Presentation on theme: "ICD-10 Changes Everything in the Revenue Cycle"— Presentation transcript:
1ICD-10 Changes Everything in the Revenue Cycle Presented by:Day Egusquiza, PresidentAR Systems, Inc.Karen Kvarfordt, RHIA, CCS-P, CCDSPresident, DiagnosisPlus, Inc.
2ICD-10 Changes Everything! It’s on your doorstep! The biggest change to happen in Health Information Management and the Revenue Cycle in more than 30 years! Preparation is the key! Will YOU be ready?
3What makes us so different? ICD-10WHO (World Health Organization) owns & publishes ‘ICD’ (International Classification of Diseases).WHO endorsed ICD-10 in 1990; members began using ICD-10 or modifications in 1994.United States is the only industrialized country not using ICD-10 for our coding & reporting of diseases, illnesses, and injuries. Why?What makes us so different?
4Countries Using ICD-10 For Case Mix United Kingdom (1995)Denmark, Finland, Iceland, Norway, Sweden (1994 – 1997)France (1997)Australia (1998)Belgium (1999)Germany (2000)Canada (2001)U.S. (2015) (Reimbursement + Case Mix + HIPAA Standard Transaction Act 2003)
5Why Should We Do ICD-10? What is the benefit to the provider? Dramatic improvement in the assignment of costs to procedures performed.ICD-10 will allow us to develop meaningful estimates about what a disease state or a procedure costs us, while ICD-9 is limited in what it can do in this regard.Identify opportunities to avoid cost & improve lives.Additional information in an ICD-10 diagnosis code includes severity and specific comorbidity, but it can also include information about demographics and some of the underlying reasons for the diagnosis.
6Additional Benefits…Share higher-quality data with other health care providers.ICD-10 increases the amount of “specific” information in every diagnosis code and makes this more valuable to other providers.For example, ICD-9 has a code for laceration of an artery.ICD-10 lets you know if that artery was in someone’s finger or in their heart.
7Reimbursements will better align with activity & cost. Payers will reimburse severe & complex cases better and simple cases at lower rates.How? By the diagnosis codes!
8Here’s an ExampleImagine you had a patient who was noncompliant with their medical therapy.In ICD-9, the only code we have available is V15.81 (personal history of noncompliance with medical treatment).Is the patient noncompliant because of their own personal reason? Or something else?
9How Will it Look in ICD-10?Z (Patient’s noncompliance with dietary regimen)Z91120 (Patient's intentional underdosing of medicationregimen due to financial hardship)Z91128 (Patient’s intentional underdosing of medicationregimen for other reason)Z91130 (Patient’s unintentional underdosing of medicationregimen due to age-related debility)Z91138 (Patient’s unintentional underdosing of medicationShows whether or not the patient’s noncompliance was intentional, but also identifies if the patient needs some form of assistance from social services, etc.
10Non-HIM Uses For ICD-9-CM- Preparing for ICD-10-CM – as we move from 15,000 codes to over 70,000 codes
11Ideas for Physician Engagement Rollout ‘monthly dedicated specialty specific’ audit and training.EX) May is ER month. Coders dual code an identified sample of ER claims. Identify ‘at risk’ documentation by provider. Turn into ‘easy to implement documentation.EX) If the facility has a CDI team, work cooperatively with the coding team to ‘coach/que’ the ER providers thru their month.EX) Do an month end dual coding – show improvement or challenges.
12Exploring new partnerships with provider offices Physician dictates, hospital coders code, UB is created.NEW: Why not share the codes with the providers who are attached to the account? Why repeat the same coding process in the office?NEW: Brown bag coding luncheons with the provider offices. Office brings samples to code, hospital coders code while teaching ICD 10 concepts. (TX: Lunch & Learn weekly)NEW: Hospital becomes the outsourcing company to assist small practices with coding.
13Non-HIM Impact Areas (HINT: Denial Busting) Scheduling –precerts, eligibility.Claims submission with scrubber – both ICD 9 and ICD 10 codes ( Min-1 yr ability to rebill, do duality with IT systems.)Medical necessity CPT codes – software, manual processes, cheat sheetsRecurring accounts – will need new precerts & recoded afterPayer acceptance of new ICD 10 codes PLUS ICD 9 codes – 2 batchesPayer contract language – Dx codesPayer remark codes/denial codesCDM – Hardcoded RT/LT needs to match with the soft coded RT/LT ICD10Trauma/Tumor registry - translatedAll IT systems within the organization837/835 HIPAA transaction sets – new for ICD 10 locatorsQuality of care indicators – translatedP4P indicators/Outcome Measures – translatedDecision Support, utilization patterns, benchmarking – translatedMedical care review – by provider, by dx, by LOSNew business plan research/future healthcare trends – translatedMonitoring and analyzing the incidence of disease & other health problems –translated & newEmbedded dx attached to CPT codesNot case sensitiveRevise forms to include new ICD 10 codes.
14Who Needs to Understand ICD-10? Beyond the coders…PFS leadership as payers may reject based on ICD -10 coding and medical necessary codes & denial software.PFS leadership and contracting to ensure contracts can accept both ICD-9 and ICD-10 on the UBs post go live.UR and all care mgt as payers will need to be able to do pre-certifications and concurrent review with ICD-10.Decision support and all areas using ICD-9/10 coding for tracking, reporting, etc. (Trauma registry, Tumor registry, outcome comparisons, contracting, etc.).IT leadership must be involved to ensure all impacted areas are ready. A team leader or leaders are identified.
15Payer Readiness - Letters with timelines to get started, test, dialogue UB submissions with ICD-9 and ICD conversion datesDenials with new reasons –as ICD-10 is far more specificContract language that addresses ICD-10 inclusions/exclusionsClaim scrubbers/payer scrubbers – ABN issues (LCD/NDC dx codes), ‘if ‘ rules, editsPre-authorization process/coverageWC and Liability are not subject to HIPAA standard transactions. Will they convert?
16More Payer Issues Will they deny ‘unspecified” dx? How many digits will they require to have a ‘pre authorization ‘ match?Testing – test pt type, create claim, thru scrubber, to payer to payment. When start?Post go live? Accept DOS with ICD 9 after go live?If delayed, notify CMS/HIPAA Standard Transaction 2003.Track and trend all payer issues – report to hospital association.
17More On LCD/NCD Diagnosis Codes Under ICD-10 The challenges…What? For each Lab NCD, the ICD-9-CM codes and descriptions will have to be translated toICD-10-CM versions.When?(A) Prepare preliminary versions of ICD-10-CM translations of Lab NCDs by end of January 2011 (for use in testing system functions).(B) Prepare ICD-10-CM versions for full ICD-10-CM implementation in 2015HEY – look at MLN Matters MM“ICD conversion from ICD-9 to related code infrastructure of the Medicare shared systems as they relate to CMS’ NCDs.”
18LCD/NCD Objectives and Goal Translate all ICD-9-CM codes and descriptors in each Lab NCD’s table of covered codes to the ICD- 10-CM equivalent(s).Provide these translated tables to the CMS contractor, so that the tables can be incorporated into the ‘codelist spreadsheet’ which will be processed for use by the shared systems for claims processing (update 2/13 – NCDs available).Goal: Allow consistent and “seamless” transition of claims for providers of laboratory test services.(CONTINUE TO WATCH for payer updates)
19Duality of SystemsWill payers, vendors (claim submission and scrubber) and other IT systems be able to handle ICD-9-CM as well as ICD-10-CM and ICD-10- PCS at the same time?Rebills of pre-conversion, medical necessity software, scrubbers, ensuring all payers are ready to convert AND test with each payer = critical to the successful conversion.P.S. Don’t forget all payers (Medicaid too!)
20Hot SpotsMake a master list of all vendors who currently support any ICD-9 activity. (Think Y2K)Look at all items /ordering tools where ICD-9 codes are present. Need reviewed and revised.Lab requisitionsOnline ordering of services that also requests ICD-9 codesPhysician super bills/encounter forms with pre-printed ICD-9 codesDept. specific ‘cheat sheets’ for covered dx. (Yep we know you have them!)
21Example of 200 Bed Hospital IT List 3M or other encoderMain frame /main IT systemRadiology-doc billing, radiology’s own systemClearing house/claimsHospital employed doctor’s software for billingSNF/RUG software for grouperHH/HHRG software for grouperLab – pathology doc billing, lab’s own systemInternal electronic medical record used for codingSoftware used for Trauma & Tumor RegistryDecision supportScheduling softwareAll tied Medical Necessity software in different areas – main frame, bolt on software, individual areas screeningInfection Control softwareCardiology – EKG systemItemized statements with dx as needed by the payer/ptClinical quality reporting softwareCheat sheets in each dept!OR softwareOccupational Med software
23What is ICD-10-CM/PCS?Department of Health and Human Services (HHS) mandated that HIPAA covered entities must update medical coding sets.Diagnosis code set changes from ICD-9-CM to ICD-10-CM.Hospital inpatient procedure code set changes fromICD-9-CM (Volume 3) to ICD-10-PCS.No impact on CPT and/or HCPCS codes. Yeah!We will still report CPT codes for all outpatient procedures/services & physician hospital visits to Observation and Inpatients (E&Ms).
24The ICD-10 Impact! ICD-10-CM (Diagnoses) ICD-10-PCS (Procedures) Will be used by all hospitals, providers, clinics, lab, radiology, psych, rehab, nursing homes, etc.ICD-10-PCS (Procedures)Will be used only for hospital claims for inpatient hospital proceduresCPT/HCPCS – No change!Procedures for Hospital Outpatients, Physician Visits, Lab and Radiology Outpatients, etc.
25Another Year Delay… Revised Date: October 1, 2015 Compliance date for implementation ofICD-10-CM (diagnoses) and ICD-10-PCS(inpatient procedures).
26ICD-10 Implementation Span Date CMS clarifies policy for processing split claims for hospital encounters that span the ICD-10 implementation date.MLN (Medical Learning Network) Matters Number: SE1325Split ClaimsRequire providers split the claim so all ICD-9 codes remain on one claim with Date of Service (DOS) through September 30, 2015, and all ICD-10 codes placed on the other claim with DOS beginning October 1, 2015 and later.Same guidance for Inpatient and Outpatient encounters!
28ICD-9-CM vs. ICD-10-CM ICD-9-CM ICD-10-CM 14,000 diagnosis codes 3 - 5 digits or characters1st character is numeric or alpha (E or V codes)2nd – 5th characters are numericDecimal placed after the first 3 characters17 Chapters and “V” & “E” codes are ‘supplemental’14,000 diagnosis codesICD-10-CM3 - 7 digits or characters1st character is alpha (all letters used except “U”)2nd – 7th characters can be alpha and/or numericDecimal placed after the first 3 characters (the same!)21 Chapters and “V” & “E” codes are ‘not’ supplemental69,000+ diagnosis codes
29ICD-10-CM Format X X X X X X X Category Etiology, anatomic site, severityExtension
30Why Are There So Many Diagnosis Codes? Greater “specificity and detail” in all diagnosis codes!But…is there supporting physician documentation in the medical record?34,250 (50%) of all ICD-10-CM codes are related to the musculoskeletal system17,045 (25%) of all ICD-10-CM codes are related to fractures10,582 fracture codes will distinguish ‘right’ vs. ‘left’25,000 (36%) of all ICD-10-CM diagnosis codes will now distinguish right vs. left
31New Features to ICD-10-CM Combination codes for conditions and common symptoms or manifestationsE Type 1 diabetes mellitus with diabetic nephropathyCombination codes for poisonings and external causesT42.4x5A Adverse effect of benzodiazepines, initial encounterAdded laterality (left vs. right)M Chrondromalacia, right shoulderAdded 7th character extensions for episode of careS06.01xA Concussion with loss of consciousness of 30 minutes or less, initial encounter
32ICD-10-CM (Injury and External Cause Extensions) A Initial encounterD Subsequent encounterS Sequelae (disease progression)Coders will need to look for the episode of care. Is this the patient’s 1st visit for treatment or is it for routine follow-up? Is it clearly documented in the medical record?
33And a Bit More… Examples of “Subsequent” care: Cast change or removal External or internal fixation removalMedication adjustmentFollow-up visits following fracture treatmentFor aftercare, the acute injury code with the 7th character ‘D’, ‘E’, or ‘F’ is assigned.Do not assign the aftercare “Z” codes!
34What is Gustilo-Anderson Scale? Gustilo-Anderson classification identifies the ‘severity of soft tissue damage’ in open fractures – may be new to coders and physiciansType I: Wound is smaller than 1 cm, clean, and generally caused by a fracture fragment that pierces the skin (low energy injury)Type II: Wound is longer than 1 cm, not contaminated, and w/o major soft tissue damage or defect (low energy injury)Type III: Wound is longer than 1 cm, with significant soft tissue disruption. The mechanism often involves high- energy trauma, resulting in a severely unstable fracture with varying degrees of fragmentation.
35Examples of ICD-10-CM *Emergency Room* I Essential (primary) hypertensionS01.02xA Laceration with foreign body of scalp, initial encounterS01.02xD Laceration with foreign body of scalp, subsequent encounterS02.2xxA Fracture of nasal bones, initial encounter for closed fractureH Acute serous otitis media, right earH Acute serous otitis media, left earH Acute serous otitis media, bilateral
36Quirky ICD-10-CM Codes On any given day, anything can happen! W17.82xA Fall from (out of) grocery cart, initial encounterV94.4xxA Injury to barefoot water-skier, initial encounterW61.43xA Pecked by turkey, initial encounterY93.C Activity, handheld interactive electronic device, i.e., cellular phoneAre we querying the provider for this level of detail? Who wants it? The payer?Have internal discussions, contact payers, gather excellent data= Decide.
37Cross Walking - GEMsCMS has created GEMs (General Equivalence Mappings) to assist hospitals with cross walking ICD-9-CM ►ICD-10-CM/PCS “forward mapping” & ICD-10-CM/PCS ◄ ICD-9-CM “backward mapping”. The correlation between the 2 code sets for some codes is fairly close, but not a straight correlation for others, i.e. OB, etc.Not always 1 to 1 crosswalk from ICD-9-CM toICD-10-CM (www.cms.gov/ICD10/11b15_2013_ICD10PCS.asp)Available on CMS’s website
38GEMs ICD-9-CM Code Diagnosis ICD-10-CM Code V20.2 Routine infant or child examinationZ (Encounter for routine child exam without abnormal findings). Z (Encounter for routine child exam with abnormal findings). “Use additional code(s) to identify abnormal findings”.250.00DM w/o complications, type II or unspecifiedE11.9 (Type II DM without complications)V04.81Need for prophylactic vaccination and inoculationZ23 (Encounter for immunization). “At this time in ICD-10-CM there is only one code for immunizations”.401.1Hypertension, benignI10 (Essential [primary] hypertension). “ICD-10-CM does not differentiate between hypertension that is controlled or uncontrolled, benign or malignant and there is only one code”.427.31Atrial fibrillationI48.0 (Atrial fibrillation)I48.1 (Atrial flutter)786.50Chest pain, unspecifiedR07.0 (Chest pain, unspecified). “ICD-10-CM expands upon chest pain symptoms and unspecified code may no longer be necessary”.465.9URIJ06.9 (Acute upper respiratory infection, unspecified)724.2LumbagoM54.5 (Low back pain)466.0Bronchitis, acuteJ20.0 (Acute bronchitis, unspecified). “ICD-10-CM includes 10 choices for acute bronchitis”.729.5Limb painM (Pain in right leg)
39Good News!We will still look up the diagnosis codes the same way as we do today. Yeah!#1 - Look up diagnostic terms in the Alphabetic Index…and then#2 - Verify the code number in the Tabular ListThat’s it!
42ICD-10-PCS: Code Structure Seven Character Alphanumeric CodeAll procedure codes will be seven characters long“I” and “O” (letters) are never usedCan you guess why?34 possible values for each characterDigits 0 – 9Letters A-H, J-N, P-Z
43ICD-10-PCS Characters (Medical and Surgical Section) RootSection Operation Approach QualifierBody Body DeviceSystem Part
44ICD-10-PCS CharactersSection: Identifies general type of procedure Body System: Identifies general body system Root Operation: Specifies objective of procedure Body Part: Identifies specific part of body system on which procedure is being performed Approach: Technique used to reach the site of the procedure Device: Identifies devices that remain after procedure is completed Qualifier: Provides additional information about a procedure, if necessary
45ICD-10-PCS codes are assigned based on the intent of operation rather than the operation name as in ICD-9-CM.Can be a big difference!Coders and CDI specialists will need to review surgical reports to identify root operations and surgical approaches and to also understand various eponyms for high- volume procedures.
46Case # 1 Diagnostic Colonoscopy 44-year-old male patient is known to have diverticulitis of the colon and has noticed melena occasionally for the past week. The initial impression was acute bleeding from diverticulitis. Patient was scheduled for colonoscopy. Colonoscopy identified the cause of the bleeding to be angiodysplasia of the ascending colon.
47Case # 1 ICD-10-CM (Diagnosis) Coding K Angiodysplasia of colon withhemorrhage (569.85)K Diverticulitis of large intestine withoutperforation or abscess withoutbleeding (562.11)
48Case # 1 ICD-10-PCS (Procedure) Coding 0DJD8ZZ Inspection of Lower Intestinal Tract, via Natural or Artificial Opening Endoscopic (45.23)
49Case # 2 Inguinal Hernia Repair Patient with hypertension and COPD is admitted for bilateral inguinal hernia repair. H&P states that the left side is recurrent. The operative report states that the surgeon repaired a left direct and right indirect inguinal hernias with mesh, via open approach.
50Case # 2 ICD-10-CM Coding K40.2 Bilateral inguinal hernia without obstruction or gangrene (550.92)I Essential (primary) hypertension (401.9)J44.9 Chronic obstructive pulmonary disease, unspecified (496)Notice anything familiar to ICD-9-CM?
51Case # 2 ICD-10-PCS Coding 0YUA0JZ Replacement of Bilateral Inguinal Region using Synthetic Substitute,Open Approach (53.16)Code options include 3 specific devices (6th)Autologous Tissue Substitute (7)Synthetic Substitute (J)Nonautologous Tissue Substitute (K)
53Estimated CostsCMS estimates cost to the private sector for implementation of ICD-10 will exceed $130 million.Hay Group White Paper in 2006 estimated cost for hospitals ranged from $35K - $150K for < 100 beds, to $500K to $2 million for 400+ beds.AAPC indicates current documentation = 50% could be coded.AHIMA indicates after ICD-10 coders will be 50% slower for up to 3 months ++ 50% more physician queries.
55Potential Hidden Costs Back log of uncoded claims with ICD-9 while trying to get coders ready for ICD-10. Remote/outsourced coding may need to occur as well as OT.Rejected claims from payers who are not ready to accept UB-04 with ICD-10 PLUS ICD-9 as necessary.Vendor software rejecting ICD-10 or edits not working correctly thus slowing claim submission. Manual intervention to ensure claims are submitted and accepted.New software if existing software for related ICD-10 work is not compatible.
56More Hidden CostsCost to conduct a ‘risk assessment’ to assess current documentation patterns for providers and care givers.Potential salary adjustments for the coders.Cost to conduct training for providers and care givers on enhanced documentation.Cost to review EMR or other software to adapt to enhanced documentation requirements.Cost to conduct a ‘readiness assessment’ pre go live to determine readiness of coders, documentation and vendors.Cost of moving ‘related’ work from the coders during training period, i.e., drug administration/charge capture.
57And More ….Loss of productivity – rebills, denials, rejections, EOB work, medical necessity rejections/follow-up (PFS+)Loss of productivity – excessive physician queries, coder slow down with new coding process (HIM)Growth in the discharged not final billed (DNFB)…Potential impact to the Case Mix IndexCost of a project manager (1 yr. contract staff to coordinate all the IT, testing, training, documentation assessments)Cost of implementing a Clinical Documentation Improvement (CDI) programCost of EMR changes and training of all impacted staffCost of any changes to the functionality of the any software and training costs
58Shortage Projections AHA & AHIMA TypeICD 9/minutesICD 10/minutesInpt acute care8.9915.99Outpt acute care4.189.03Physician practice3.046.70Free standing ASC2.274.82Nursing/SNF6.7112.98Rehab facility4.9710.94Additional time projected by CMS2 minutes additional for each encounter30% estimated loss in productivity
59Shortage Strategies Mentorship program /formal 30% less productive – alternatives?Back fill with remote codingExplore Computer Assisted Coding –uses natural language processing, cost analysisOutpt ancillary –high potential usage (MN screening)Other outpt areas – depending on how well the provider is documenting new elements of ICD (Queries)
60EducationAHIMA estimates approximately 16 hours of coding training is needed for outpatient coders and 50 hours for inpatient coders.Additional time may be needed to refresh anatomy & physiology (A&P) fundamentals.Learn foundational knowledge before more intensive training.Allow time for practice, practice, practice (key!)Down time during training and practice time.And don’t forget the NON-HIM training needs.
61So When Should We Begin?The time is NOW, if you have not already started!Plan weekly, monthly, and yearly implementation goals.Assess impact on your organization, systems, processes, staff and productivity.Start your ICD-10 training by assessing your coders’ preparedness.Test coding staff on basic anatomy & physiologyQuizzes – identifies areas in which further training may be neededStart early and conduct ongoing assessments so that all of your coders will be ready
62Preparation Begins! Communicate to leadership, managers & staff Create & maintain organizational awarenessCreate ICD-10 Planning or Implementation CommitteeAssess organizational impact for: billing, EMR, system vendors, physician education for coding & documentation, coders, billers, reimbursement analysts, compliance, business operations, finance (budget, reimbursement, cash flow), managed care contracts, data, reports.
64Top 10 Documentation Tips! Laterality (left vs. right) 25,000+ codes!Stage of Care (initial, subsequent & sequelae)Specific Diagnosis (acute vs. chronic)Specific Anatomy (specific bone in the hand)Associated and/or Related ConditionsCause of Injury (hit by baseball, fall)Documentation of Additional Symptoms or ConditionsDominant vs. Non-Dominant SideTobacco Exposure or UseGustilo-Anderson Scale
65Biggest Change in ICD-10-CM? Laterality! left vs. right vs. bilateralFor bilateral sites, the final character of the codes in ICD-10-CM indicate laterality.Right side is always character 1 (RT)Left side is always character 2 (LT)Bilateral code is always character 3 (RT & LT)But wait! Not all codes will have a ‘bilateral’ distinction, i.e., carpal tunnel, etc.“Unspecified” side code is also provided should the side not be documented in the medical record.Did we just lose our specificity?
66Diagnoses/Conditions That Will Require Laterality Joint painJoint effusionInjuryFractures Start working with your physiciansDislocations now to get them in the habit ofArthritis documenting laterality!Cerebral infarctionExtremity atherosclerosisPressure ulcersCancers, neoplasms (breast, lung, bones, etc.)
67Respiratory Documentation “Additional Code” will be captured related to tobacco exposure and useExposure to environmental tobacco smokeExposure to tobacco smoke in the perinatal periodHistory of tobacco usePersistent Asthma3 levels of severity:Mild persistent – more than two times per weekModerate persistent – daily and may restrict physical activitySevere persistent – throughout the day with frequent severe attacks limiting the ability to breathe
68Diabetes Mellitus – Huge Expansion! Diabetes mellitus codes are expanded to include the classification of the diabetes and the manifestation by using 4th or 5th characters.Moving from 1 category of “250” ► 5 categories in ICD-10!ICD-9-CM = 59 diagnosis codesICD-10-CM = 200+ diagnosis codes!Whether or not diabetes is stated as ‘controlled’ or ‘uncontrolled’ is not a factor in ICD-10.E Type 1 diabetes mellitus with ketoacidosis with comaE Type 2 diabetes with diabetic mononeuropathyE Drug or chemical induced diabetes mellitus withdiabetic peripheral angiopathy with gangrene
69Changes to Hypertension ICD-10-CM in the Tabular List states:I10 Essential (primary) hypertensionIncludes: High blood pressureHypertension (arterial) (benign) (essential) (malignant) (primary) (systemic)Excludes1: Hypertensive disease complicating pregnancy, childbirth and the puerperiumExcludes2: Essential (primary) hypertension involving vessels of brain, essential (primary) hypertension involving vessels of eyeNo longer matters whether hypertension is malignantor benign in ICD-10-CM!
70Nicotine DependenceICD-10-CM contains a separate category (F17) for nicotine dependence with further subcategories to identify the specific tobacco product and nicotine induced disorder. Some examples:CigarettesChewing tobaccoCigar, etc.ICD-9 has only one diagnosis code 305.1!
71NeoplasmsFinally! ICD-10-CM neoplasm codes can provide information on whether a neoplasm occurred in a right-sided or left-sided body part.But…we need to have this documented by the doc in the medical record. Is it?Includes a tabular list and an alphabetic index just like in ICD-9-CM.ICD-10-CM neoplasm guidelines are very similar to those found in ICD-9-CM. However, there are a few variations! Anemia is one!
72Burns and Corrosions Burn codes identify: Thermal burns, except for sunburns, that come from a heat source.Also burns resulting from electricityand/or radiation.Addition of the term “corrosion” is new inICD-10-CM.Corrosions are burns due to chemicals.
73Another New ICD-10-CM Term! “Underdosing” will be a new term in ICD-10- CM and is defined as taking less of a medication that is prescribed by a physician and/or manufacturer’s instructions with a resulting negative health consequence.Financial Reasons (#1)Patient Non-Compliance
74Coding QueriesIt is anticipated that you will see a significant increase in the # of physician queries that will be generated from ICD-10.Existing coding queries will most likely have to be “updated” as you will be asking for different documentation to capture “specificity”.Make sure they are not ‘leading’ the physician to document one way or another!Consider making the query part of the permanent medical record (physician addendum).Track and trend for patterns and then do more education!
75Reduce Rework, Engage At Time Of Coding, Think Outside The Box! Think concurrent inpatient coding.Immediate interaction with the provider and other caregivers on weak or incomplete documentation.Have coders on the floor with the care team. Back office coding results in ‘chasing’ the provider = delay in coding = delay in cash.Expand the CDI team…to include both UR needs/severity of illness & intensity of service PLUS specificity/laterality/ and other unique.ICD-10 needs as identified thru queries and risk audits.
77Developing an ICD-10 Implementation Team When? By late (Already done, right?)Who? Key leaders in the revenue cycle/IT and HIM. Will a designated project leader need identified?What? Create master list of all revenue cycle areas, IT, HIM and physician issuesHow? Identify timelines for when components will be done, who does it, results reviewed, testing, with ownership and timelines for completionKey benchmarks for completion done beginning 1st Q 2015 or once final go live date is establishedAfter go live, complete a 2nd set of benchmark assessments with barriers, delays, more education, etc.
78Develop Phase 1 and Phase 2 Attack Plan Phase 1: Goal: 1st Q 2014Awareness training of leadershipAwareness training of coders – inpt/all others/providersConduct a risk assessment of current documentation patternsTrack and trend ALL queries for a defined period of timeUsing the query, develop provider education –with structured rollout time framesDevelop master list of impact areas – coders, PFS, IT, providers, etc.Develop structured coder education –based on type of pt.Phase 2: End of 2014 and after to liveConduct a readiness assessment – audit of documentation, testing of coders/per pt type, review of all IT functions, new forms, software testing, payer, contracting, etc.Coding comparison for case mix impact, MS-DRGAggressively code all pending ICD-9 accounts prior to Oct. 2015Remote/outsourced coding before/during transition and training neededContract coding company should have a ‘preparedness plan’Contract ICD-10 program manager or dedicated staff (Think Y2K)
79Steps to Implementation - Communication Make a master list of all software where ICD-9 is being used. This will be essential to the seamless implementation of ICD-10 (or less anguish).Contact each vendor NOW to identify their roll out plan for compliance and when they will be ready to test.Test with each vendor early in 2015 or as soon as they are available for testing.Keep Sr. Leadership well aware of the status of ALL software testing and compliance. Be prepared to make changes if compliance is not achieved with testing 9 months prior to go live.
80Audits of Course! Documentation Audits Coding Audits CDI (Clinical Documentation Improvement) department can start now conducting ICD-10 documentation audits this year – risk assessments of current documentation practices.Audit top 25 ICD-9-CM principal diagnosis codes and map to ICD-10-CM codes and begin auditing to determine whether the records contain the necessary clinical information to support the ICD-10-CM principal diagnosis code.Coding AuditsTarget certain inpatient cases for review based on the MS- DRG assignment or the CC’s because both of these IP PPS components will undergo changes when reconfigured with the ICD-10-CM codes.
81October 2015 & Beyond Possible decrease in cash flow due to: Increase in time to code medical recordsLearning curves, potential increase in errorsDecreased coder productivity, when, or will it recoverSystem, vendor or software issuesPotential reimbursement impact due to payer systems, claim edits or processing issuesExpect denials and underpayments
83Defense for 2015 It’s never too late to start! Provide adequate system and coding resources for go live:Will you need additional coding support? Need contracted coders? Who will handle the coding of ‘prior to’ accounts vs. ‘go live’ accounts? Possible concurrent coding?Post go live auditing & monitoring of:Coding & Documentation coding queries!Systems, data, reportsClaims (UB & 1500), payments, denialsAudit and then more auditing from a RISK to a READINESS environment…Remember, we are ALL in this together!
84Accreditation for Coders AAPC (American Academy of Professional Coders)Certified coders will have opportunity to take the ICD-10 proficiency exam beginning October 1, 2012 and must successfully complete the exam by September 30, 2015.NOTE: Currently being re-evaluated due to the 1 year delayMust take and pass proficiency exam to maintain AAPC certification► Online, timed, 75 questions, open book► May use any resource available to complete► $60 exam fee – includes ability to take the exam twiceAHIMA (American Health Information Management Association)Continuing education hours with ICD-10-CM/PCS content will be required based on the specific AHIMA credential(s).RHIA/RHIT - Required to least 6 CEUsCCS-P credential – 12 CEUsCCS credential – 18 CEUsAnd many others…