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ICD-10 Provider Education Developmental Disabilities Provider Association Cathy Munn, MPH RHIA CPHQ Sr. Consultant 1.

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Presentation on theme: "ICD-10 Provider Education Developmental Disabilities Provider Association Cathy Munn, MPH RHIA CPHQ Sr. Consultant 1."— Presentation transcript:

1 ICD-10 Provider Education Developmental Disabilities Provider Association Cathy Munn, MPH RHIA CPHQ Sr. Consultant 1

2 Overview of ICD-10 Transition – Industry Update Impact of the Change – Providers – Payers Provider Preparation – Translation Examples Arkansas DHS Preparation & Planning Next Steps & Resources 2 Agenda

3 The change to ICD-10 only applies to Medicaid…. The implementation date for ICD-10 is 10/1/2014… CPT codes will be replaced with ICD-10 codes… The ICD-10 code composition will now be alphanumeric…. ICD-10 is just like any other annual coding update… Before We Begin….. 3

4 ICD-9-CM: International Classification of Diseases, 9 th revision, Clinical Modification – US transitioned from ICD-8 to ICD-9 in 1979 – Annual updates ICD-10: Developed by the World Health Organization as the nomenclature for all countries – ICD-10-CM: International Classification of Diseases, 10 th revision, Clinical Modification – US only – ICD-10-PCS: International Classification of Diseases, 10 th revision, Procedure Classification System – US only ICD-10-CM/PCS 4

5 Final Rule Originally Published by HHS on January 16, 2009 requiring the adoption of ICD-10 on October 1, 2013 NO GRACE PERIOD – Dates of Service (outpatient) After 10/1/2013 – Dates of Discharge (Inpatient) After 10/1/2013 Federal Mandate Updated Timeline: – February 14, 2012 – CMS announces they will “reexamine the pace” of implementing ICD-10 – May 17, 2012 – All comments due to HHS for consideration prior to publication of the final rule – August 27, 2012 – Revised compliance date announced by CMS stating a one-year extension would be granted – October 1, 2014 is the revised ICD-10 Implementation Compliance Date Federal Mandate 5

6 ICD-10-CM (diagnoses) will be used by all providers in every health care setting ICD-10-PCS (procedures) will be used only for hospital claims for inpatient hospital procedures No impact on Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes CPT and HCPCS will continue to be used for physician and ambulatory services including physician inpatient hospital visits Release of DSM-V codes occurred in May 2013; however DSM-V is not HIPAA compliant for claims or transactions Things to Remember 6

7 Systems will have to utilize both ICD-9-CM and ICD- 10-CM for overlap e.g. claims backlog, Arkansas Medicaid allows providers 365 days to submit a claim. Inpatient discharges occurring on or after will use ICD-10-CM and ICD-10-PCS codes regardless of date of admission. Outpatient dates of service occurring on or after will use ICD-10-CM codes There will be period of time when payers will be processing claims in both ICD-9 and ICD-10 Important Information 7

8 ICD-9 Current State 8 ICD-9 lacks the specificity & granularity needed to accurately reflect care provided Technology & practice patterns have changed dramatically in 30 years ICD-9 has run out of codes to accurately capture current medical practice

9 ICD-10 Future State 9 Updates terminology & disease classification consistent w/current practice Expands flexibility for future updates based on technical advances Enhances research & outcomes data capture & quality measure reporting

10 Better data will be available for: – Measuring the quality, safety, and efficacy of care – Designing payment systems and processing claims for reimbursement – Conducting research, epidemiological studies, and clinical trials – Setting health policy – Operational and strategic planning and designing healthcare delivery systems – Monitoring resource utilization – Improving clinical, financial, and administrative performance – Preventing and detecting healthcare fraud and abuse – Tracking public health and risks A Few ICD-10 Benefits 10

11 Other Competing Priorities 11 ICD-10: Key to the success of each initiative ACOs/ Patient Centered Medical Home EHR/ Meaningful Use Value Based Purchasing Public Reporting & Quality Measures

12 Alpha CharacterNarrative Description A and BCertain infectious and parasitic diseases. C00 to D48Neoplasms. D50 to D89 Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism. EEndocrine, nutritional and metabolic diseases. FMental and behavioral disorders. GDiseases of the nervous system. H00 to H59Diseases of the eye and adnexa. H60 to H95Diseases of the ear and mastoid process. ICD-10 Chapter Headings 12

13 13 ICD-9 vs. ICD-10 Diagnosis Codes ICD-9 Diagnosis Codes – 13,000ICD-10 Diagnosis Codes – 68, Characters3-7 Characters First character is numeric or alpha (E or V) First character is alpha Use of decimal after 3 rd character Characters 2-7 are alpha or numeric – letter U is not used Use of dummy placeholder “X” for future code expansion E codes reference External Causes of Injury & Poisoning in ICD-9. E references the Endocrine system in ICD-10 V codes reference Health Status & Contact with Health Services in ICD-9 V – Y codes reference External Causes of Morbidity in ICD-10

14 XXXX Category: Superficial injury of knee & lower leg. Etiology, anatomic site, severity: Other superficial injuries of knee 1 – Right; 2 – Left; 9 – Unspecified Added 7 th character for obstetrics, injuries, and external causes of injury Abrasion of the right knee, initial encounter Structure and Seventh Character XXX 14 AMS A Additional Characters Alpha (Except U) 2 Numeric 3-7 Numeric or Alpha 3–7 Characters

15 15 ICD-9 Procedure vs. ICD-10-PCS ICD-9 Procedure Codes – 4,000ICD-10 Procedure Codes – 87, Digits7 Digits All digits are numericAlpha or numeric composition Numbers Letters O & I are omitted Example: Artery suture has 1 codeExample: Artery suture – 195 coding options The increase in the number of procedure codes is driven by the increased specificity, granularity & laterality contained within the ICD-10 codes.

16 16 ICD-10 Procedure Code Structure

17 FY2013 ICD-9- CM procedureSource Code Title Source Status FY2013 ICD- 10-PCS procedure Target Code Title 94.27Other electroshock therapyGZB0ZZZ Electroconvulsive Therapy, Unilateral- Single Seizure 94.27Other electroshock therapyGZB1ZZZ Electroconvulsive Therapy, Unilateral- Multiple Seizure 94.27Other electroshock therapyGZB2ZZZ Electroconvulsive Therapy, Bilateral- Single Seizure 94.27Other electroshock therapyGZB3ZZZ Electroconvulsive Therapy, Bilateral- Multiple Seizure 94.27Other electroshock therapyGZB4ZZZ Other Electroconvulsive Therapy ECT Code Translation 17

18 18 Patient Flow Impact Start Patient Encounter Diagnose Patient Code Claim Submit Claim Receive Claim Begin Adjudication Check Eligibility Determine Benefits Select provider & contract Check Auth Price Claim Payment & Remit Back end processes Providers change coding practices based on ICD-10 Update practice management system Update claims submission process Update system to accept claims Update benefit logic & edits Revise authorization process Claim priced based on revised fee schedules Update data repositories to accommodate new coding Revise for ICD- 10 reporting

19 19 Impact on Providers Systems Operations and Processes Clinical Documentation

20 Identify your current systems and work processes that use ICD-9 codes. This could include: – Clinical Documentation – Encounter Forms and Superbills – Practice Management Systems – Electronic Medical Record Systems – Contracts and Fees Schedules – Public Health and Quality Reporting Protocols & Reports A good rule of thumb: Wherever ICD-9 codes appear today, ICD-10 codes will need to replace them in the future System Impacts 20

21 Talk with your practice management system vendor about accommodations for both ICD-9 and ICD-10 codes – Will your current system require upgrades? – Is the vendor planning system updates for accommodation of ICD-10 codes? – When will they be ready to install/update? – Are the upgrades included in your current contract? Discuss readiness and remediation plans with any clearinghouses or billing services you may use System Impacts 21

22 Discuss implementation plans with all your clearinghouses, billing services, and payers to ensure a smooth transition Be proactive; don’t wait for vendors to contact you Ask about their plans for ICD-10 compliance and when they will be ready to collaboratively test their systems Ask to see their Remediation Roadmap that supports their claims of “readiness” Utilize CMS checklists and resources as a guide System & Operational Impacts 22

23 Talk with your payers about how ICD-10 implementation might impact your contracts. Because ICD-10 codes are much more specific than ICD-9 codes, payers may modify terms of contracts, fee schedules or reimbursement methodologies Understand your metrics: – Coding Productivity – Coding Accuracy – Financial Stability Days in A/R Cash on hand Operational Impacts 23

24 Identify potential changes to work flow and business processes Consider changes to existing processes including: – Clinical documentation – viewed as an increasing area of vulnerability & concern in the industry – Prior authorization – Encounter forms and Superbills – Quality and Public Health reporting – Involvement in any Care Management or community outreach initiatives Operational Impacts 24

25 Identify the staff in your office who code, or have a need to know the new codes….anticipate that everyone in your office will require some level of awareness training Don’t forget the physicians in the awareness training There are a wide variety of training opportunities and materials available through a variety of resources: – Professional Coding Associations – AAPC, AHIMA – Online Courses – ICD10 Monitor, Contexo University, Precyse, Nuance – Webinars – ICD10 Monitor, HCPro – Onsite Training – Train-the-Trainer approach, Coding Boot Camp – Non-Traditional - Partner with the HIM Department at a nearby hospital Operational Impacts 25

26 Budget for time and costs related to ICD-10 implementation including: – Expenses for system changes and software updates – Resource materials – Training – Modifications to forms and Superbills Other budgetary considerations: – Unanticipated payment delays, appeals & denials – Understand your operational metrics – benchmark for efficiency – Establish a line of credit…… Anticipate something you didn’t plan for or expect…. Operational Impacts 26

27 Increased size Increased specificity Examples can be found at along with other valuable ICD-10-CM resources Superbills - How Will They Change? 27

28 FY2013 ICD-9-CM DiagnosisSource Code Title FY2013 ICD-10- CM DiagnosisTarget Code Title Autistic disorder, current or active stateF84.0Autistic disorder Autistic disorder, residual stateF84.0Autistic disorder Childhood disintegrative disorder, current or active stateF84.3 Other childhood disintegrative disorder Childhood disintegrative disorder, residual stateF84.3 Other childhood disintegrative disorder Pervasive Developmental Disorders 28

29 FY2013 ICD-9-CM DiagnosisSource Code Title FY2013 ICD-10- CM DiagnosisTarget Code Title Other specified pervasive developmental disorders, current or active stateF84.5Asperger's syndrome Other specified pervasive developmental disorders, current or active stateF84.8 Other pervasive developmental disorders Other specified pervasive developmental disorders, residual stateF84.5Asperger's syndrome Other specified pervasive developmental disorders, residual stateF84.8 Other pervasive developmental disorders Unspecified pervasive developmental disorder, current or active stateF84.9 Pervasive developmental disorder, unspecified Unspecified pervasive developmental disorder, residual stateF84.9 Pervasive developmental disorder, unspecified Pervasive Developmental Disorders Cont. 29

30 FY2013 ICD-9-CM DiagnosisSource Code Title FY2013 ICD-10-CM DiagnosisTarget Code Title Unspecified delay in developmentF81.9 Developmental disorder of scholastic skills, unspecified Unspecified delay in developmentF89 Unspecified disorder of psychological development 317 Mild intellectual disabilitiesF70 Mild intellectual disabilities Moderate intellectual disabilitiesF71 Moderate intellectual disabilities Severe intellectual disabilitiesF72 Severe intellectual disabilities Profound intellectual disabilitiesF73 Profound intellectual disabilities 319 Unspecified intellectual disabilitiesF78 Other intellectual disabilities 319 Unspecified intellectual disabilitiesF79 Unspecified intellectual disabilities Intellectual Disabilities 30

31 ICD-10 CodeDefinitionIQ Level F70Mild Intellectual DisabilitiesIQ level 50 – 55 to approximately 70 Mild mental subnormality F71Moderate Intellectual DisabilitiesIQ level 35 – 40 to 50 – 55 Moderate mental subnormality F72Severe Intellectual DisabilitiesIQ level 20 – 25 to 35 – 40 Severe mental subnormality F73Profound Intellectual DisabilitiesIQ level 20 – 25 Profound mental subnormality NOTE – Borderline intellectual functioning with IQ level above 70 – 84 is coded R41.83 Intellectual Disabilities 31

32 FY2013 ICD-9-CM DiagnosisSource Code Title FY2013 ICD-10- CM DiagnosisTarget Code Title Lack of normal physiological development, unspecifiedR62.50 Unspecified lack of expected normal physiological development in childhood Lack of normal physiological development, unspecifiedR62.59 Other lack of expected normal physiological development in childhood Developmental Delays 32

33 FY2013 ICD-9-CM Diagnosis Source Code Title FY2013 ICD-10- CM Diagnosis Target Code Title 343.2Congenital quadriplegiaG80.0 Spastic quadriplegic cerebral palsy 343.0Congenital diplegiaG80.1 Spastic diplegic cerebral palsy 343.1Congenital hemiplegiaG80.2 Spastic hemiplegic cerebral palsy Athetoid cerebral palsyG80.3Athetoid cerebral palsy Other specified infantile cerebral palsyG80.4Ataxic cerebral palsy 343.3Congenital monoplegiaG80.8Other cerebral palsy Other specified infantile cerebral palsyG80.8Other cerebral palsy Infantile cerebral palsy, unspecifiedG80.9Cerebral palsy, unspecified Cerebral Palsy 33

34 FY2013 ICD-9-CM DiagnosisSource Code Title FY2013 ICD-10-CM DiagnosisTarget Code Title 758.0Down's syndromeQ90.0 Trisomy 21, nonmosaicism (meiotic nondisjunction) 758.0Down's syndromeQ90.1 Trisomy 21, mosaicism (mitotic nondisjunction) 758.0Down's syndromeQ90.2Trisomy 21, translocation 758.0Down's syndromeQ90.9 Down syndrome, unspecified Down’s Syndrome 34

35 If it’s not documented….it’s not done – Outcome Data – Liability – Reimbursement Clinical Documentation 35

36 Clinical documentation improvement “best practices” provide an opportunity for accurate coding and richer clinical data. Accurate data will allow us to better understand our patients; their compliance with care management initiatives and which treatments lead to better outcomes. Complete clinical documentation will promote accurate coding thus leading to more accurate payment that could legitimately look different than it does today. Clinical Documentation Practices 36

37 37 Clinical Scenario Patient presents to the ER for severe right lower leg pain with an open leg wound following a fall from a ladder. The physician documented that the patient had an open transverse fracture of the shafts of the tibia & fibula. ICD-9-CM code: , Open fracture of shaft, fibula with tibia E881.0 Accidental fall from ladder ICD-10-CM codes: S82.221B Displaced transverse fracture of shaft of right tibia, initial encounter for open fracture NOS S82.421B Displaced transverse fracture of shaft of right fibula, initial encounter for open fracture NOS W11.XXXA Fall on and from ladder, initial encounter

38 38 Changes to E & V Codes in ICD-10 E codes reference External Causes of Injury & Poisoning in ICD-9 – E code references the Endocrine system in ICD-10 Thyroid gland disorders: E00 – E07 Diabetes codes: E08 – E13 Disorders of glucose regulation & pancreatic internal secretion: E15 – E16 V codes reference Health Status & Contact with Health Services in ICD-9 – Z codes reference Health Status & Contact with Health Services in ICD-10 V – Y codes reference External Causes of Morbidity in ICD-10

39 39 Other Resources & Reminders Additional information & resources you might find helpful….

40 CMS Resources 40

41 CMS Resources 41

42 42

43 43 Arkansas DHS Current State Arkansas Medicaid has been working on ICD-10 for over two years Progress to date: – Operational assessment complete – Remediation of Medical Policy, Edits and Audits complete – Remediation of Pharmacy Policy & edits nearing completion – Provider Manuals currently under review – Systems requirements obtained – HP/MMIS, Xerox/ACS & other integrated & stand alone systems – Arkansas DHS reports, forms, and brochures currently under review – Ongoing Provider Outreach Meetings/Webcasts Provider Bulletins Newsletters ICD-10 Website Internal & external testing scenarios are under development Per CMS; external testing should begin October, 2013

44 44 Now What?

45 45 Communication & Planning Engage the support of leadership Define your strategy & approach to ensure success Understand the financial implications of non-compliance Ensure everyone understands the impact of ICD-10 – Receptionist – Nursing Staff – Physicians – Coders – Billing Staff – CFO/COO – Senior Practice Management Staff Share regular updates & communication briefings with staff

46 46 Operational Assessment Understand which systems & processes will be impacted Understand the impact that the transition will have on people, process & technology; both internal & external to the practice – Staff & providers Education & awareness Training – just in time – Workflows Office through-put Clinical documentation Code utilization within the practice – Superbill assessment Coding & billing turn-around-time/cash flow Denials & resubmission of claims – Systems upgrades/enhancements Practice management systems Billing transmissions – EDI Vendor readiness

47 Provider practices and specialty departments should examine their patient population in terms of: –High volume/high cost –Patient demographic & payer mix: Medicare, Medicaid, Commercial insurance –Diagnoses that lead to the highest denial, physician query and re-bill rates; and –Areas related to quality reporting, improvement initiatives and published RAC reviews Documentation Assessment 47

48 Evaluate your current documentation – Does it specify right vs. left? – Does it provide the specificity needed to accurately assign an ICD-10 code? Conduct a sample audit to evaluate clinical documentation – Review claims coded in ICD-9 and code them in ICD-10 – Is the documentation sufficient? Share the audit results with the providers – Understanding of the future documentation needs will reduce queries, pended claims & denials post 10/1/2013 Documentation Assessment 48

49 49 Testing Largest testing effort in the history of healthcare Not a routine upgrade with minimal testing before implementation Recommended that you employ end to end testing with vendors, providers & payers to include: – Creation of the claim – Submission to payer/EDI vendor/clearinghouse via 837 – Adjudication of claim – Reporting back to the provider via EOP/835 – Adjustments/denials/resubmissions – Report creation – Denial tracking & analysis Monitor the AR ICD-10 Website for information regarding testing

50 50 Industry Web Site Resources /Downloads/ICD10SmallandMediumPractices508.pdf 10/Downloads/ICD10SmallandMediumPractices508.pdf

51 51 CMS Resources

52 52 For More ICD-10 Information White Papers (including but not limited to) – ICD-10 A Primer – ICD-10 Clinical Documentation – ICD-10 Physician Impact – ICD-10 Advantages – ICD-10 Specified or Unspecified Checklists published by CMS for providers (small, medium and large) at: – 10ImplementationTimelines.html 10ImplementationTimelines.html

53 53 AR Medicaid ICD-10 Website

54 54 Questions & Comments


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