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3 Reasons Why Diagnosis Codes Should Be the “Single Source of Truth” for ACOs

Last week, the Centers for Medicare and Medicaid Services (CMS) announced that it reduced the Medicare Accountable Care Organization (ACO) awards for 65 organizations by $41 million due to poor quality performance.

ACOs are groups of doctors and hospitals who are collectively responsible for the quality and cost outcomes of a group of patients. This recent action by CMS has made clear that existing ACOs are having difficulty meeting the quality outcome standards that have been set . There could be many reasons for this, but part of it is that care coordination amongst the various providers in an ACO is very difficult. Patients see so many different providers in so many different settings, it’s vital to establish a single digestible source of truth for any patient’s relevant medical history in order to ensure quality care. For this goal, ACOs should seek help from a perhaps-unexpected source: International Classification of Diseases (ICD), or patient diagnosis codes.

These diagnosis codes, which are based on the patient encounter note, have historically been important for billing and public health purposes. But there are three reasons why these codes are especially suited to being the “single source of truth” for individual patient medical history.

  1. They are short and concise. Your diagnosis codes compress your health history into digestible tidbits. I’ll use myself as an example. In code terms, this year I had a 92002 (routine eye exam), last year I had a 466.0 (acute bronchitis), and way back in 2007 I had a 061 (dengue fever!). Because they are so brief, there’s a higher likelihood they’ll be read and used by providers than other sources like the lengthy, sometimes repetitive problem list.
  2. They are comprehensive. The new set of standard codes, ICD-10, have components beyond the direct illness they concern ( e.g. I97.13 is heart failure following surgery while I11.0 is heart failure due to hypertension). They are particularly rich and include more complete condition identification.
  3. They are heavily scrutinized. Another reason to rely on diagnosis codes is that compared with other types of data, codes are particularly standardized and scrutinized. The U.S. Department of Health and Human Services sets standards for how codes should be applied and the Centers for Medicare and Medicaid Services audits them for their accuracy (and because most every provider and payer takes some Medicare patients, efforts to perform well on these audits have a halo effect).

Because these diagnosis codes are based on information in the patient encounter note, to take advantage of them the patient encounter data needs to be complete and correct. We at Apixio help providers and payers to do this. Good quality outcomes start with an accurate knowledge of how healthy a person is and has been. This is the context from which a provider can prescribe future care. For this reason, diagnosis codes  can play an invaluable part in the effort to improve quality outcomes and provide coordinated care across the continuum.

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