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ICD-10-CM Making a Successful, Timely Transition

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1 ICD-10-CM Making a Successful, Timely Transition
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. 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 flow Know how to make a project plan; budget, training, vendor management Take 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 consistently Improved care with better documentation Address technology and healthcare reform initiatives Reduce the hassle of audits Determine 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 registries Quality reporting Consumer health sites Reduce 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 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” “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 coders Everyone 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 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 Next 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-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.

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 PAGE 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…, 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 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. For example

16 ICD-10-CM vs. ICD-9 Code Structure
ICD-10-CM Code Format Ex: Unspecified asthma with acute exacerbation ICD-9               ICD-10             J45.901 (Etiology means “cause or origin”) ICD-9-CM Code Format PAGE 14 Show SSTS, fracture of patella, then asthma

17 ICD-10 Code Set Websites CMS: AMA: 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! 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 documentation Choose the correct code Make sure you have the medical necessity to justify the procedure or service Page 16

21 Examples of ICD-10-CM Codes
I10 - Hypertension (Seriously? I10?) H Sensorineural hearing loss bilateral K80.63 Calculus of gallbladder and bile duct with acute cholecystitis with obstruction Fracture 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 Winkler Michigan Blue Cross’ Director of Technical Program Management Justifying medically necessary procedures and services depends on specificity of diagnoses coding! PAGE 18 Remember I asked the question, “Do insurance companies want to pay you or not pay you?”

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? 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. 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 * PAGE 20

27 Combination Codes Multiple conditions that may include common symptoms or manifestations Diabetes with ophthalmic manifestations Sequencing 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 coders Everyone 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-CM ICD-10-CM Diabetes with ophthalmic manifestations – To identify Retinopathy AND Macular edema E Type 2 Diabetes with unspecified diabetic retinopathy with macular edema E Type 2 Diabetes with mild nonproliferative diabetic retinopathy with macular edema E Type 2 Diabetes with moderate nonproliferative diabetic retinopathy with macular edema E Type 2 Diabetes with severe nonproliferative diabetic retinopathy with macular edema E 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 providers Practice 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-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 PAGE 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 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 PAGE 23

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 PAGE 25

33 Fracture of Patella

34 Fracture of Patella in ICD-10?

35 Elements of Documentation

36 Elements of documentation

37 Flash Cards

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! PAGE 35

39 Fall from or off toilet with subsequent striking against an object
W18.12X Fall from or off toilet with subsequent striking against an object W18.12XA Initial Encounter W18.12XD Subsequent Encounter W18.12XS Sequela

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


42 Striking against other stationary object,
W22.09ZD Striking 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!) W22.09ZD Striking against other stationary object, Subsequent Encounter How about this one…


46 Activity, Milking an animal
Y93.K2 Activity, Milking an animal


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


50 Burn due to water-skis on fire, subsequent encounter
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 Hypothermia, Initial Encounter
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
Per Doctor: list top 25 diagnoses (by revenue, frequency) Use GEMS to translate ICD-9 to ICD-10 Pull patient charts containing those ICD- 9 diagnoses Assess current documentation as sufficient or not Create report for providers Customize training by provider Continue to monitor documentation PAGE 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 codes Use the GEMs mapping tool to translate the ICD-9 codes to ICD-10 For each ICD-10-CM code, highlight unique documentation and coding requirements 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 These impacts can be postive or negative depending onhow ell you are prepared!

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

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!

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! 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 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: Providers 6 – 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. 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 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 $650,000 Total $83,295 $398,695 $2,703,780

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 Are 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 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

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

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