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ICD-10 The Provider Perspective Presented by: Joe Nichols MD Date: May 3, 2014.

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Presentation on theme: "ICD-10 The Provider Perspective Presented by: Joe Nichols MD Date: May 3, 2014."— Presentation transcript:

1 ICD-10 The Provider Perspective Presented by: Joe Nichols MD Date: May 3, 2014

2 Agenda 2 ICD-10, the basic facts How is ICD-10 different? What are the business impacts? Clinical documentation. What’s needed to support proper coding in ICD-10? What do I need to do to prepare?

3 ICD-10 What is it? 3 Source: Health Data Consulting

4 ICD10 Quick Facts 4 ICD-10 international version – Adopted by WHO in 1990 – Most countries other than the US currently use ICD-10 – ICD-10 (International version) ~ 12,500 diagnostic codes – ICD-10 used for mortality reporting in the US ICD-10-CM (US version) – ~ 69,000 diagnostic codes – Final rule published – 2009 – Compliance date – Oct 1, 2014 ICD-10-PCS – ~72,000 codes – Not part of an international standard – Inpatient procedures only – Compliance date – Oct 1, 2014 Source: Health Data Consulting Health Data Consulting © 2012

5 5 ICD-9 Diagnosis Codes vs. ICD-10-CM (Diagnosis Codes) ICD-9-CM Diagnosis CodesICD-10-CM Diagnosis Codes 3 to 5 digits Alpha “E” and “V” on 1 st character No place holder characters Terminology Index and Tabular Structure Coding Guidelines Approximately 14,000 codes Severity parameters limited Does not include laterality Combination codes limited 7 digits Alpha or numeric for any character Include place holder characters (‘x’) Similar Some what similar Approximately 69,000 codes Extensive severity parameters Common definition of laterality Combination codes common Health Data Consulting © 2012

6 Same Condition – Different Codes September What’s the Difference? October 2014 ICD-9ICD : Open fracture of Shaft of Femur S72351C: Displaced comminuted fracture of shaft of right femur, initial encounter for open fracture type IIIA, IIIB, or IIIC All codes for femur fractures = 16All codes for femur fractures = 1530 Source: Health Data Consulting Health Data Consulting © 2012

7 ICD9 Comparison to ICD10-CM 7 Diagnosis Codes – Clinical Example A patient is seen in the emergency room with. [severe] [persistent] [asthma] with [acute exacerbation]. ICD9 CodeDescription Intrinsic asthma with (acute) exacerbation ICD10 CodeDescription J4551Severe persistent asthma with (acute) exacerbation Source: Health Data Consulting Health Data Consulting © 2012

8 ICD9 Comparison to ICD10-CM 8 Diagnosis Codes – Clinical Example A patient is seen in the emergency room with. [severe] [persistent] [asthma] with [acute exacerbation]. ICD9 CodeDescription 49312Intrinsic asthma with (acute) exacerbation ICD10 CodeDescription J4551Severe persistent asthma with (acute) exacerbation Health Data Consulting © 2012

9 ICD9 Comparison to ICD10-CM 9 Diagnosis Codes – Clinical Example A patient is admitted as the result of [rupture of the cardiac wall without bleeding into the pericardium]. The patient is [within 4 weeks] of a [myocardial infarction]. ICD9 CodeDescription Certain sequelae of myocardial infarction, not elsewhere classified, other ICD10 CodeDescription I233 Rupture of cardiac wall without hemopericardium as current complication following acute myocardial infarction Health Data Consulting © 2012

10 ICD9 Comparison to ICD10-CM 10 Diagnosis Codes – Clinical Example A patient is admitted as the result of [rupture of the cardiac wall without bleeding into the pericardium]. The patient is [within 4 weeks] of a [myocardial infarction]. ICD9 CodeDescription Certain sequelae of myocardial infarction, not elsewhere classified, other ICD10 CodeDescription I233 Rupture of cardiac wall without hemopericardium as current complication following acute myocardial infarction Health Data Consulting © 2012

11 Nature of the Changes Volume 11 DiagnosisProcedure Source: Health Data Consulting Health Data Consulting © 2012

12 “There are too many Codes” There are lots of words in the dictionary, but that doesn’t seem to trouble authors… 34,250 (50%) of all ICD-10CM codes are related to the musculoskeletal system 17,045 (25%) of all ICD-10CM codes are related to fractures 10,582 (62%) of fracture codes to distinguish ‘right’ vs. ‘left’ There are over 1800 codes for fractures of the radius (forearm) but only ~ 50 concepts used repeatedly in different patterns Only a very small percentage of the codes will be used most providers 12Health Data Consulting © 2012

13 Current Distribution of ICD-9 diagnosis codes 13 3 Years of Data - All claims - All lines of business - 1million Lives Source: Health Data Consulting Health Data Consulting © 2012

14 Lots of Codes, Lots of Repetition codes for fractures of the femur

15 Documentation Requirements 15 Recurring Concepts Health Data Consulting © 2013

16 Varying Code Volume 16 By Clinical Area Source: Health Data Consulting Health Data Consulting © 2012

17 Other Key Changes 17 Code Example – Down’s Syndrome Health Data Consulting © 2012

18 Other Key Changes 18 Code Examples – Benign neoplasms of the colon: Health Data Consulting © 2012

19 Other Key Changes 19 Code Examples – Leukemia: Health Data Consulting © 2012

20 The Challenge 20 Current Physician thinking on ICD-10

21 “There are a bunch of dumb codes that make no sense.” Clinician organizations have used codes like; “Hit by a spacecraft” or “Suicide by paintball gun” as examples of the “stupidity” of the ICD-10 codes. Interesting to note however is that the codes noted above are ICD-9 codes and have been around for a long time. The bottom line; don’t use the codes that don’t make sense or don’t accurately represent your patient’s condition. They may mean something to someone, but shouldn’t bother you. 21Health Data Consulting © 2012

22 “ICD-10 won’t help me take care of my patients.” Difficult to make the case about how ICD-10 will help Dr. Smith with his encounter with Mary Jones Healthcare goes crosses the boundary of time and providers Improving healthcare requires a broad understanding of what works and what doesn't work Clinicians should be leaders in the healthcare industry by providing accurate data, accurate analysis of the data and change in healthcare to continuously improve the value their patients receive 22

23 “Documentation for ICD-10 is an unnecessary burden.” The number and type of new concepts required for ICD-10 are not foreign to clinicians The focus of documentation is good patient care Patients deserve to have accurate and complete documentation of their conditions If other industries understand the value of accurate and complete documentation of data about encounters; shouldn’t we? Health Data Consulting ©

24 “ICD diagnosis codes are irrelevant to my business.” Health Data Consulting © ICD-10 codes are likely to factor into: Changes in reimbursement based on both “what” was done and “why” Managing financial risks for contracted populations (ACO’s) Changes in reimbursement based on more robust models of payment adjusted for risk and severity More sophisticated weighting of payments based on DRGs, episodes or other groupers of care.

25 25 Business Impacts It’s bigger than you think

26 Business Impacts 26 Coding EHR updates Super Bill??? Training Coding software Contracting Scope of services Case rates Carve outs Billing Billing code updates Charge masters Billing Edits Benefits and coverage determinations

27 Business Impacts (Cont.)  Compliance HIPAA Reporting  National  State  Regional Initiatives Contract requirement Accreditation  Reimbursement Pay for performance POA, “never events”, re-admissions, HACs, tiered payment models Network inclusion Denials  Audits RAC Fraud and abuse Coding Health Data Consulting ©

28 Coding ICD-10-CM - Challenges 28 Getting there Example look up for “Coronary Artery Disease” + “Angina” Health Data Consulting © 2012

29 Coding ICD-10 CM - Challenges 29 Same concept in many places Health Data Consulting © 2012

30 Coding ICD-10 CM - Challenges 30 Relevant Quote "If you don't find it in the index, look very carefully through the entire catalogue." -- UnknownUnknown

31 Business Impacts Health Data Consulting © Coding EHR updates Super Bill??? Training Coding software Contracting Scope of services Case rates Carve outs Billing Billing code updates Charge masters Billing Edits Benefits and coverage determinations

32 Business Impacts 32 Compliance HIPAA Reporting  National  State  Regional Initiatives Contract Accreditation Reimbursement Pay for performance POA, “Never Events”, Tier Models Network inclusion Denials Audits RAC Fraud and abuse Coding

33 Quality Measures Impacts Health Data Consulting © AMI example Definition of acute myocardial infarction (MI) has changed ICD-9 – Eight weeks from initial onset ICD-10 – Four weeks from initial onset Subsequent vs. Initial episode of care ICD-9 – Fifth character defines initial vs. subsequent episode of care ICD-10 – No ability to distinguish initial vs. subsequent episode of care Subsequent (MI) ICD-9 – No ability to relate a subsequent MI to an initial MI ICD-10 – Separate category to define a subsequent MI occurring within 4 weeks of an initial MI

34 Fraud Waste and Abuse If you can’t stop expenditures upfront … 34 Source: National Health Care Anti-Fraud Association / OMB $60,000,000,000/Year Fraud, Waste and Abuse Enough money to take care of a lot of need. The Office of Management and Budget estimates that every $1 invested to fight fraud results in approximately $17 in savings.

35 Coding: The Prime Directive The goal of coding is to reflect as accurately as possible key parameters of the patient health condition and/or the procedures done to maintain or improve that condition. Coding focused on maximizing payment over accurate definition of the condition begins to cross the boundary of fraud and abuse. 35Health Data Consulting © 2012

36 Fraud, Waste and Abuse 36 Medicare Definition Source: CMS

37 Fraud, Waste and Abuse With increasing challenges to control cost, the intensity of audits related to fraud, waste and abuse is increasing. In the “Justification of Estimates for Appropriations Committees” CMS states: “Although the ICD-10 code set will not eliminate all fraud, waste, and abuse, CMS believes that its increased specificity will make it much more difficult for fraud, waste and abuse to occur.” 37 Don’t get caught in the trap… Source: CMS

38 38 4 Billion Recovered in 2013 Fraud, Waste and Abuse Don’t get caught in the trap… Source: CMS

39 Healthcare on the “RAC” 39 Getting tighter… Source: CMS Health Data Consulting © 2012

40 The Super Bill Health Data Consulting © Not That Super Really… [Note] For all codes related to fractures of the radius: ICD-9 codes = 33 ICD-10 codes = 1818

41 Cash Flow Health Data Consulting © Impacts inbound and outbound Increased Cost Coding Challenges Payment Delays

42 Cash Flow Health Data Consulting © Impacts inbound and outbound Source: CMS

43 Documentation and Coding – The Patient Interface 43 Where it all begins History Physical Exam Internal Record Review External Record Review Assessment/Diagnosis Studies

44 Documentation 44 It could be better… Poor quality documentation is bad for Payers, Providers and Patients. Billing accuracy Quality measures Population management Risk management Healthcare analytics Patient Care Bad Mojo is not a diagnosis Bad Mojo is not a diagnosis

45 Documentation

46 Documentation

47 Documentation

48 Documentation

49 Documentation Progress?

50 50

51 Documentation Supports proper payment reduced denials Assures accurate measures of quality and efficiency Assures accountability and transparency Captures the level of risk and severity Provides better business intelligence Supports clinical research Enhances communication with hospital and other providers It’s just good care! 51 Why is it important? Source: Health Data Consulting Health Data Consulting © 2012

52 Good patient data 1.Complete observation of all objective and subjective facts relevant to the patient condition 2.Documentation of all of the key medical concepts relevant to patient care currently and in the future 3.Coding that includes all of the key medical concepts supported by the coding standard and guidelines 52 It’s all about good patient care… Health Data Consulting © 2012

53 Medical Concepts 53 Medical Scenario: A [27 year old] [male] patient is seen in [follow-up] for a [Smith’s fracture] on the [right] that was exposed through an [open wound] with [minimal opening and minimal tissue damage]. The fracture has [not healed after 6 months]. Though not explicitly stated in this scenario certain expressions imply other concepts: “Smith’s fracture” >> [fracture], [radius], [distal], [dorsal angulation], [extra- articular], [displaced] “minimal opening and minimal tissue damage” >> [Gustilo classification I] “not healed after 6 months” >> [nonunion] Expressing the patient condition in codes. Health Data Consulting © 2012

54 54Health Data Consulting © 2012

55 Coding ICD-10 CM 55 Diabetes Concepts Diabetes = 276 ICD-10 Codes / 83 ICD-9 Codes Unique concepts within in ICD-10 codes = 62 Health Data Consulting © 2012

56 Coding ICD-10 CM 56 Diabetes Concepts Health Data Consulting © 2012

57 Coding ICD-10 CM 57 Diabetes Concepts Health Data Consulting © 2012

58 Coding ICD-10 CM 58 Diabetes Concepts Health Data Consulting © 2012

59 Otitis Media 59 Source: Health Data Consulting Health Data Consulting © 2012

60 ICD-10 Relevant Documentation 60 Otitis Media Concepts: Type: Serous Supparative or non-supparative Tubotympanic Atticoantral Allergic Mucoid Health Data Consulting © 2012

61 ICD-10 Relevant Documentation 61 Type (alternate terms): Sanguinous Seromucinous Exudative Transudative Secretory with effusion (non-purulent) Catarrhal Purulent Myringitis Otitis Media Concepts: Health Data Consulting © 2012

62 ICD-10 Relevant Documentation 62 Associated with: With spontaneous rupture of the TM Without spontaneous rupture of the TM Infectious or other external agent… Smoking Exposure to environmental tobacco smoke History of tobacco use Occupational exposure to environmental tobacco smoke Tobacco dependence Tobacco use Allergic or non-allergic Otitis Media Concepts: Health Data Consulting © 2012

63 ICD-10 Relevant Documentation 63 Temporal Factors: Acute or subacute or chronic Recurrent Laterality: Left or right Bilateral or unilateral Otitis Media Concepts: Health Data Consulting © 2012

64 ICD-10 Relevant Documentation 64 Code Examples – Otitis Media: Health Data Consulting © 2012

65 Fractures Radius Femur 65 Source: Health Data Consulting Health Data Consulting © 2013

66 ICD-10 Relevant Documentation 66 Fracture Concepts: Type of Fracture: Pathologic fracture Stress fracture Torus fracture Greenstick fracture Osteoporosis related Health Data Consulting © 2013

67 ICD-10 Relevant Documentation 67 Fracture Concepts: Type of Fracture: Open or Closed Gustillo type I or II Gustillo type IIIA, IIIB, or IIIC Physeal Fracture Salter Harris I Salter Harris II Salter Harris III Salter Harris IV Health Data Consulting © 2013

68 Open Fractures 68 Gustilo Classification Grade I: - wound less than 1 cm w/ minimal soft tissue injury; - wound bed is clean - bone injury is simple w/ minimal comminution; - w/ IM nailing, average time to union is weeks; Grade II: - wound is greater than 1 cm w/ moderate soft tissue injury; - wound bed is moderately contaminated; - fracture contains moderate comminution; - w/ IM nailing, average time to union is weeks; *Source: Duke Orthopedics Health Data Consulting © 2013

69 Open Fractures 69 Gustilo Classification Grade III: - following frx automatically results in classification as type III: - segmental frx w/ displacement - frx w/ diaphyseal segmental loss; - frx w/ associated vascular injury requiring repair; - farmyard injuries or highly contaminated wounds; - high velocity BSW; - frx caused by crushing force from fast moving vehicle *Source: Duke Orthopedics Health Data Consulting © 2012

70 Open Fractures 70 Gustilo Classification Grade III A: - wound less than 10 cm w/ crushed tissue and contamination; - soft tissue coverage of bone is usually possible; - w/ IM nailing, average time to union is weeks; *Source: Duke Orthopedics Grade III B: - wound greater than 10 cm w/ crushed tissue and contamination; - soft tissue is inadequate and requires regional or free flap; - w/ IM nailing, average time to union is weeks; Grade III C: - is frx in which there is a major vascular injury requiring repair for limb salvage; - fractures can be classified using the MESS: - in some cases it will be necessary to consider BKA following tibial frx Health Data Consulting © 2013

71 Growth Plate Fractures 71 Salter-Harris Classification Health Data Consulting © 2013

72 ICD-10 Relevant Documentation 72 Fracture Concepts: Laterality: Left Right Unilateral Bilateral Spatial Localization: Proximal Distal Medial Lateral Health Data Consulting © 2013

73 ICD-10 Relevant Documentation 73 Fracture Concepts: Encounter: Initial Subsequent Sequela Healing pattern: Routine Healing Delayed healing Nonunion Malunion Health Data Consulting © 2013

74 ICD-10 Relevant Documentation 74 Fracture Concepts: Fracture Patterns: Displace/Non-displaced Transverse, Oblique, Spiral Simple, Comminuted, Segmental 3 part.., Intra-articular/Extra-articular Avulsion Health Data Consulting © 2013

75 ICD-10 Relevant Documentation 75 Fracture Concepts: Fracture Patterns: Osteochondral or Articular Blowout Fracture Longitudinal Pilon Fracture Compression Fracture Wedge Fracture Health Data Consulting © 2012

76 ICD-10 Relevant Documentation 76 Fracture Concepts - Radius: Parts of the Bone: Radius Radial Head Radial Styloid Shaft Neck Radius and ulna Radial tuberosity

77 ICD-10 Relevant Documentation 77 Fracture Concepts-Radius: Named Fractures of the Radius: Colles’ Smith’s Galeazzi’s Barton’s Chauffeur’s

78 ICD-10 Relevant Documentation 78 Code Example – Radial Fractures: Health Data Consulting © 2013

79 The Femur 79 Anatomy Health Data Consulting © 2013

80 The Femur 80 Fracture Patterns Transverse Oblique Sub-Trochanteric Lateral Condylar Medial Condylar Supra-Condylar Sub Capital Inter-Trochanteric Spiral Intra-Condylar

81 ICD-10 Relevant Documentation 81 Code Example – Femur: Health Data Consulting © 2013

82 Getting Specific 82 When is unspecified OK?

83 Coding specificity Does specificity require more than one code? When is unspecified the right choice? When should unspecified change to specified? 83 What’s an unspecified code? Health Data Consulting © 2012

84 Poorly Specified Coding “Coding that does not fully define important parameters of the patient condition that could otherwise be defined given information available to the observer (clinician) and the coder.” 84 A proposed definition Health Data Consulting © 2012

85 Coding specificity Beyond the primary code, accurate representation of the patient’s health condition may require other codes to represent: Causation Infectious, chemical, physical or other agents Location of Injury External causes of injury Manifestations Comorbid condition or contributing factors Sequela Findings Multiple other factors associated with the primary condition being treated or evaluated 85 More than one code. Health Data Consulting © 2012

86 Coding specificity Sometimes unspecified makes sense… The patient may be early in the course of evaluation The claim may be coming from a provider who is not directly related to diagnosis of the patients condition The clinician seeing the patient may be more of a generalist and not able to define the condition at a level of detail expected by a specialist 86 A place for “unspecified” codes Source: Health Data Consulting

87 Coding specificity If there is sufficient information available to more accurately define the condition For basic concepts such as: Laterality (Right, Left, Bilateral, Unilateral) Anatomical locations Trimester Type of diabetes Known complications or comorbidities Description of severity, acute or chronic or other known parameters… Where care is implemented that demands a more specific level of detail At specialty level that should be able to define the detail required 87 No place for “unspecified” codes Health Data Consulting © 2012

88 Clinical / Business/Coding Relationships 1.The role of the clinician is to document as accurately as possible the nature of the patient conditions and services done to maintain or improve those conditions 2.The role of the coding professional is to assure that coding is consistent with the documentation 3.The role of the business manager is to assure that all billing is accurately coded and supported by the documented facts. 88 Creating a new working relationship Source: Health Data Consulting Health Data Consulting © 2012

89 Implementation 89 Getting your ducks in a row

90 Implementation Strategy Short term goals with a long term visions What solution do I need today? Will that solution extend to tomorrows needs? Awareness of touch points with other initiatives Overlap and conflicts Down Stream Impacts What works well for one business area, may bring another business area to it’s knees Positioning for competitive advantage Can you predict risk better than you competitor? Are you perceived as a supporter and facilitator for the transition challenge to providers and other stakeholders? Can you manage the “burden of illness” of your population better than your competitors? 90Health Data Consulting © 2012

91 Phases of Transition 91 1.Assessment Inventory of impacted systems and processes Identifying risk 2.Analysis/Planning Prioritizing focus Establishing business area specific approaches Creating specifications for mapping to support implementation 3.Implementation and Operations Translating codes from 9 to 10 and from 10 to 9 using crosswalks Changing analytic models to support both codes Operationalization of coding to ICD10 from source information Changing processing logic to operate directly from ICD10 codes 4.Leveraging ICD10 capabilities Using the enhanced information within ICD10 codes to improve processing and analysis based on improved concepts buried within the ICD10 codes Health Data Consulting © 2012

92 Scenario-Based Testing The scenario: The identification of some event or condition that we are familiar with today Recreating that event virtually through some verbal or data representation Defining a variety of assumptions and variables around this virtual representation Applying one or more of these scenarios in a Reference Implementation Model (RIM). Walk through current systems or processes using these scenarios with varying assumptions and variables to determine if expected results can be achieved and the required changes to achieve those expected results. 92 What is it? Health Data Consulting © 2012

93 Leveraging ICD10 Accurate and complete documentation and coding provides opportunities to support the transition into a “value-based”, “accountable care” reimbursement environment. Better representation of severity and risk Recognition of varying levels of complexity Better claim information to support automated processing and more rapid reimbursement Opportunities to reduce audit risk exposure Improved business intelligence to support population risk management More accurate measures of quality and efficiency 93 A changing world of cost containment Health Data Consulting © 2012

94 Summary ICD-10 will be a substantial change in the standard for defining the patient’s health state and the institutional procedures performed to maintain or improve that health state. There are significant impacts and changes to both the clinical and business side of the practice. Coding accuracy and productivity will be substantially impacted during the transition and will impact both cost and revenue. There are significant new opportunities to leverage ICD-10 in a new payment environment (ACO). 94 Key Points Source: Health Data Consulting Health Data Consulting © 2012

95 Summary Establish awareness across members of your organization Clearly define strategic goals Identify internal and external dependencies Identify and prioritized key risks Clearly define all business requirements and implementation tasks Create a realistic project plan and support it as a priority Test early and often. Get started now!! 95 Action Items Source: Health Data Consulting Health Data Consulting © 2012

96 96

97 Online Resources CMS - https://www.cms.gov/ICD10/ Coding Documentation (Indexes, Coding Guidelines, Code Files) General Equivalency Mapping [GEM] (Mapping files, Guidelines, Procedure and Diagnosis) FAQ, Coordination and maintenance Committee minutes WEDI - List serves Workgroups White papers Implementation forums Industry advocacy and issue Access to standards leaders AHIMA - Training and certification Extensive documentation libraries Bookstore Communities of practices ICD-10 focused conferences 97 Source: Health Data Consulting

98 Online Resources HIMSS - White papers Bookstore Webinars Vendors Consulting Organization Online news ICD-10 watch -http://www.icd10watch.com/ Blogs 98 Source: Health Data Consulting

99 Online Resources Health Data Consulting white papers: ICD-10 Vendor Evaluation ICD-10 A Primer ICD-10 Physician Impacts ICD-10 Hospital Impacts Scenario Based Testing ICD-10 The Case for Moving Forward Transition to ICD-10: Getting Started Reconciling Analytics Across the ICD-10 Transition Contingency Planning 99 Source: Health Data Consulting


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