Presentation on theme: "ICD-10-CM Making a Successful, Timely Transition"— Presentation transcript:
1 ICD-10-CM Making a Successful, Timely Transition Presented by Jerry BridgePresident LifeWorks EducationHealthcare Collections & Training
2 PurposeTo provide the knowledge, tools & resources in order to make a successful, timely transition to ICD-10.All of this info may not be applicable to each of you. But I am going to give you ALL the info you need to take back for everyone else. This is not a CODING seminar. Its too soon for that. The codes are still evolving and it’s too early. This is an awareness and readiness workshop.
3 Objectives Know the regulatory mandate and background for ICD-10 Know pervasive impacts on revenue, reimbursement, productivity and work flowKnow how to make a project plan; budget, training, vendor managementTake away tools & resources to help you get there!PAGE 4
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?
5 How Can Providers' Benefit from ICD-10? Determine severity of illness and prove medical necessity consistentlyImproved care with better documentationAddress technology and healthcare reform initiativesReduce the hassle of auditsDetermine severity of illness and prove medical necessity consistently. ICD-10 codes better describe the gravity of a patient’s illness, in turn facilitating validation of conditions in support of utilization of goods, services and complex procedures.Grow compensation and reimbursement. ICD-10 codes help physicians create an electronic trail of evidence, allowing them to receive proper credit and payment from government payors, insurers, hospitals, health systems, medical groups and others.Address technology and healthcare reform initiatives. These include the value-based purchasing system managed by the Centers for Medicare & Medicaid Services (CMS), pay-for-performance programs (P4P), coordinated care models such as Accountable Care Organizations (ACOs) and Patient-Centered Medical Homes (PCMHs); the government’s Physician Quality Reporting System (PQRS); and the move toward adoption of an electronic health record (EHR).Ensure a strong reputation. A physician’s documentation trail in ICD-10 will inform:Physician profiling/national registriesQuality reportingConsumer health sitesReduce the hassle of audits. ICD-10 codes allow physician documentation to be translated into a more accurate clinical picture, thereby reducing the chance of misinterpretation by third parties, auditors and attorneys. Understanding ICD-10 and implementing documentation integrity safeguards will help save time and resources during a Recovery Audit Contractor (RAC) audit, or, even better, prevent the audit from occurring in the first place. Insufficient documentation, on the other hand, may lead to scrutiny and potentially takebacks by CMS.Improve care. ICD-10 codes will generate more detailed healthcare data and an improved flow of that data to improve medical communication, which could contribute to the development of more advanced disease protocols and clinical pathways.
6 Reimbursement Benefits Reduced coding error rates = reduced denialsDescribing higher complexity justifies higher complexity procedure/service paymentBetter data with which to justify better payment for physicians and pay-for-performance metricsLevels the insurance company tactics “playing field”“Because of the detail and specificity of the codes, the advantages are…” Also: The new ICD-10 coding language offers a level playing field for codersEveryone has to learn the new code sets. Recertification for coders. Certified coders must successfully pass proficiency exam FRONT END LOAD THIS LIST WITH REIMBURSEMENT STUFF – TWO SLIDES (REIMBURSEMENT BENEFIT AND OTHER BENEFITS
7 Why Do We Need ICD-10? ICD-9-CM is outdated: Over 30 years oldMany categories fullNot descriptive enoughA coding system needs to be:Flexible to quickly incorporate emerging diagnosesExact enough to precisely identify diagnosesNext slide is an example of lack of specificity
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.
9 The bottom line on ICD-9Any 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.
10 ICD Background Information Published by WHO in 1990U.S. last industrialized nation to implement ICD-10Two parts: ICD-10-CM and ICD-10-PCSICD-10-CM – 69,000 codes, ICD-9-CM – 14,000 codes3–7 alpha and numeric characters for ICD-10-CMPAGE 11 - The good news is that being last to adopt ICD-10-CM, there is ample knowledge to be gained from other countries who have already made the transition. UK-1995, France-1997, Australia-1998, Germany-2000 and Canada And guess what the overriding advice from these countries was? DON”T WAIT! PREPARE EARLY!
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.Page 10
12 Therefore…..Your clinic will need to maintain the ability to submit both ICD-9-CM and ICD-10-CM!(i.e…..software, 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.Page 9
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.One of the biggest concerns with ICD-10 is driving accurate representation of the severity of our patients' illnesses and hence, the medical necessity of the procedures and tests we will perform.If a secondary condition is not on our problem list or we do not have quick access to more specific code choices, the physician may miss out on opportunities to capture this greater specificity and severity of illness leading to possible greater scrutiny. Documentation education is also key because if we do not have the documentation to support the code selected, then we open ourselves up to significant risk. EHRs are a vital aspect of our transition to ICD-10, but understanding of the core concepts of ICD-10 physician documentation and coding are required to be successful.
15 Myth or Fact?ICD-10-CM is a reimbursement system not built for physiciansFactICD-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.For example
16 ICD-10-CM vs. ICD-9 Code Structure ICD-10-CM Code FormatEx: Unspecified asthma with acute exacerbationICD-9 ICD-10 J45.901(Etiology means “cause or origin”)ICD-9-CM Code FormatPAGE 14 Show SSTS, fracture of patella, then asthma
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!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/PCS doesn’t necessarily make it more complex to use. In fact, the greater number of codes in ICD-10-CM/PCS makes it easier for you to find the right code. In addition, just as you don’t have to search the entire list of ICD-9-CM codes for the proper code, you also don’t have to conduct searches of the entire list of ICD-10-CM/PCS codes.The Alphabetic Index and electronic coding tools are available to help you select the proper code. It is anticipated that the improved structure and specificity of ICD-10-CM/PCS will assist in developing increasingly sophisticated electronic coding tools that will help you more quickly select codes.Because ICD-10-CM/PCS is much more specific, is more clinically accurate, and uses a more logical structure, it is much easier to use than ICD-9-CM. Most physician practices use a relatively small number of Diagnosis Codes that are generally related to a specific type of specialty.
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)PAGE 16
20 Overall Coding Process Is The Same! Capture the required encounter documentationChoose the correct codeMake sure you have the medical necessity to justify the procedure or servicePage 16
21 Examples of ICD-10-CM Codes I10 - Hypertension (Seriously? I10?)H Sensorineural hearing loss bilateralK80.63 Calculus of gallbladder and bile duct with acute cholecystitis with obstructionFracture of Patella (GEMs)Note the higher specificity. What does that mean? Thorough, easily accessible documentation is required to code
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 WinklerMichigan Blue Cross’ Director of Technical Program ManagementJustifying medically necessary procedures and services depends on specificity of diagnoses coding!PAGE 18Remember I asked the question, “Do insurance companies want to pay you or not pay you?”
23 Unspecified CodesUse 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 CodesWhen 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?What is the result of poor documentation? Dr. doesn’t get paid, patient doesn’t receive proper treatment because the Medical Record does not support the testing or procedure the patient needs and it is left up to the clinic’s coding and billing staff to sort it all out.
26 Example: Patient is seen for Asthma with Status Asthmaticus ICD-9-CM =Extrinsic vs. intrinsicChronic obstructive asthmaWith status asthmaticusWith exacerbationExercise induced bronchospasmCough variant asthma Additional documentation requiredICD-10-CM = J45.902Mild intermittent Mild persistent Moderate persistent Severe persistent With status asthmaticusWith exacerbationExercise induced bronchospasmCough variant asthmaTobacco use or exposure Excludes chronic obstructive asthma *PAGE 20
27 Combination CodesMultiple conditions that may include common symptoms or manifestationsDiabetes with ophthalmic manifestationsSequencing errors reduced“Because of the detail and specificity of the codes, the advantages are…” Also: The new ICD-10 coding language offers a level playing field for codersEveryone has to learn the new code sets. Recertification for coders. Certified coders must successfully pass proficiency exam FRONT END LOAD THIS LIST WITH REIMBURSEMENT STUFF – TWO SLIDES (REIMBURSEMENT BENEFIT AND OTHER BENEFITS
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-CMDiabetes withophthalmic manifestations– To identify RetinopathyANDMacular edemaE Type 2 Diabetes with unspecified diabetic retinopathy withmacular edemaE Type 2 Diabetes with mild nonproliferative diabetic retinopathy with macular edemaE Type 2 Diabetes with moderate nonproliferative diabetic retinopathy with macular edemaE Type 2 Diabetes with severe nonproliferative diabetic retinopathy with macular edemaE Type 2 Diabetes with proliferative diabetic retinopathy with macular edema
29 How Can You Prepare? Don’t focus on 69,000 Codes Convert your codes!!! Engage your providersPractice coding in I 10 -Now!
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-CMan 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 relationshipsPAGE 23 With GEMS, you can get basic coding training started now. We’ll talk about this later but this is a great place for technology to help you. A good EMR can help automate the coding to the highest specificity
31 Characteristics of a Good GEMs Tool Outpatient settingSearch by code and descriptionBi-directional: ICD-9 to ICD-10 and vice versaMultiple code lookups at one timeStore most frequently used codes (“Favorites”)“Print” function: easily create training toolsPAGE 23
32 Practical Uses of GEMs Create immediate awareness Engage providers and staffFacilitate chart audits to analyze current documentationAssess managed care contractsFacilitates EMR templates updatesHelps identify “role based” trainingSaves time over manual conversionPAGE 25
38 Engage the Entire Team!Promote benefits of ICD-10Make a planProvide real world toolsIf all else fails, show them the really fun codes they’ll miss out on if they don’t go ICD-10!PAGE 35
39 Fall from or off toilet with subsequent striking against an object W18.12XFall from or off toilet with subsequent striking against an objectW18.12XA Initial EncounterW18.12XD Subsequent EncounterW18.12XS Sequela
40 Assault by Human Bite, Initial Encounter Y04.1XXAAssault by Human Bite, Initial Encounter
42 Striking against other stationary object, W22.09ZDStriking against other stationary object,Subsequent Encounter
43 Two fish were swimming along and ran into a cement wall Two fish were swimming along and ran into a cement wall. One looked at the other and said, “Dam.”
44 Striking against other stationary object, Subsequent Encounter Ok, we don’t really treat fish… (Unless they have really good insurance!)W22.09ZDStriking against other stationary object, Subsequent EncounterHow about this one…
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 Per Doctor: list top 25 diagnoses (by revenue, frequency)Use GEMS to translate ICD-9 to ICD-10Pull patient charts containing those ICD- 9 diagnosesAssess current documentation as sufficient or notCreate report for providersCustomize training by providerContinue to monitor documentationPAGE 33 - Successful transition to ICD-10 requires organization-wide commitment. It is no longer ok to assume “someone in the billing staff will take care of this.” Preparing your provider staff to change ingrained documentation habits requires an organized process that allows the practice to identify providers and staff requiring more and/or specific training. It is important for providers to see their “grade” periodically. Remember, it is not enough to merely note and report the documentation shortfall, show commitment by offering helpful suggestions. You may also consider getting an experienced chart auditor.
61 Do Now: Create Documentation Coding Tools Make a list of your practice’s top 100 most frequently used ICD-9-CM diagnosis codesUse the GEMs mapping tool to translate the ICD-9 codes to ICD-10For each ICD-10-CM code, highlight unique documentation and coding requirementsCreate flash cards, one per code, for your providersIf 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.
63 Impacts to Your Organization DocumentationReportingOffice processesReferralsPayers and business partnersBudget and productivityClaims and other electronic transactionsPM and EMR softwareThese impacts can be postive or negative depending onhow ell you are prepared!
65 SuperbillThe 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!
66 Work Flow Impacts Diagnostic Orders (Lab, Radiology, etc) Other service requests: PT, OT, DMEReferralsHome Health Treatment Plans
67 Work Flow Impacts Pharmacy Admin services: Insurance verification, pre-authorization and surgery schedulingRetrospective reporting
68 Payer and Business Partner Begin a dialogue with your payers about:testingICD-10 implementation planprovider contractscoverage and reimbursement policiesStart asking the important questions NOW!Delaying until the last minute could have a devastating effect on cash flow!MORE SPECIFIC DIAGNOSES. THEY WONT STOP ASKING FOR MORE ADDITIONAL INFO. IT AFFORDS THEM TOO GOOD AN OPPORTUNITY TO NOT PAY. SO ASK IF THEY HAVE SPECIFIC ADDITIONAL INFORMATION TO JUSTIFY PAYING.
69 TrainingIdentify the staff in your office who code, or have a need to know the codesNot all staff require the same level of training.Role Based training is essentialProfessional Coding Associations recommend:Providers 6 – 12 hoursCoders 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.Too soon and staff will forget or the codes will change. Too late and…well it will be too late to successfully transition. DO AN OVERVIEW OF EACH STAFF POSITION IN THE PRACTICE.
71 Budget Expense Small: 3 Providers & 2 administrative staff Medium:10 Providers, 1 full time coder, 6 administrative staffLarge: 100 providers, 64 codersStaff education and training$2,405$4,745$46,280Business process analysis$6,905$12,000$48,000Changes to forms$2,985$9,950$99,500IT costs$7,500$15,000$100,000Increased documentation$44,000$178,500$1.76 millionCash flow disruption$19,500$650,000Total$83,295$398,695$2,703,780
72 Hardware/SoftwareTalk with your practice management software vendor about accommodations for both version 5010 and ICD-10 codesDiscuss implementation plans with your clearinghouses, billing services, and payers to ensure a smooth transitionConduct 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 trainingConfirm PM/EMR services will accommodate both ICD-9 and ICD-10 as you work with claims for services provided before and after the transition deadlineConfirm current hardware resources are sufficient to handle the increased loadCreate 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 PayersAre top-revenue-producing insurance plans going to ICD 10? _____When? (Will they meet the Oct. 1, 2014 deadline? _____Have contract negotiations been completed for plans tying reimbursement to ICD 10? _____
76 ICD 10 Readiness Checklist Internal ProcessesImpact 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 SummaryEarly, effective preparation can turn the ICD-10-CM transition from a predicament to a significant opportunity for your practice.ReimbursementProductivityAccuracySoftware and hardware upgradesTrainingAdministrative functionsEMR adoption that enhances the ICD-10 transition
78 Tools You Will NeedICD-10 Transition Software – saves valuable conversion timeDocumentation and Coding Training GuidesDo-it-yourself ICD-10 Implementation Tool Kits - Impact Assessment/Planning GuideChart Documentation ReviewsRole Based Training PlanBudget- 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
80 Questions, Comments or Feedback? Thank You!Questions, Comments or Feedback?Please call orJerry Bridge