a top concern and a reason why they’d consider abandoning their independent status.

A data brief from the National Center of Health Statistics (NCHS) focused on physicians’ widespread use of EHR technology. The NCHS data showed that in 2013 78% of all office-based physicians were using some type of EHR, an increase from  18%  in 2001 — something Karen Desalvo, national coordinator for health IT, noted in a recent blog post. Meaningful use incentives are driving many providers to adopt EHR systems. The NCHS brief reported that 69% of physicians intend to participate in the Medicaid or Medicare EHR incentive programs, though only 13% of them had EHR systems in place to support 14 of the 17 stage 2 core objectives. Those statistics represent a fear of independent physicians — adopting an EHR system without qualifying for reimbursement payments.

ICD-10 – Not Just A Coder’s Problem

by Jill Raykovicz

The deadline to transition ICD-10 for all covered entities is October 1, 2014.   If that seems like a long way off, it isn’t.   In terms of actual work days[1], this timeframe is compressed to six months for medical and other healthcare practices to train staff, communicate with vendors, test software systems and claim files, and evaluate current processes to determine in what areas ICD-10 will affect day-to-day office functions.


If this sounds like a problem reserved for coders and billing staff, it isn’t.   CMS’  ICD-10 Implementation Guide for Physician Practices advises,  “Consider getting a line of credit to cover cash flow disruptions due to changing reimbursement models, delays in claims processing and re-processing, staff learning curve and long-term effects of the ICD-10 transition”[2]

Although  CPT and HCPC based reimbursements will not change with the ICD-10 transition, indirectly, fee-for-service payments may have a potential to be adversely affected for the following reasons:

  • Denials will increase because of  incomplete or inaccurate translation of payment rules in payer systems as they attempt to translate these rules from ICD-9 to ICD-10
  • Payments will be delayed because of challenges in claim processing in the ICD-10 environment.

Increased detail contained in ICD-10-CM means that the documentation required will change dramatically.   The level of severity, comorbidities, complications, sequalae, manifestations, and causes that characterize the patient’s condition increases within the ICD-10 coding guidelines.



ICD-10 Coordination Manager

Every office should have an ICD-10 Coordination Manager. Depending on the size of the practice, this could be one person or a committee of persons responsible for communication and coordination with staff, providers, and vendors on key dates and project timelines for an ICD-10 pre and post go-live.

The Coordination Manager will also:

  • Coordinate training schedules and verify staff has attended and completed.
  • Set an ICD-10 project budget in terms of training and software upgrade  costs, coding books and guides, re-printing of encounter or referral forms with the new codes, if necessary, and other costs associated with ICD-10.
  • Determine if re-training is necessary, as we get closer to the October 2014 timeframe.  

He or she (or they) should ensure accurate coding decisions are being made, clinical documentation supports the new ICD-10 specificity requirements, and associated lags in productivity are identified and communicated.


Speaking of training, although most ICD-10 literature advises staff and providers receive training no more than six to nine months from implementation, it is imperative to reserve slots now before classes fill up, or before less than desirable dates and times are the only ones left for either on-site training or off-site seminar.  Don’t wait to contact professional associations around the April 2014 timeframe to find out the on-site ICD-10 trainer’s only availability is the same week Suzie in the business office goes out for surgery.  Or, the only off-site workshop with any seats available is the week before Jane, your charge entry clerk, returns from maternity leave.  


CMS, the American Academy of Professional Coders (AAPC)American InformationManagement Association (AHIMA) and Workgroup for Electronic Data Interchange(WEDI) all have information on ICD-10 training and factors to success.

WEDI and CMS have partnered in taking a proactive approach to answer questions and concerns regarding the ICD-10 transition.  Organizations can submit questions, free of charge, to an online database.

IN CONCLUSIONExpect no more delays or movement of the October 1st, 2014 deadline.  Ready or not, here ICD-10 comes. Through planning, resource management, and effective leadership, medical and other healthcare practices can mitigate disruptions in cash flow as a result of ICD-10.

[1] Based on regular Monday through Friday office hours

[2] ICD Implementation Guide for Small and Medium Practices, p. 31

Physician Practice Consultants is led by Jill Raykovicz, MHA, CMPE, CPC.  Jill has over 15 years’ experience in physician practice management.  She has a strong passion for leveraging this experience and expertise within the private-practice setting, in order to assist independent practices struggling to keep up with changes in healthcare reform, pay-for-performance quality measures, and shrinking reimbursement from third party payers.

Jill holds a Master of Health Administration from Cornell University, is a board-certified medical practice executive (CMPE) through the American College of Medical Practice Executives, and is a Certified Professional Coder (CPC) with the American Association of Professional Coders.

She is also a member of the National Society of Certified Healthcare Business Consultants and the North Carolina Healthcare Information and Communication Alliance ICD-10 Taskforce.

Jill may be reached at

A Cloud Based EMR Does Not A Compliant Entity Make

Snake-oilRecently, a question came up that involved entities that said they are perfectly fine with HIPAA compliance because they use a cloud based EMR (or EHR) who takes care of all their HIPAA compliance for them.

A discussion ensued ending with the question:     This can’t really be true, can it?

I suppose someone could dream up some condition and try to argue it is true.  I, however, tend to follow the statistics.  The chances any group is able to have all the HIPAA compliance requirements handled by their cloud based software provider is so very tiny I will say it can not actually be true.  Yes, some vendors may tell you just that but the term snake oil salesman comes to mind……

Here is your check list of things your vendor must provide to take care of all your compliance for you.  If you actually do have a vendor with all this covered and documented, please let me know.  I am eager to get to know them and work with them.

Does your vendor….

  • Provide a complete and thorough Risk Analysis looking at everything you store in your office that could include PHI.
  • Know every record that comes in and out of your office and how it is managed?
  • Configure your network security and firewall?
  • Monitor you computer systems to confirm they have all their security updates and an active antivirus/malware system?
  • Provide documentation and reports that compliance activity is taking place and reviewing the results?
  • Confirm data you exchange with every single business associate you work with is secured and protected properly?
  • Confirm your Business Associate Agreements are properly in place with every entity that you have a BA relationship?
  • Perform due diligence with all your Business Associates?
  • Update your Notice of Privacy Practices (NPP) to make sure all cases your office should cover is included properly?
  • Confirm you post your updated NPP properly to meet the new requirements?
  • Create a complete disaster recovery and business continuity plan that covers all aspects of your operation being functional?
  • Complete a physical site security checklist and determine all your physical safeguards are adequate and properly documented?
  • Review your administrative safeguards to confirm they are adequate and meet the required and addressable elements properly with documentation of same?
  • Create and monitor a plan for disposal of all media and equipment that may contain PHI – like printers and copiers?
  • Create and document a breach response plan?
  • Create, monitor and execute a training plan for every member of your staff regarding HIPAA terms, requirements, acceptable uses and disclosures, how to identify a breach, what your own internal policies and procedures require for HIPAA and more?

Should I go on, because there is more?  For now, I will just leave it at that.

Don’t get me wrong.  There are a lot of HIPAA things, in the Security Rule especially, that you can outsource to your cloud software provider.  But, even those things don’t relieve you of responsibility.  It is up to you to make sure you document completely and audit regularly to make sure those functions like backup and recovery of the data they maintain, up-time guarantees,encryption at rest and in transit, password and user access controls, etc are actually working as required.

The wall of shame is full of CEs and BAs that thought someone else was taking care of their compliance.  You can’t just say someone else is doing it for me.  If you do, you probably need more training before making your final HIPAA decisions and, of course, detailed documentation of those decisions.   It really takes time and effort on every entity’s part to create their culture of compliance that is really required to make an honest stab at HIPAA compliance in your office.

All this is really a question any CE or BA should be asking themselves no matter who their vendor may be.  Do we have all these things covered?  If you don’t then you definitely need to consider getting some help.  There is a lot to do and you can’t just “mail in” your compliance requirements.


Re-posted with permission. Original post located here.

How Do You Know Who is a HIPAA Business Associate?

One of the first processes we go through for HIPAA Compliance is to identify all Business Associates (BAs).  That has to be done for CEs and BAs alike.  The Final Rule has changed the status and viewpoints for many CEs and BAs. We have addressed a lot of questions on the topic lately.  Now seemed like a good time to go through some of the examples and tips we have discussed with a variety of clients.

The new rule makes it clear.  Signing an agreement doesn’t make you a BA, doing work that gives you access to PHI makes you a BA.  People have claimed exemptions for various reasons for years and that can’t be done any longer.  There are many BAs struggling with the process right now.  Last week, a BA responded to a readiness survey from one of the CEs in our compliance program with a single question “Do we have to fill this out?”.  I am certain that business qualifies as a BA and they obviously have no idea what is going on.  Checking on your BAs should be a top priority based on what we are seeing and hearing.

A great way to make sure you have all BAs on a list is to use your accounts payable as well as the 1099s you generated.  Take a minute to think about every one of them because some may need attention for other HIPAA reasons than being a BA.  We expect at least 5 or 6 BAs for most groups we work with on compliance.  Depending on their structure, size and activities there can many more.  Small CEs and BAs have a different environment than large entities.  It is worth going through the whole list.

Here is a list of similar businesses you may find on your AP/1099 list.

  1. Scrubs That Are Best   – Scrubs Service – We will call them STAB
  2. Clean and Pretty – Cleaning Service – CaP
  3. People Ask You,  Inc – Collections Service  – PAY
  4. Patterson, Salvatori, Bitterman and Enis – Attorneys –  PSBE
  5. Zimmerman and Pierce – Heating and Air Service –  ZaP
  6. Melissa Odum-Madison – Contracted bookkeeper – MOM
  7. Shred, Haul, Install and Track – document management – we will just call them shredding company
  8. Hippert, Ikemoto, Paine, Abruzzo and Alvarez  –  CPA Firm – HIPAA
  9. Advanced Concepts for Your Information Technology – IT support – what everyone calls them –  the computer guy
  10. Medical Equipment Devices – provide medical devices for tests – MED

Now, let’s go through the list and discuss how they may be classified and evaluated.

1- STAB only supplies scrubs for the office so that shouldn’t be a big deal and no HIPAA involved right.  But, in our conversation about BAs we learned that the STAB delivery staff has keys to the back door to drop off the clean and pick up the dirty each week.  That leads to more questions and decisions that must be made due to their physical access controls.  While they aren’t a BA for the work they do, they have access that does involve HIPAA regulations and may have been missed without this exercise.  Don’t put them on your BA list but put it on your “gotta deal with that one” list.

2- CaP only comes in to clean so they should be fine.  We have had them for years and it is a family business.  No HIPAA problems, right.  That depends.  Do you lock up all your charts and computers every night?  Do they only clean when someone is at the office who watches over their work?   In March, the Atlanta Journal reported a case of identify theft that involved office cleaning companies.  People would work for a cleaning company just for a week filling in for someone and stick a usb device in a couple of computers the first night.  Pick it up the last night of their temp job.  The whole time it is logging keystrokes on each computer.  They end up with all the information typed on that computer for the week.  Personally, I find it hard to give cleaning companies the benefit of the doubt in offices any longer.  I think they need to be BAs to be cleaning offices for CEs and BAs now.  There are some cases where they aren’t but it requires laying out very specific guidelines on how the service will be managed in your office.  Most small businesses don’t have that ability.

3- PAY gets a list of patients and all their contact information in order to do the collections.  I have heard some collection companies claim they don’t get treatment information so they aren’t BAs.  What do you give them to contact your patients?  To do your collections they know they saw your practice and they have to have some reference like date of service maybe.  Then, you have to give the date of birth, address, phone.  Well, you see what I mean.  I recommend you treat them as a BA or get a HIPAA attorney involved with an opinion.

4- PSBE handles malpractice claims among other duties for your practice.  There are plenty of references pointing out that they are BAs.  Don’t be surprised if they aren’t eager to admit it, though.  It isn’t unheard of but should be less likely under the new rules.

5- ZaP doesn’t need access to any PHI in order to do their job for you.  But, just as with STAB, the discussion does bring up another issue.  When they come in to work on things in your office does anyone notice what they are doing or where they are at while they are doing it?  Incidental disclosures may happen through the vents they are working on but what about the story about the USB drive and the cleaning crew.  Should you really just let them roam around the office without a thought?  Add another one to the ”gotta deal with that one” list.

6- Good ol’ MOM comes in and helps do the bookkeeping.  She works for us on a 1099 basis but only for us and no other practices or businesses.  Part of the bookkeeping work does make it necessary for her to have access to PHI so what do we do?  Is MOM a BA?  Oh no!  That will just not work – what are we going to do?  Who is going to tell Dr. Madison that MOM is a BA.  Wait, calm down.  No one needs to upset MOM or Dr. Madison.  A 1099 does not make anyone a BA.  In this case, MOM is a member of your workforce under HIPAA definitions.  Include her in the same training and rules you use for all your other employees.  Add it to your ”gotta deal with that one” list to make sure she is included in all the training programs.

7- The shredding company.  We have them covered, they know they are a BA and we have a BAA with them.  But, we still need to see the status of the BAA and update it with the latest requirements.  They also need to provide some assurance they actually are following compliance requirements.  Another thing, though.  As you were pointing out your shredding bins they are just large garbage containers with a lid on them.  There are no locks or anything.  Anyone can open them up and take things out, at will.  They sit over out of the way so no one notices them.  When you contact your shredding company you should probably ask for a more secure container.  One that isn’t so likely to dump things out on the street or be easy access to grab a handful of documents.

8- HIPAA knows they have to deal with HIPAA.  It is in their name!  They write refund checks and have all the details of that patient to reference for accounting for the refund checks.  BA.

9- The computer guy is what everyone calls IT companies in their office.  We are used to it.  We are also used to having access to everything.  There are some “computer guys” that make a case for not being a BA themselves because they never look at the patient data.  Having access to everything means access to everything including ePHI.  You really must have an IT company that is a BA and understands HIPAA Security Rule requirements.  They have to help you implement, monitor and manage your compliance.  BA, big time, because you need them to be one unless you have your own in house IT skills to manage it.

10- MED is like most device companies trying to figure out exactly how they will handle HIPAA.  They have to do it.  It is in discussions all over the place how much data those devices hold now.  They should be prepared more than any of the others on this list for your BA readiness survey.

Hopefully, this helps answer some questions concerning BAs for all those involved.  It may open up more questions but at least we are talking about it differently than before.

Reposted with permission from