As Occupational Therapy Month comes to a close, it’s a good time to consider all of the pending changes in health care and how they will affect our field. Soon, healthcare providers will be reimbursed for their services in very different ways: new payment models will be driven by data demonstrating effective care, and ICD-10 codes—which serve as one method for gathering such quality data—will be scrutinized to determine what types of people are consuming health care and how they’re faring as a result. Thus, occupational therapists who master this new code set can use it to improve patient outcomes and underscore the cost-effective benefits of their services.
Where We Came From
In 1996, I graduated with a Bachelor of Science degree in occupational therapy. The Diagnosis-Related Group (DRG) payment methodology was new, and lump-sum payments for inpatient hospital stays were doled out based on a patient’s diagnosis. Aside from DRGs, no other sector of health care had to consider cost when providing care. In fact, the fee-for-service model encouraged overutilization of services without consideration of patient outcomes.
At that time, health care felt very much like the Wild West. Each provider was running his or her own show, and coordination of care was an aspirational concept. Often, including occupational therapy in the plan of care was an afterthought—if it happened at all. I often felt like I was designing patient treatment plans in a vacuum, and I questioned how much I was able to help those patients in this manner.
In 2010, the Patient Protection and Affordable Care Act introduced a new, comprehensive focus on patients. The Affordable Care Act recognized that many diseases—such as obesity and adult onset diabetes—require a preventive approach. This new perspective on health care paved the way for the Triple Aim’s objectives of improving access, care, and health, while lowering costs. However, better, more cost-effective care requires new payment models, which demand critical changes in provider behavior. Communication and collaboration with an eye toward cost is no longer optional—it’s now a crucial component of provider and patient success.
Where We’re Heading
New payment models reimburse for value as opposed to volume. The old fee-for-service model eventually may be entirely replaced with the Merit Based Incentive Payment System (MIPS), which cobbles together the best parts of the Physician Quality Reporting System, the Value Based Payment Modifier, and the Medicare Electronic Health Record Incentive Program into a reimbursement model that focuses on quality care, sharing electronic information, and evidence-based practice. Another part of payment reform, Alternative Payment Models (APMs), will bundle payments and encourage providers along the care continuum to share those payments as well as financial risk tied to lack of patient improvement. Providers delivering cost-effective, quality care that improves patient outcomes will benefit by sharing the savings. APMs include Accountable Care Organizations (ACOs), Patient-Centered Medical Homes, and bundled payments for specific services, such as joint replacements.
That being said, payment reform can only be effective through analysis of quality data. ICD-10 is a way for payers—including the Centers for Medicare and Medicaid Services (CMS),—to scrutinize data and drive reform. Therefore, it’s critical for occupational therapists to fully understand ICD-10 so they can use codes that paint a comprehensive picture of the patients they are treating. ICD-10 codes allow us to fully, accurately, and specifically communicate the complexity of each patient, underscore the value of occupational therapy, and justify our treatment plans. However, old habits die hard , and busy OTs may be tempted to rely on what worked in the past.
I am guilty of these bad habits. In the past, I memorized a few ICD-9 codes and applied them broadly to a range of patients. I wasn’t alone in this practice. Most clinics and rehabilitation departments had a weathered Post-it note with their go-to ICD-9 codes taped to a computer monitor. But this technique only worked because ICD-9 lacked specificity, leaving providers with limited choices.
With ICD-10, occupational therapists should resist the urge to replace those tattered Post-it notes with ICD-10 crosswalks, or worse—tape up fresh notes with the code M62.82 (Generalized Weakness). These bad habits will fail us by undermining the value of our services. By using non-specific codes—or not enough codes—we could harm our patients, who may be denied continued services because we did not demonstrate the complexity of their care.
The Power of Occupational Therapy—and ICD-10
Think of your most complicated patient and the impact your occupational therapy plan of care had on that patient’s outcomes. What if your patient was a young woman with brittle diabetes who suffered from low vision, poor balance after several toe amputations, and severe muscle atrophy and neuropathy that impeded her ability to use her hands? Maybe she lives alone, has a small business, and is very active in the community. Her goal is to return to her home and her life, but her most recent fall has left her severely incapacitated. As occupational therapists, we are well equipped to help patients like this young woman achieve their goals. No challenge is too great—unless the payer stops paying because you only coded for“Generalized Muscle Weakness” on your initial evaluation, which did not justify your plan of care for four weeks of therapy to address a variety of complex issues, including low vision and safety needs.
It’s not difficult to see how ICD-10 codes will not only improve patient outcomes, but also demonstrate occupational therapy’s critical role in achieving the Triple Aim’s objectives. We are uniquely trained to (1) identify the factors limiting a person’s ability to engage in his or her occupational roles and (2) develop strategies for returning that person to those roles. Occupational therapists have been thinking about external causes long before ICD-10 stuck a code on it. We asked why our patient was trapped in the bathtub for three days before help arrived or how our patient ran her power wheelchair into the side of a parked car. These factors guided our plans of care and helped us help our patients. Consistently selecting the most specific codes helps us paint a clear picture of our patients and explain why occupational therapy is a critical factor in improving each patient’s outcomes.
So, as April winds down, rip up those notes with your go-to codes,and make a commitment to master ICD-10. First, develop a plan to identify the most specific codes in the shortest amount of time. And don’t be afraid to use all of the tools available to help you get the job done. Here are a few tips and tricks:
While I would never suggest that you rely on a crosswalking tool for determining the right code to use, you can use one—like this one for AOTA members—to help you get familiar with the ICD-10 code set.
Websites such as ICD-10Data.com can help you visually map the ICD-10 CM code set and drill down into specific areas.
I also recommend keeping a Word document with some of your most commonly used codes as well as PDF copies of the Alphabetic Index, Tabular Index, and the CDC’s ICD-10 CM Official Guidelines for Coding and Reporting saved to your laptop.
When the time comes to use M62.82—and at some point it will—you’ll feel good about it, because you’ll know that it really does tie in with your treatment plan and reflect your patient’s deficits. Only an occupational therapist who’s mastered ICD-10 could.