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Presented by Jerry Bridge President LifeWorks Education Healthcare Collections & Training.

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1 Presented by Jerry Bridge President LifeWorks Education Healthcare Collections & Training

2 Purpose To provide the knowledge, tools & resources in order to make a successful, timely transition to ICD- 10.

3 Objectives Know the regulatory mandate and background for ICD- 10 Know pervasive impacts on revenue, reimbursement, productivity and work flow Know how to make a project plan; budget, training, vendor management Take away tools & resources to help you get there!

4 What have you heard? What have you heard, assume or know about ICD- 10 ? Have you started to transition? What have you done to prepare? 4

5 How Can Providers' Benefit from ICD-10? Determine severity of illness and prove medical necessity consistently Improved care with better documentation Address technology and healthcare reform initiatives Reduce the hassle of audits

6 Reimbursement Benefits Reduced coding error rates = reduced denials Describing higher complexity justifies higher complexity procedure/service payment Better data with which to justify better payment for physicians and pay-for-performance metrics Levels the insurance company tactics “playing field”

7 Why Do We Need ICD-10?  ICD-9-CM is outdated: Over 30 years old Many categories full Not descriptive enough  A coding system needs to be: Flexible to quickly incorporate emerging diagnoses Exact enough to precisely identify diagnoses

8 An outdated coding system A patient is diagnosed with acute tonsillitis, his second diagnoses within 6 months. In ICD-9, acute tonsillitis is reported using ICD-9-CM code 463. There is no fourth or fifth digit to report the acute condition or the specific organism causing it. In ICD-10-CM, the code set for tonsillitis is expanded to a fourth character extension to identify whether the acute condition is recurrent and the causative organism, if known. 8

9 The bottom line on ICD-9 Any ICD-9 codes used in transactions for services or discharges on or after October 1, 2014 will be rejected as non-compliant and the transactions will not be processed. 9

10 ICD Background Information Published by WHO in 1990 U.S. last industrialized nation to implement ICD-10 Two parts: ICD-10-CM and ICD-10-PCS ICD-10-CM – 69,000 codes, ICD-9-CM – 14,000 codes 3–7 alpha and numeric characters for ICD-10- CM

11 Myth or Fact? Non-covered entities (those not covered by HIPAA) such as Worker’s Compensation, may choose not to implement ICD-10. Fact Workers’ Compensation and auto insurance companies are noncovered entities under HIPAA and are not “required” to comply with the October 1, 2014 deadline. However, ICD-9 will no longer be maintained and it will be in the noncovered entities’ best interest to use the new coding system.

12 Therefore….. Your clinic will need to maintain the ability to submit both ICD-9-CM and ICD- 10 -CM! (i.e…, hardware capacity and coding capability needed for both code sets)

13 Myth or Fact? State Medicaid Programs will not be required to update their systems in order to utilize ICD-10 codes. Fact State Medicaid Programs are all covered entities under HIPAA; therefore must comply with the October 1, 2014 deadline.

14 Myth or Fact? Physicians who choose their own codes will not have to worry about training as their EHR will do this for them. Fact Although EHRs are starting to do some great things in regards to prompts, problem lists, and other assistive tools for ICD-10, they do not take the place of required education for those physicians selecting their own codes. 14

15 Myth or Fact? ICD-10-CM is a reimbursement system not built for physicians Fact ICD-10 started its origins at the WHO through the efforts of a team of physicians, clinicians, coders, and other healthcare professionals and then further modified by the United States again by a team of clinicians and other healthcare professionals. ICD- 10 is far more rooted in current clinical thought and practice than the ICD-9 system. 15

16 ICD-10-CM vs. ICD-9 Code Structure ICD-10-CM Code Format Ex: Unspecified asthma with acute exacerbation ICD-9 493.92 ICD-10 J45.901 (Etiology means “cause or origin”) ICD-9-CM Code Format

17 ICD-10 Code Set Websites CMS: AMA: http://www.ama-assn.org AHIMA: AAPC:

18 More is Better! Just as an increase in the number of words in a dictionary doesn’t make it more difficult to use, the greater number of codes in ICD-10-CM, the easier it is for you to find the right code!

19 Increase in Codes: The Real Story Gastroenterologists: 596 ICD-9 codes and 706 codes in ICD-10 (+110) Pulmonologists: 255 codes in ICD-9 and 336 codes in ICD-10 (+81) Urologists: 389 codes in ICD-9 and 591 codes in ICD-10 (+202) Endocrinologists: 335 codes in ICD-9 and 675 codes in ICD-10 (+340)* Neurologists: 459 codes in ICD-9 and 591 codes in ICD-10 (+132) Pediatricians: 702 codes in ICD-9 down to 591 codes in ICD-10 (-111) Infectious disease: 1,270 in ICD-9 down to 1,056 in ICD-10 (-214) A few hundred new codes = a few dozen new documentation elements * ICD-10-CM includes more combination codes containing co-morbidities and associated conditions. (e.g.- Diabetes)

20 Overall Coding Process Is The Same! 1. Capture the required encounter documentation 2. Choose the correct code 3. Make sure you have the medical necessity to justify the procedure or service

21 Examples of ICD-10-CM Codes  I10 - Hypertension (Seriously? I10?)  H90.3 - Sensorineural hearing loss bilateral  K80.63 Calculus of gallbladder and bile duct with acute cholecystitis with obstruction  Fracture of Patella (GEMs)

22 “Unspecified” = “Unpaid” “Physicians may be ICD-10 compliant, but if they abuse the “other” or “unspecified” codes, payment will not occur if a more specific alternative exists.” David Winkler Michigan Blue Cross’ Director of Technical Program Management Justifying medically necessary procedures and services depends on specificity of diagnoses coding!

23 Unspecified Codes Use of signs, symptoms, and unspecified codes is “acceptable, even necessary” in both ICD-9-CM and ICD-10-CM, says CMS. For example, if the physician has not determined a definitive diagnosis by the end of the encounter, codes for sign(s) and/or symptom(s) may be reported.

24 Unspecified Codes When a more specific code can’t be assigned because the clinical information provided isn’t sufficient, the appropriate unspecified code may be used (such as when a physician determines a diagnosis of pneumonia but not the specific type). Always remember that, in all cases, the medical record documentation must support the code choice!

25 Documentation: The KEY to ICD-10 Success With increased dx coding specificity comes a requirement for detailed documentation. Jeri Leong, President, Healthcare Coding Consultants of Hawaii: “…(for current audits), 40% of the time we were unable to assign a specific ICD-10-CM code based on current documentation.” How good is YOUR current documentation?

26 Example: Patient is seen for Asthma with Status Asthmaticus ICD-9-CM = 493.91 Extrinsic vs. intrinsic Chronic obstructive asthma With status asthmaticus With exacerbation Exercise induced bronchospasm Cough variant asthma  Additional documentation required ICD-10-CM = J45.902 Mild intermittent  Mild persistent  Moderate persistent  Severe persistent  With status asthmaticus With exacerbation Exercise induced bronchospasm Cough variant asthma Tobacco use or exposure  Excludes chronic obstructive asthma *

27 Combination Codes Multiple conditions that may include common symptoms or manifestations 250.50 Diabetes with ophthalmic manifestations Sequencing errors reduced

28 A patient is being treated by his physician for moderate nonproliferative diabetic retinopathy. The physician documents Type II diabetes with macular edema. ICD-9-CMICD-10-CM 250.50 Diabetes with ophthalmic manifestations 362.01 – 362.06 To identify Retinopathy AND 362.07 Macular edema E11.311 Type 2 Diabetes with unspecified diabetic retinopathy with macular edema E11.321 Type 2 Diabetes with mild nonproliferative diabetic retinopathy with macular edema E11.331 Type 2 Diabetes with moderate nonproliferative diabetic retinopathy with macular edema E11.341 Type 2 Diabetes with severe nonproliferative diabetic retinopathy with macular edema E11.351 Type 2 Diabetes with proliferative diabetic retinopathy with macular edema 28

29 How Can You Prepare? Don’t focus on 69,000 Codes Convert your codes!!! Engage your providers Practice coding in I 10 -Now! 29

30 GEMs Translation and Training Tool GEMs=General Equivalence Mapping: a reference mapping tool that attempts to include all valid relationships between the codes in ICD-9-CM and ICD-10-CM an excellent training tool to be used to familiarize differences between ICD 9 and ICD-10 and to be able to select the correct ICD-10 code. The mapping identifies one-to-one and one-to- many code relationships

31 Characteristics of a Good GEMs Tool Outpatient setting Search by code and description Bi-directional: ICD-9 to ICD-10 and vice versa Multiple code lookups at one time Store most frequently used codes (“Favorites”) “Print” function: easily create training tools

32 Practical Uses of GEMs Create immediate awareness Engage providers and staff Facilitate chart audits to analyze current documentation Assess managed care contracts Facilitates EMR templates updates Helps identify “role based” training Saves time over manual conversion

33 Fracture of Patella 33

34 Fracture of Patella in ICD-10? 34

35 Elements of Documentation 35

36 Elements of documentation 36

37 Flash Cards 37

38 Engage the Entire Team! Promote benefits of ICD-10 Make a plan Provide real world tools If all else fails, show them the really fun codes they’ll miss out on if they don’t go ICD-10! 38

39 W18.12X Fall from or off toilet with subsequent striking against an object W18.12XAInitial Encounter W18.12XDSubsequent Encounter W18.12XSSequela

40 Y04.1XXA Assault by Human Bite, Initial Encounter


42 W22.09ZD Striking against other stationary object, Subsequent Encounter

43 Two fish were swimming along and ran into a cement wall. One looked at the other and said, “Dam.”

44 Ok, we don’t really treat fis h… (Unless they have really good insurance!) W22.09ZD Striking against other stationary object, Subsequent Encounter How about this one…


46 Y93.K2 Activity, Milking an animal


48 (If the milking goes badly) …the related W55.22XS Struck by cow, Sequela


50 V91.07XD Burn due to water- skis on fire, subsequent encounter

51 V91.07XD Ok…so I looked everywhere. I could not find a single burning water skis picture. But I DID find incidents involving SNOW SKIS

52 V98.3XXA Accident to, on, or involving Ski Lift, initial encounter


54 T68.XXXA Unfortunately, upon rescue our intrepid skier suffered from… Hypothermia, Initial Encounter


56 W61.91XA Bitten by other birds, Initial Encounter


58 Please Note Separate Codes For: Being bitten or struck by… Turkey, chicken, macaw, parrot, other psittacines, goose, duck, mouse, rodent, rat, squirrel, sea lion, orca, horse, cow, pig, raccoon, lizard, snake, alligator or crocodile.

59 And….the ever popular: R46.1 Bizarre Personal Appearance

60 Do Now: Physician’s Documentation: A Chart Audit 1. Per Doctor: list top 25 diagnoses (by revenue, frequency) 2. Use GEMS to translate ICD-9 to ICD-10 3. Pull patient charts containing those ICD- 9 diagnoses 4. Assess current documentation as sufficient or not 5. Create report for providers 6. Customize training by provider 7. Continue to monitor documentation

61 Do Now: Create Documentation Coding Tools 1. Make a list of your practice’s top 100 most frequently used ICD-9-CM diagnosis codes 2. Use the GEMs mapping tool to translate the ICD-9 codes to ICD-10 3. For each ICD-10-CM code, highlight unique documentation and coding requirements 4. Create flash cards, one per code, for your providers If providers start now and learn the unique documentation and coding requirements for 1 or 2 diagnoses codes per week, they will be prepared for ICD- 10-CM when the Oct. 1, 2014 deadline arrives.

62 ASTHMA Documentation Quick Reference Guide J45 (ICD-10-CM Root Code) – Asthma Required Documentation Elements Mild Intermittent Mild Persistent Moderate Persistent Severe Persistent Tobacco Use or Exposure

63 Impacts to Your Organization Documentation Reporting Office processes Referrals Payers and business partners Budget and productivity Claims and other electronic transactions PM and EMR software

64 Documentation Impact Adequate Documentation Accurate Coding Timely Claims Filing = $$$ 64

65 Superbill The AAFP conducted a study by converting the most common dx codes in the family practice environment In ICD-10 the superbill/encounter form would expand on average to 9 pages! 65

66 Work Flow Impacts Diagnostic Orders (Lab, Radiology, etc) Other service requests: PT, OT, DME Referrals Home Health Treatment Plans

67 Work Flow Impacts Pharmacy Admin services: Insurance verification, pre- authorization and surgery scheduling Retrospective reporting

68 Payer and Business Partner Begin a dialogue with your payers about: testing ICD-10 implementation plan provider contracts coverage and reimbursement policies Start asking the important questions NOW! Delaying until the last minute could have a devastating effect on cash flow!

69 Training Identify the staff in your office who code, or have a need to know the codes Not all staff require the same level of training. Role Based training is essential Professional Coding Associations recommend:  Providers6 – 12 hours  Coders 16 hours (for outpatient coders)  Other Staff 2-8 hours (depending on involvement)

70 Time Frame When the training will be delivered? ICD-10 Awareness-Immediately! Workflow/Process/Coding 6-9 months prior to the go live date. Code Training- Suggested start for coding training is 6-12 months prior to go live date. You may need to schedule ‘refresher’ trainings as needed.

71 Budget Expense Small: 3 Providers & 2 administrative staff Medium:10 Providers, 1 full time coder, 6 administrative staff Large: 100 providers, 64 coders Staff education and training$2,405$4,745$46,280 Business process analysis$6,905$12,000$48,000 Changes to forms$2,985$9,950$99,500 IT costs$7,500$15,000$100,000 Increased documentation$44,000$178,500$1.76 million Cash flow disruption$19,500$178,500$650,000 Total$83,295$398,695$2,703,780 71

72 Hardware/Software Talk with your practice management software vendor about accommodations for both version 5010 and ICD- 10 codes Discuss implementation plans with your clearinghouses, billing services, and payers to ensure a smooth transition Conduct test transactions using version 5010 and ICD- 10 codes with your payers and clearinghouses

73 Hardware/Software (cont.) Confirm systems upgrades are covered by existing contracts and if not, budget for them. Confirm vendor will provide support and training Confirm PM/EMR services will accommodate both ICD-9 and ICD-10 as you work with claims for services provided before and after the transition deadline Confirm current hardware resources are sufficient to handle the increased load Create budget for H/W, S/W purchase and possible IS personnel additional workload

74 EMR ICD-10-CM adds coding, documenting and work process complications. EMR is an excellent way to mitigate current and ongoing challenges due to the new transition. Government incentives to transition to EMR make NOW the perfect time to do so.

75 ICD 10 Readiness Checklist Payers 1. Are top-revenue-producing insurance plans going to ICD 10? _____ 2. When? (Will they meet the Oct. 1, 2014 deadline? _____ 3. Have contract negotiations been completed for plans tying reimbursement to ICD 10? _____

76 ICD 10 Readiness Checklist Internal Processes  Impact assessed for everywhere ICD 10 touches?  ICD 10 coding resources (manual, encoder or online lookups) updated?  Chart audit Completed?  Documentation training for physicians completed?  GEMs available and in use?

77 ICD-10 Summary Early, effective preparation can turn the ICD-10-CM transition from a predicament to a significant opportunity for your practice. Reimbursement Productivity Accuracy Software and hardware upgrades Training Administrative functions EMR adoption that enhances the ICD-10 transition

78 Tools You Will Need  ICD-10 Transition Software – saves valuable conversion time  Documentation and Coding Training Guides  Do-it-yourself ICD-10 Implementation Tool Kits - Impact Assessment/Planning Guide  Chart Documentation Reviews  Role Based Training Plan  Budget- Money and time !

79 The ICD-10 Transition “Practice Manager- Planning Guide” Organized and designed specifically for practice-project managers responsible for ICD-10-CM implementation. Your ICD-10 Planning Guide includes: The 4 critical action steps you should be taking now! ‘Project Planner’: broken down by quarter with action steps! Training & Budget Planner ‘Vendor Tracker & Query Forms’ keep your vendors on track! CD-ROM Recommendations and resources on how to conduct End to End testing! ICD-10 Planning Guide $399 With Code Translation Software: Convert ICD-9 codes to ICD-10 in seconds! Features multiple code lookups, print capabilities, ability to save favorites and create flash cards. Create training tools for your entire staff, accessible anywhere, from any computer! Planning Guide with Code Translation Software, Only $599 79

80 Thank You! Questions, Comments or Feedback? Please call or email: Jerry Bridge 760.918.6701

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