1. 1 This material must be reviewed prior to attending your General Orientation class. Please ask any related questions at your General Orientation class. Welcome to the 2015 Catholic Health Online Orientation Component

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3. 3 Risk Management is the systematic review of events that present a potential for harm and could result in loss for the system.

4. 4 Review Identification Review Occurrence Reports Review Patient/Visitor Complaints Participate in Root Cause Analysis Review concerns expressed by CH staff

5. 5 Loss Prevention Educational programs through CH University Department specific in-services

6. 6 Claims Management Investigating and reporting occurrences and claims made to insurance carriers Assist with discovery requests for lawsuits Process Summons, Complaints and Subpoenas ** NOTIFY RISK MANAGEMENT IMMEDIATELY UPON RECEIPT OF A WORK RELATED SUMMONS OR SUBPOENA

7. 7 Claims Management - Continued Within CH, a process server is to be directed to Administration of the facility in order to serve a Summons or Subpoena. (HIM may accept subpoenas for hospital records.) *** INDIVIDUAL DEPARTMENTS SHOULD NOT ACCEPT, EVEN IF IT IS FOR SOMEONE IN THE DEPARTMENT.

8. 8 Risk Financing Obtaining and maintaining appropriate insurance coverage: HPL (Healthcare Professional Liability) GL (General Liability) D&O (Directors and Officers) Property and Casualty Auto Crime Fiduciary (Finance)

9. 9 An occurrence is an event that was unplanned, unexpected and unrelated to the natural course of a patient’s disease process or routine care and treatment.

10. 10 Patient harm/potential harm like falls, medication errors Visitor injury Patient related equipment “failure” Security issues like elopement, crime, altercations Lost or damaged property

11. 11 Enhance the quality of patient care Assist in providing a safe environment Quick notice of potential liability

12. 12 Any associate or physician who discovers, witnesses or to whom an occurrence is reported, is responsible for documenting the event immediately by means of the Occurrence Report. Anyone who requires assistance should contact the department manager. DO NOT MAKE COPIES OF AN OCCURRENCE REPORT.

13. 13 The completed Occurrence Report is to be forwarded to the Department Manager who will investigate the occurrence and forward to Quality & Patient Safety Department who will forward to Risk Management.

14. 14 Patient and visitor safety are assessed from both clinical and environmental perspectives Notify Quality & Patient Safety of patient occurrences Notify Security of visitor or property occurrences Risk Management will be notified and will participate in evaluation of occurrence Risk Management will report occurrences to insurance carrier in cases of potential liability Risk Management will manage claim as indicated

15. 15 Date (MM/DD/YY) and time (military) State facts, be clear and concise Your own observations If event described to writer, use quotes or “according to …” Do not place blame in the record DO NOT REFER TO OCCURRENCE REPORT IN THE MEDICAL RECORD

16. 16 EMTALA is the Emergency Medical Treatment and Active Labor Act (aka COBRA) EMTALA provides a guideline for safely and appropriately transferring patients in accordance with Federal regulations.

17. 17 The law provides for a medical screening exam (MSE) to all individuals seeking emergency services on hospital property. Hospital property includes the driveway, parking lot, lobby, waiting rooms and areas within 250 yards of the facility. If an emergency medical condition is found, it will be stabilized within the hospital’s ability to do so, prior to the patient’s transfer or discharge. If a patient does not have an emergency medical condition, EMTALA does not apply. *** IMPORTANT: NEVER SUGGEST THAT A PATIENT GO ELSEWHERE FOR TREATMENT

18. 18 Fair and Accurate Credit Transactions Act of 2003 or “RED Flag Rules” Hospitals that maintain covered accounts must develop and implement written policies and procedures to identify, detect, prevent, and mitigate identity theft.

19. 19 Alerts, notifications, warnings Presentation of suspicious information Suspicious activity Notice from patient, law enforcement, etc. ** Patient Access, Health Information, Finance, I.T. departments primarily involved.

20. 20 You can help reduce opportunities for Identity Theft by keeping PHI confidential and out of public view. If you believe someone is presenting suspicious documents or acting in a suspicious manner, notify your supervisor who will notify Risk Management.

21. 21 Nancy Sheehan, 821-4462 Interim Director, Risk Management Joanne Ricotta, RN, BSN821-4463 Risk Management Coordinator Terri Tobola 821-4467 Risk Management Technical Assistant Penny Arnold821-4468 Legal Services Administrative Assistant

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23. 23 Social Media Policy Review What is Social Media? Social Media is defined as user generated content that is shared over the internet via technologies that promote engagement, sharing and collaboration. What does Social Media Include: It includes, but is not limited to: Social networking sites such as Facebook, LinkedIn, Flickr and Twitter Personal websites News forums Chat rooms

24. 24 Catholic Health recognizes social media as an avenue for self-expression. Associates must remember that they are personally responsible for the content they contribute and should use social media responsibly. The following Catholic Health policies apply to all associates on line conduct: Human resources policies, Equal employment opportunity policies Sexual harassment/non-harassment policies Patient confidentiality/HIPAA policies

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26. 26 The policy is divided into three distinct sections that grant different rights to patients based on the following Catholic Health ministries: Acute Care Continuing Care Home Healthcare

27. 27 All uninsured patients of Catholic Health receiving treatment at one of the Catholic Health’s acute care facilities who are residents of New York State, a contiguous State or the state of Ohio, excluding the following services: - Non-Medically Necessary Elective Services (e.g. cosmetic surgery), - Long term level of care services (Sub-Acute or Skilled Nursing), - Physician services other than Catholic Health primary care physician services, and - Medical equipment and supplies Who does this policy apply to?

28. 28 All residents of Catholic Health receiving treatment at one of the Catholic Health’s Long Term Care facilities (Hospital and Non Hospital Based) that are subject to insurance co-payments or deductibles and Adult Home residents may be eligible for charity care. Who does this policy apply to?

29. 29 All patients that receive services within the Catholic Health Home Care division (Certified Agencies, Licensed Agencies, and Infusion Pharmacy) may be eligible for Charity Care. Who does this policy apply to?

30. 30 All patients registered as uninsured (i.e., those without insurance, also often referred to as self pay) will automatically be enrolled in the Healthcare Assistance Program. An optional application form will be offered at time of registration, but failure to complete the application will not exclude enrollment. As such, uninsured patients presenting for care at a Catholic Healthcare acute care facility need do nothing to apply for healthcare assistance.

31. 31 o Balances after insurance payment due from the patient or patient guarantor are referred to as After Insurance Balances. o These balances include, but are not limited to, co- pays, deductibles and co-insurance. o For insured patients without the financial ability to pay After Insurance Balances, After Insurance Balance Allowances are available based on a sliding scale. o A different set of procedures must be followed in order to be the eligible for this allowance.

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33. 33 NIOSH (National Institute for Occupational Safety and Health) defines workplace violence as violent acts (including physical assaults and threats of assaults) directed toward persons at work or on duty.

34. 34 Threats: Expressions of intent to cause harm, including verbal threats, threatening body language, and written threats. Physical Assaults: Attacks ranging from slapping and beating to rape, homicide, and use of weapons such as firearms, bombs, or knives. Muggings: Aggravated assaults, usually conducted by surprise and with intent to rob.

35. 35 Workplace violence in hospitals usually results from patients and occasionally from family members who feel frustrated, vulnerable, and out of control.

36. 36 Violence takes place During times of high activity such as meal time or visiting hours or patient transportation When service is denied When a patient is involuntarily admitted When limits are set regarding eating, drinking, tobacco use or alcohol use

37. 37 Hospital personnel having direct contact with patients and families are at increase risk.

38. 38 An elderly patient verbally abused a nurse and pulled her hair when she prevented him from leaving the hospital to go home in the middle of the night. An agitated psychotic patient attacked a nurse, broke her arm, and scratched and bruised her. A disturbed family member whose father had died in surgery walked into the E.D. and fired a handgun, killing a nurse and an EMT and wounding a physician.

39. 39 Anywhere in the hospital, but it is most frequent in the following areas: Emergency Departments Any Critical Care area Waiting Rooms Geriatric Units

40. 40 Violence can have a negative effect on an organization as reflected by: Low morale Increased job stress Increased worker turnover Reduced trust of management or co-workers

41. 41 Contact with violent people or those with history of violence Contact with those under the influence of drugs and/or alcohol Contact with people having psychotic diagnoses Contact while transporting patients Contact with people perceiving a long wait for service Working alone

42. 42 Watch for signals of impending violence: Verbally expressed anger and frustration Body Language such as threatening gestures Signs of drug or alcohol use Presence of weapons

43. 43 Assess current demeanor when you enter a room or begin to relate to a patient or visitor Be vigilant throughout the encounter Don’t isolate yourself with a potentially violent person Keep an open path for exiting

44. 44 Present a calm, caring attitude Don’t match the threats Avoid giving commands Acknowledge a person’s feelings Avoid behavior that may be interpreted as aggressive

45. 45 Remove yourself from the situation Call Security or 911 for HELP if needed Report any potential or actual violent incidents to your department manager

46. 46 No universal strategy exists to prevent violence All hospital workers should be alert and cautious when interacting with patients and visitors Staff need to be aware of polices and procedures relating to violence prevention

47. 47 The Bariatric Patient : Understanding, Awareness, and Sensitivity

48. 48 Consequences of Obesity Psychological and Social Well-Being Negative Self-Image Discrimination Difficulty maintaining personal hygiene Depression Turnstiles, cars, and seating may be too small Diminished sexual activity

49. 49 Social Discrimination Studies show society has a low respect for morbidly obese These people may have limited number of friends The people may experience social rejection These people may have poor quality relationships

50. 50 Weight Bias in Healthcare What assumptions do I make based only on weight regarding a person’s character, intelligence, professional success, health status, or lifestyle behaviors? Could my assumptions impact my ability to care for these patients? Do I only look at their weight problem, and not other health related issues?

51. 51 Challenge the Bias Lead by example: influence peers and others to demonstrate patient sensitivity, become a good role model. Don’t tolerate behind-the-back whispers, jokes, even in private. If no one questions obesity bias, what will ever stop it?

52. 52 Strategies for Healthcare Professionals Consider that patients may have had negative experiences with other healthcare professionals regarding their weight; approach patients with sensitivity. Recognize that many patients have tried to lose weight repeatedly. Acknowledge the difficulty of lifestyle changes.

53. 53 Our Role We need to care for both physical and emotional needs. Support and encouragement are so important. Compassion and empathy must be conveyed. Communication and listening skills are essential. Smile, look at the person, do not ignore a patient because of their obesity.

54. Catholic Health Systems Employee Breastfeeding Support Overview

55. Catholic Health WomenCare l WomenCareWNY.org 55 Support of Breastfeeding is a Priority Reduced Risk for Infants with Exclusive Breastfeeding 1, 2 Obesity Ear Infections Respiratory Infections Asthma Gastrointestinal Infections Atopic Dermatitis Type 1 & Type 2 Diabetes Leukemia Sudden Infant Death Syndrome Necrotizing Enterocolitis

56. Catholic Health WomenCare l WomenCareWNY.org 56 Public Health Case Breastfeeding is the standard for infant feeding and protects infants and children from many significant infectious and chronic diseases. $13 billion of direct pediatric health-care costs and more than 900 lives would be saved annually if 90% of women were able to breastfeed exclusively for six months as recommended. 2 Women who breastfeed have a reduced risk of breast and ovarian cancer, type 2 diabetes, postpartum depression, and cardiovascular disease. 3-5

57. Catholic Health WomenCare l WomenCareWNY.org 57 Work Remains a Barrier to Breastfeeding 6-10 Full-time employment decreases breastfeeding duration by an average of more than eight weeks. Mothers are most likely to wean their infants within the first month after returning to work. Only 10% of full-time working women exclusively breastfeed for six months. Catholic Health is a leader in supporting breastfeeding moms in the workplace.

58. Catholic Health WomenCare l WomenCareWNY.org 58 If a mother chooses to breastfeed, she needs to pump breast milk during the workday in order to maintain her milk supply. Missing even one needed pumping session can lead to decreased milk production and other undesirable consequences.

59. Catholic Health WomenCare l WomenCareWNY.org 59 Women Need Worksite Lactation Support 11 Breaks for lactation are similar to other work breaks for attending to physical needs: Time to eat/drink, restroom breaks, accommodation for health needs (e.g., diabetes) When mother and child are separated for more than a few hours, the woman must express milk. Missing even one needed pumping session can have undesirable consequences: – Discomfort – Leaking – Inflammation – Infection – Decreased Milk Production – Breastfeeding Cessation

60. Catholic Health WomenCare l WomenCareWNY.org 60 How to Support Breastfeeding Employees In general, women need 30 minutes (15 to 20 minutes for milk expression, plus time to get to and from a private space and to wash hands and equipment) approximately every 2 to 3 hours to express breast milk or to breastfeed. Needs may vary from woman to woman and over the course of the breastfeeding period.

61. Catholic Health WomenCare l WomenCareWNY.org 61 Business Case 11 Lactation programs are cost-effective, showing a $3 return for every $1 invested. By supporting lactation at work, employers can reduce turnover, lower recruitment and training costs, cut rates of absenteeism, boost morale and productivity, and reduce health-care costs. Lactation accommodation is not one-size-fits-all. Flexible programs can be designed to meet the needs of both the employer and employee.

62. Catholic Health WomenCare l WomenCareWNY.org 62 Breastfeeding = Increased Productivity 11 Breastfeeding reduces illness of the baby = fewer absences of parent employees = immediate return on investment. Breastfeeding support in the workplace helps families meet their breastfeeding and childrearing goals = higher job satisfaction, increased loyalty, increased ability to focus on job responsibilities, higher return to work postpartum, and lower turnover = immediate return on investment. Breastfeeding prevents chronic disease in women who breastfeed and contributes to a healthier future workforce through reduction of obesity and chronic disease = long-term payoff that keeps on giving.

63. Catholic Health WomenCare l WomenCareWNY.org 63 Fair Labor Standards Act Section 7 of the Fair Labor Standards Act was amended effective March 2010:  Employers are required to provide “reasonable break time for an employee to express breast milk for her nursing child for 1 year after the child’s birth each time such employee has need to express the milk.”  Employers are also required to provide “a place, other than a bathroom, that is shielded from view and free from intrusion from coworkers and the public, that may be used by an employee to express breast milk.” Legal Basis

64. Catholic Health WomenCare l WomenCareWNY.org 64 Common Concerns of Breastfeeding Mothers 11 Modesty Time and social constraints Lack of support Making enough milk for their babies Talk with your manager – if you want to breastfeed your baby – you are encouraged to at Catholic Health. We are here for you!

65. Catholic Health WomenCare l WomenCareWNY.org 65 Resources What resources are available for managers? Catholic Health Policy on Lactation (Compliance 360) Identify location within your department for your associate – talk with your manager about a room for your use Direct associates with specific breastfeeding/personal questions regarding lactation that they can call 862-1939 What resources are available for employees? Baby Café at Sisters Mercy and Sisters Hospital Lactation Department Educational materials, professional support.

66. Catholic Health WomenCare l WomenCareWNY.org 66 References (1-6) 1.Ip S, Chung M, Raman G, Chew P, Magula N, DeVine D, Trikalinos T, Lau J. (Tufts-New England Medical Center Evidence-based Practice Center). Breastfeeding and maternal and infant health outcomes in developed countries. Evidence Report/Technology Assessment No. 153. Rockville, MD: Agency for Healthcare Research and Quality; 2007 Apr. AHRQ Publication No. 07-E007. Contract Nu. 290-02-0022. 415 pp. Available from: http://www.ahrq.gov/Clinic/tp/brfouttp.htm http://www.ahrq.gov/Clinic/tp/brfouttp.htm 2.American Academy of Pediatrics Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 2012;129(3):e827-41. 3.Bartick M, Reinhold A. The burden of suboptimal breastfeeding in the in the United States: A pediatric cost analysis. Pediatrics. 2010;125(5): e1048-56. 4.Schwarz EB, Ray RM, Stuebe AM, Allison MA, Ness RB, Freiberg MS, Cauley JA. Duration of lactation and risk factors for maternal cardiovascular disease. Obstet Gynecol. 2009;113(5):974-82. 5. Gunderson EP, Jacobs DR, Chiang V, et al. Duration of lactation and incidence of the metabolic syndrome in women of reproductive age according to gestational diabetes mellitus status: A 20-year prospective study in CARDIA—The Coronary Artery Risk Development in Young Adults Study. Diabetes. 2010;59(2):495-504. 6. Fein B, Roe B. The effect of work status on initiation and duration of breast-feeding. American Journal Public Health. 1998:88(7): 1042-46.

67. Catholic Health WomenCare l WomenCareWNY.org 67 References (7-12) 7. Cardenas R, Major D. Combining employment and breastfeeding: Utilizing a work-family conflict framework to understand obstacles and solutions. J Bus Psychol. 2005; 20(1): 31- 51. 8. Galtry J. Lactation and the labor market: Breastfeeding, labor market changes, and public policy in the United States. Health Care Women Int. 1997;18(5): 467-80. 9. Texas Department of State Health Services. WIC Infant Feeding Practices Survey, 2009. 10.United States Breastfeeding Committee. Workplace Accommodations to Support and Protect Breastfeeding. Washington, DC: United States Breastfeeding Committee; 2010. Available from: http://www.usbreastfeeding.org/Portals/0/Publications/Workplace- Background-2010-USBC.pdfhttp://www.usbreastfeeding.org/Portals/0/Publications/Workplace- Background-2010-USBC.pdf 11.Department of Health and Human Services (U.S.). The Business Case for Breastfeeding. Steps for Creating a Breastfeeding Friendly Worksite: Bottom Line Benefits [Kit]. US Department of Health and Human Services, Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau. 2008. HRSA Inventory Code: MCH00254. Available from: http://www.womenshealth.gov/breastfeeding/programs/business- case/index.cfmhttp://www.womenshealth.gov/breastfeeding/programs/business- case/index.cfm 12.US Department of Labor. Break Time for Nursing Mothers. [Online]. 2010. Available from: http://www.dol.gov/whd/nursingmothers http://www.dol.gov/whd/nursingmothers

68. Harassment and Diversity in the Workplace

69. What is Harassment? Verbal or physical conduct that denigrates or shows “hostility” or aversion toward a person. Verbal or physical conduct that denigrates or shows “hostility” or aversion toward a person. Harassment can be based on race, color, national origin, citizenship, religion, gender, marital status, sexual orientation, age, disability, or any other characteristic protected by law. Harassment can be based on race, color, national origin, citizenship, religion, gender, marital status, sexual orientation, age, disability, or any other characteristic protected by law.

70. What is Harassment? Harassing conduct includes: Harassing conduct includes: Abusive words, phrases, slurs, put-down jokes, or negative stereotypes. Abusive words, phrases, slurs, put-down jokes, or negative stereotypes. Harassing behavior can be hidden behind humor, insinuations, and/or subtle remarks or acts. Harassing behavior can be hidden behind humor, insinuations, and/or subtle remarks or acts.

71. The Costs of Harassment? The cost of harassment is high and includes: Legal costs and out-of-court settlements Legal costs and out-of-court settlements Decreased productivity Decreased productivity Lowered morale Lowered morale Increased employee turnover Increased employee turnover The chance of workplace violence The chance of workplace violence Loss of credibility in the community Loss of credibility in the community

72. Title VII of the Civil Rights Act of 1964 prohibits discrimination The Civil Rights Act prohibits discrimination based on the following traits: Race Race Color Color Religion Religion Sex Sex National Origin National Origin

73. What Prohibits Further Types of Discrimination or Harassment? Age Discrimination Act of 1975 Age Discrimination Act of 1975 Americans with Disabilities Act of 1990 Americans with Disabilities Act of 1990 In 1998, a Supreme Court ruled that employers can still be held liable in a harassment suit even if they did not know it was happening in their own workplace. In 1998, a Supreme Court ruled that employers can still be held liable in a harassment suit even if they did not know it was happening in their own workplace.

74. Hostile & Pervasive Harassment and/or discrimination must be both hostile and pervasive: Hostile statements make another person uncomfortable. Hostile statements make another person uncomfortable. Hostile” might not mean angry or violent. Hostile” might not mean angry or violent. Hostile comments/behaviors that are pervasive and ongoing. Hostile comments/behaviors that are pervasive and ongoing.

75. Preventing Harassment Think before you speak! Think before you speak! Think twice before you “send” emails. Think twice before you “send” emails. Be careful with humor. Be careful with humor. Ask yourself: How would I feel? Ask yourself: How would I feel?

76. What to do if you are Harassed? Tell the offender their behavior is unwelcome and needs to stop! Tell the offender their behavior is unwelcome and needs to stop! If it is too awkward to talk to the offender, speak to your HR manager. If it is too awkward to talk to the offender, speak to your HR manager.

77. What to do if you think you Harassed Someone? Apologize to the person you may have offended. Apologize to the person you may have offended. Be careful not to repeat the behavior! Be careful not to repeat the behavior!

78. Harassment Summary Every associate is responsible for their professional on- stage behavior. Every associate is responsible for their professional on- stage behavior. The costs of harassment are high: think before you speak! The costs of harassment are high: think before you speak!

79. Respect for Diversity Cultural competence is a set of attitudes, behaviors and skills that enable staff to work effectively in cross-cultural situations. It reflects the ability to gain and use knowledge of health- related beliefs, attitudes, practices and communication. Cultural competence is a set of attitudes, behaviors and skills that enable staff to work effectively in cross-cultural situations. It reflects the ability to gain and use knowledge of health- related beliefs, attitudes, practices and communication.

80. Respect for Diversity It should be understood that there is no one way to treat any racial and ethnic group. As health care providers, we must provide evidence-based care that is appropriately tailored to meet the needs of our patients, their families and the community. It should be understood that there is no one way to treat any racial and ethnic group. As health care providers, we must provide evidence-based care that is appropriately tailored to meet the needs of our patients, their families and the community.

81. Respect for Diversity Cultural competence begins with an honest desire not to allow biases to keep us from providing care and treating each patient with respect. Cultural competence begins with an honest desire not to allow biases to keep us from providing care and treating each patient with respect.

82. Respect for Diversity Cultural Diversity covers many obvious and less-obvious manifestations to include: Religion, Ethnicity (race), National Origin, Gender, Age, Education, Mobility – including handicaps Cultural Diversity covers many obvious and less-obvious manifestations to include: Religion, Ethnicity (race), National Origin, Gender, Age, Education, Mobility – including handicaps

83. Respect for Diversity To respect diversity, staff need to understand the following terminology: Culture Culture –is the sum-total of the way-of-living that includes values, beliefs, standards, language, thinking patterns, behavioral norms and communication styles. –Culture guides decisions and actions.

84. Respect for Diversity Culture affects health belief systems in the following ways: Culture affects health belief systems in the following ways: –Define and categorize health and illness –Offers explanatory models for illness –Based upon theories of the relationships between cause and the nature of illness and treatments –Defines the specific “scope” of practice for healers

85. Respect for Diversity Culturally diverse populations have varying belief preferences, nutritional preferences, communication preferences and varying beliefs on patient-care and dealing with death. Culturally diverse populations have varying belief preferences, nutritional preferences, communication preferences and varying beliefs on patient-care and dealing with death. To assist you with the care of culturally diverse populations, the Catholic Health Culture Tool will be provided to you at General Orientation To assist you with the care of culturally diverse populations, the Catholic Health Culture Tool will be provided to you at General Orientation

86. Respect for Diversity Acquiring cultural competence starts with awareness, groups with knowledge, is handled with specific skills, and is refined through cross-cultural encounters. In caring for culturally diverse populations: Acquiring cultural competence starts with awareness, groups with knowledge, is handled with specific skills, and is refined through cross-cultural encounters. In caring for culturally diverse populations: –Listen to the patient’s perception of the problem –Explain your understanding of the problem –Discuss differences and similarities –Recommend a treatment-plan and negotiate the plan

87. Harassment & Diversity If you would like additional information on Harrassment and Diversity in the Workplace, the video link below can be viewed on Internet Explorer: If you would like additional information on Harrassment and Diversity in the Workplace, the video link below can be viewed on Internet Explorer: http://www.youtube.com/watch?v=V1PY8kgO1PA http://www.youtube.com/watch?v=V1PY8kgO1PA http://www.youtube.com/watch?v=V1PY8kgO1PA

88. ICD-10 Transition General Overview Contact Info: Allison Spara aspara@chsbuffalo.org 601-3607

89. Content ICD-10 Overview: ICD-10 Overview: What is driving the change and why? What is driving the change and why? Who is impacted? Who is impacted? ICD-10 Transition Introduction & Basics ICD-10 Transition Introduction & Basics Difference between ICD-9 and ICD-10 Diagnosis Codes and Procedure Codes Difference between ICD-9 and ICD-10 Diagnosis Codes and Procedure Codes What is the change in documentation and systems we need to accommodate? What is the change in documentation and systems we need to accommodate? Impacts to the System Impacts to the System C HS and External Resources for Education C HS and External Resources for Education Competency Questions Competency Questions

90. What Is Driving the Change? The World Health Organization (WHO) publishes the International Classifications of Diseases (ICD) code set, which defines diseases, signs, symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or disease. As part of the Health Insurance Portability and Accountability Act of 1996, all “covered entities” will be required to adopt ICD 10 codes for use in all HIPAA transactions with dates of service on or after October 2013* * Implementation has been delayed to October 1, 2015 ICD-9, the current methodology is over 30 years old, contains outdated terminology, and is inconsistent with current medical practice. In addition, the codes lack specificity and detailed support

91. Why Change to ICD-10? ICD-10 is used internationally, converting will enable global diagnosis comparison. ICD-10 is used internationally, converting will enable global diagnosis comparison. ICD-9 is 30 years old and does not contain enough detail for meaningful analysis and disease reporting. ICD-9 is 30 years old and does not contain enough detail for meaningful analysis and disease reporting. ICD-10 is expected to result in better medical necessity justification, fewer claim errors and reduced opportunity for fraud. ICD-10 is expected to result in better medical necessity justification, fewer claim errors and reduced opportunity for fraud. Specific reporting of diagnosis codes is key to many health insurance coverage policies and are used in pay-for-performance initiatives. Specific reporting of diagnosis codes is key to many health insurance coverage policies and are used in pay-for-performance initiatives. Better quality data collection for research, improved measures for severity, risk and outcomes, and disease tracking affecting public health. Better quality data collection for research, improved measures for severity, risk and outcomes, and disease tracking affecting public health. Practice management and electronic health records will be improved with more effective use of diagnosis and procedure codes. Practice management and electronic health records will be improved with more effective use of diagnosis and procedure codes.

92. Who Is Impacted By ICD – 10? All Covered Entities: Physicians Hospitals Home Health Care Long Term Care Rehab, Lab, Imaging Teams Impacted: Physicians Health Information Management – Coding Patient Financial Services Clinical Documentation Improvement Care Management/Utilization Review Quality Financial Reporting

93. ICD-10 Overview ICD International Classification of Diseases is used on virtually 100% of patients and visits within CH – all ministries ICD International Classification of Diseases is used on virtually 100% of patients and visits within CH – all ministries ICD CODES are used to describe and catalog the patients’ conditions (Diagnosis) and the Acute Inpatient Procedures ICD CODES are used to describe and catalog the patients’ conditions (Diagnosis) and the Acute Inpatient Procedures ICD directly influences 90% plus of all of CH Revenue Streams ICD directly influences 90% plus of all of CH Revenue Streams The WORDS and Clinical VALUES (a tumor size measurement) present in the clinical record are used to assign the CODES The WORDS and Clinical VALUES (a tumor size measurement) present in the clinical record are used to assign the CODES Physicians must document with the correct specificity in order to code ICD-10 Physicians must document with the correct specificity in order to code ICD-10 ICD-10 is federally mandated change from ICD-9, due Oct 2015 ICD-10 is federally mandated change from ICD-9, due Oct 2015 ICD-10 directly impacts all Software Applications that process/contain ICD-9 codes and their interfaces – all will need to be upgraded ICD-10 directly impacts all Software Applications that process/contain ICD-9 codes and their interfaces – all will need to be upgraded ICD-10 is a major Financial risk and carries significant clinical impact ICD-10 is a major Financial risk and carries significant clinical impact

94. Introduction to ICD-10-CM/PCS The implementation date for ICD-10-CM is October 1, 2015. The implementation date for ICD-10-CM is October 1, 2015. Physicians are responsible for ensuring that their documentation supports the services provided to the patient in order for appropriate code assignment to be completed. Physicians are responsible for ensuring that their documentation supports the services provided to the patient in order for appropriate code assignment to be completed. Due to ICD-10 code specificity, documentation is more crucial than ever. Due to ICD-10 code specificity, documentation is more crucial than ever. Coders are responsible for translating the documentation into the ICD-10 codes per the coding guidelines to populate claims for billing; however, this cannot be done appropriately without the correct specificity documented. Coders are responsible for translating the documentation into the ICD-10 codes per the coding guidelines to populate claims for billing; however, this cannot be done appropriately without the correct specificity documented. If documentation is not present to support the codes needed for billing, we will be at significant financial risk. If documentation is not present to support the codes needed for billing, we will be at significant financial risk.

95. Basic Facts about the Change from ICD-9 to ICD-10 ICD-10-CM is Diagnosis coding used by all providers in every healthcare setting ICD-10-CM is Diagnosis coding used by all providers in every healthcare setting ICD-10-PCS will be used for inpatient hospital procedures. It will not be used on physician claims of any kind. ICD-10-PCS will be used for inpatient hospital procedures. It will not be used on physician claims of any kind. CPT and HCPCS codes used for outpatient procedure coding are not affected CPT and HCPCS codes used for outpatient procedure coding are not affected Use of ICD-10-CM and ICD-10-PCS will start with visits or discharges that occur on or after October 1, 2015. Use of ICD-10-CM and ICD-10-PCS will start with visits or discharges that occur on or after October 1, 2015. All IT software that houses, uses or generates ICD-9 codes will need to be updated to an ICD-10 compatible version by the go-live date. All IT software that houses, uses or generates ICD-9 codes will need to be updated to an ICD-10 compatible version by the go-live date. Practice tools such as charge capture forms, problem lists or superbills will need to be converted to ICD-10 codes. Practice tools such as charge capture forms, problem lists or superbills will need to be converted to ICD-10 codes.

96. Diagnosis Codes: Comparison of ICD-9 to ICD-10-CM ICD-10-CM (NEW) ICD-9 (OLD) 3 – 7 Characters in Length 3 – 5 Characters in Length Approximately 68,000 codes Approximately 13,000 codes Digit 1 is alpha; digits 2 and 3 are numeric; digits 4-7 are alpha or numeric First digit may be alpha (E or V) or numeric; digits 2-5 are numeric Flexible for adding new codes Limited space for adding new codes Very specific Lacks detail Has laterality (codes identify right vs. left) Lacks laterality Example: K21.0 – Gastro-esophageal reflux disease with esophagitis Example: 540.9 – Acute appendicitis

97. Comparison of ICD-10-CM to ICD-9 Specificity ICD-10-CMICD-9 Multiple codes differentiating unique types of mechanical complications and grafts and devices One code for a mechanical complication of a vascular device, implant or graft T82.41XA – Breakdown (mechanical) of vascular dialysis catheter, initial encounter T82.511A – Breakdown (mechanical) of vascular created arteriovenous shunt, initial encounter T82.513A – Breakdown (mechanical) of balloon (counterpulsation) device, initial encounter T82.515A – Breakdown (mechanical) of umbrella device, initial encounter 996.1 – Mechanical complication of other vascular device, implant, and graft

98. Procedure Codes: Comparison of ICD-9 to ICD-10-PCS ICD-10-PCS (NEW) ICD-9 (OLD) 7 alpha-numeric characters in length 3 – 4 Numbers in length Approximately 87,000 codes Approximately 3,000 codes Reflects current usage of medical terminology and devices Based on outdated technology Flexible for adding new codes Limited space for adding new codes Very specific Lacks detail Has laterality Lacks laterality Detailed descriptions for body parts Generic terms for body parts Provides detailed descriptions of methodology and approach for procedures Lacks descriptions of methodology and approach for procedures Precisely defines procedures with detail regarding body part, approach, any devices used, and qualifying information Lacks precision to adequately define procedures

99. ICD-10-PCS Character Meanings Character1234567 Definition Name of Section Body System Root Operatio n Body Part ApproachDeviceQualifier Right Knee Joint Replacement = 0SRD0JZ0 Medical and Surgical Section S Lower Joints RReplacement D Knee Joint, Right 0Open J Synthetic Substitute Z No Qualifier *When documenting procedures, these documentation elements must be specified in order for coding to occur

100. Clinician Impacts Documentation practices must change to specify as required by codes Documentation practices must change to specify as required by codes Encounter forms, charge capture forms, scripts for tests such as lab work and super bills must be modified to use ICD-10 codes Encounter forms, charge capture forms, scripts for tests such as lab work and super bills must be modified to use ICD-10 codes The number of documentation queries to physicians to provide more detailed diagnosis information may increase The number of documentation queries to physicians to provide more detailed diagnosis information may increase Potential delays in reimbursement if coding cannot be completed due to lack of documentation or denials due to incorrect coding on claims. Potential delays in reimbursement if coding cannot be completed due to lack of documentation or denials due to incorrect coding on claims.

101. Patient Financial Services and Patient Registration/Scheduling Impacts Potential risk for increase of denials due to coding/claim issues related to ICD-10 Potential risk for increase of denials due to coding/claim issues related to ICD-10 Scripts for tests such as lab work must use ICD-10 codes, if the code on the script is not an ICD-10 code follow up will need to be done to get the correct code for processes such as medical necessity checking, etc. Scripts for tests such as lab work must use ICD-10 codes, if the code on the script is not an ICD-10 code follow up will need to be done to get the correct code for processes such as medical necessity checking, etc. Any registration tip sheets that used ICD-9 codes will need to be updated and/or new tools will need to be used to look up ICD-10 codes Any registration tip sheets that used ICD-9 codes will need to be updated and/or new tools will need to be used to look up ICD-10 codes The individuals should become familiar with ICD-10-CM and ICD-10- PCS codes in order to better understand when issues arise and/or identify issues with registrations, claim creation, or payer remittances. The individuals should become familiar with ICD-10-CM and ICD-10- PCS codes in order to better understand when issues arise and/or identify issues with registrations, claim creation, or payer remittances. Scheduling systems must accommodate ICD-10 codes. Scheduling systems must accommodate ICD-10 codes.

102. Reporting Impacts Code structure is changing, so all reports using ICD-9 codes will need to be updated with applicable ICD-10 codes. Code structure is changing, so all reports using ICD-9 codes will need to be updated with applicable ICD-10 codes. Codes are changing from being numeric to alpha-numeric Codes are changing from being numeric to alpha-numeric No one-to-one match exists between ICD-9-CM and ICD-10, so manual intervention will be required to map information and develop comparable reports No one-to-one match exists between ICD-9-CM and ICD-10, so manual intervention will be required to map information and develop comparable reports ICD-10-CM and ICD-10-PCS may use more or fewer codes to identify procedures or conditions. ICD-10-CM and ICD-10-PCS may use more or fewer codes to identify procedures or conditions. Reporting in both ICD-9-CM and ICD-10-CM/PCS may be necessary for a period of time during the transition Reporting in both ICD-9-CM and ICD-10-CM/PCS may be necessary for a period of time during the transition Increased specificity of ICD-10 codes will require more documentation and change the definitions of what is reported Increased specificity of ICD-10 codes will require more documentation and change the definitions of what is reported

103. Coding/Clinical Documentation Impacts Coders and Clinical Documentation specialists must have in depth education in order to learn the new coding system and how to code in ICD-10 format Coders and Clinical Documentation specialists must have in depth education in order to learn the new coding system and how to code in ICD-10 format Coders must learn documentation and coding guidelines in order to identify when physician queries are needed to complete coding Coders must learn documentation and coding guidelines in order to identify when physician queries are needed to complete coding

104. CHS Intranet  Education & Training  ICD- 10 CHS Intranet  Education & Training  ICD- 10 https://my.chsbuffalo.org/edu/icd-10 https://my.chsbuffalo.org/edu/icd-10https://my.chsbuffalo.org/edu/icd-10 CHS Education and Training Resources: Catholic Health Intranet

105. CHS Resources: Elsevier Online Training Elsevier/MC Strategies Performance Manager – ICD-10 eLearning Page Elsevier/MC Strategies Performance Manager – ICD-10 eLearning Page www.webinservice.com/CatholicCoreLearning www.webinservice.com/CatholicCoreLearning www.webinservice.com/CatholicCoreLearning All CHS employees and CMP physicians/office managers have access to ICD-10 education modules via Elsevier. Default username and password prompts are on the Elsevier homepage linked above. All CHS employees and CMP physicians/office managers have access to ICD-10 education modules via Elsevier. Default username and password prompts are on the Elsevier homepage linked above.

106. CMS Resources: Implementation Guide & Timeline CMS ICD-10 Implementation Guide for Small and Medium Practices CMS ICD-10 Implementation Guide for Small and Medium Practices http://www.cms.gov/Medicare/Coding/ICD10/Downl oads/ICD10SmallMediumPracticeHandbook.pdf http://www.cms.gov/Medicare/Coding/ICD10/Downl oads/ICD10SmallMediumPracticeHandbook.pdf http://www.cms.gov/Medicare/Coding/ICD10/Downl oads/ICD10SmallMediumPracticeHandbook.pdf http://www.cms.gov/Medicare/Coding/ICD10/Downl oads/ICD10SmallMediumPracticeHandbook.pdf CMS ICD-10 Small Providers Timeline CMS ICD-10 Small Providers Timeline http://www.cms.gov/Medicare/Coding/ICD10/Downl oads/ICD10SmallProvidersTimeline.pdf http://www.cms.gov/Medicare/Coding/ICD10/Downl oads/ICD10SmallProvidersTimeline.pdf http://www.cms.gov/Medicare/Coding/ICD10/Downl oads/ICD10SmallProvidersTimeline.pdf http://www.cms.gov/Medicare/Coding/ICD10/Downl oads/ICD10SmallProvidersTimeline.pdf CMS ICD-10 Myths and Facts CMS ICD-10 Myths and Facts http://cms.gov/Medicare/Coding/ICD10/Downloads /ICD-10MythsandFacts.pdf http://cms.gov/Medicare/Coding/ICD10/Downloads /ICD-10MythsandFacts.pdf http://cms.gov/Medicare/Coding/ICD10/Downloads /ICD-10MythsandFacts.pdf http://cms.gov/Medicare/Coding/ICD10/Downloads /ICD-10MythsandFacts.pdf

107. AMA Resources AMA ICD-10 Resource Page: AMA ICD-10 Resource Page: http://www.ama- assn.org/ama/pub/physician- resources/solutions-managing- your-practice/coding-billing- insurance/hipaahealth- insurance-portability- accountability-act/transaction- code-set-standards/icd10-code- set.page http://www.ama- assn.org/ama/pub/physician- resources/solutions-managing- your-practice/coding-billing- insurance/hipaahealth- insurance-portability- accountability-act/transaction- code-set-standards/icd10-code- set.page http://www.ama- assn.org/ama/pub/physician- resources/solutions-managing- your-practice/coding-billing- insurance/hipaahealth- insurance-portability- accountability-act/transaction- code-set-standards/icd10-code- set.page http://www.ama- assn.org/ama/pub/physician- resources/solutions-managing- your-practice/coding-billing- insurance/hipaahealth- insurance-portability- accountability-act/transaction- code-set-standards/icd10-code- set.page See AMA Educational Resources  Fact Sheets #4 & #5 for Implementation See AMA Educational Resources  Fact Sheets #4 & #5 for Implementation

108. 108

109. 109 The following content will be covered live in General Orientation Please review this information so that you are familiar with the terminology before attending class This material can also be used as a reference after class

110. 110 Leonardo Sette ‐ Camara, Esq. Corporate Compliance & Privacy Officer

111. 111 To prevent, find and correct violations of CHS standards, governmental laws, regulations and rules To promote honest, ethical behavior in the day-to-day operations To understand the ethical, professional, and legal obligations associates have and our role in meeting those obligations Integrity

112. 112 As healthcare professionals and providers, we are dedicated to caring for and improving the health and well being of the people we serve in the community Compliance means “doing the right thing”

113. 113 Attain compliance by: Embracing our Mission and Values Adherence to Policies and Procedures Found in Compliance 360 Maintaining high standards of business and ethical conduct Delivering high quality patient care

114. 114 Standards of Conduct & Ethical Conduct Deal openly and honestly with other Maintain high standards of conduct in accordance to the CH Mission, directives of the Catholic Church, and applicable federal, state and local laws and regulations Documentation and Billing Must be accurate and complete Conflict of Interest We have a responsibility to act on the best interests of Catholic Health. We need to avoid situations that lead to actual or perceived conflicts of interest

115. 115 Associate Compliance Guidebook Provides information on the Standards of Conduct. Available on CH website. An observation of failure to follow Standards of Conduct, Policies or Procedures, or observation of an error requires reporting. Associates can face disciplinary action and even termination for failure to report such events.

116. 116 Promotes ethical behavior in the workplace every day All associates are expected to follow standards for: Legal and Regulatory Compliance Business Ethics Conflict of Interest Appropriate Use of Resources Confidentiality Professional Conduct Responsibility And to follow the Code of Ethics

117. 117 Enhance the Patient Experience Have a questioning attitude Pay attention to details Follow the rules Be accountable for your actions Providing high quality services and upholding patient rights supports the Compliance Program.

118. 118 Compliance policies and procedures are available on Compliance 360 (or in an on-site reference manual) and apply to all CH associates. Additional compliance policies are applicable to: Hospital Clinical Laboratory Physician Practices Nursing Facilities Home Health Agency & Infusion Pharmacy CH- LIFE

119. 119 It is fraudulent to either document services that were not performed or to submit claims for services without appropriately documenting those services. Missing clinical notes or test results, (dates, signatures, orders, care or service rendered) incomplete or illegible documents, or improper billing and coding can be interpreted as fraud or abuse and lead to a false claim with the government resulting in penalties. Reimbursement can only be sought for services or items that have been provided and appropriately documented. If it’s not documented, it’s not done.

120. 120 It is a crime to knowingly make a false record, file, or submit a false claim with the government for payment. A false claim can include billing for service that:  was not provided or documented  was not ordered by a physician  was of substandard quality  improperly coded or billed Allows for Qui Tam Relator – notification to government with protection (Whistleblower provision) It is also unlawful to improperly retain overpayments.

121. 121 Government Sanctions Individuals or entities can be excluded from participation in Medicare and Medicaid programs. CHS must not submit any claims to Medicare and/or Medicaid in which a sanctioned individual or entity provided care or services. If an associate/provider is sanctioned, he/she must provide notification immediately to the Compliance Officer.

122. 122 If working on behalf of CH, do your actions or activities result in personal gain or advantage, potential adverse effect for CH or the potential to interfere with professional judgment, objectivity or ethical responsibilities? Potential conflicts of interest relationships include financial relationship for yourself or your immediate family member or secondary employment as Consultant Speakers’ Bureau Advisory Panel Administrative positions with Pharm or DME Third Party Payor Other entities doing business with CH All potential Conflicts of Interest must be reported.

123. 123 Associates may NOT accept any cash gifts or cash equivalent gifts (gift cards) from any person or business conducting or seeking to conduct business with Catholic Health Prior to receiving work-related Gifts Social or entertainment events Free meals Associates must consult with their supervisor. See CH Policy for further information.

124. 124 Language Assistance Ensures that limited English proficient or hearing impaired persons are able to understand and communicate with CH associates & physicians. Language Assistance is provided FREE of charge to the patient a MANDATORY service by law and needs to be DOCUMENTED Language Assistance information can be found in the Communication Assistance Policy Blind or Visually Impaired Patient The hospital must “offer” pre-admission information or a patient discharge plan in enlarged print to the visually impaired patient. If a blind patient requests an audio of the above documents, follow policy or check with your manager.

125. 125 HEALTH INSURANCE PORTABILITY ACCOUTABILITY ACT and new regulations of HITECH and the Omnibus Rule Privacy and Security Policies are found in Compliance 360

126. 126 Individually identifiable health information also known as Protected Health Information (PHI) Transmitted or maintained in any form or medium

127. 127 Names Full face photos Medical Record Number Health Plan Number Account Numbers Certificate/License Numbers Vehicle Identifiers E-mail and web addresses Biometric Identifiers Geographic subdivisions smaller than a state All elements of dates related to birth date, admission, discharge, or date of death, ages over 89 Telephone and fax numbers Social Security Number Any other unique identifying data

128. 128

129. 129 Be aware of surroundings Be conscious of who is in the immediate area when discussing sensitive patient information or at your computer terminal (lower your voice) Secure area when not attended Log off of computer screens containing PHI before leaving the area Close medical records/chart when not in use Do not allow other associates to utilize your password Report theft or loss of computer devices immediately Correctly Dispose of PHI Use of shred bin

130. 130 Telephones Be careful with phone call pertaining to patient information Fax Machines and Scanners Pick up faxed or printed PHI immediately Use fax cover sheet, verify # and receipt Scan PHI only to CH e-mail accounts E-Mail Encrypt e-mail sent outside CH Careful forwarding and replying Mail Double check name/address and material prior to sending

131. 131 Computer accounts and passwords are confidential and are not to be shared with others Do NOT download any programs or software without permission from the IT department Never leave Mobile Computing Devices (ie. Laptops, etc) unsecured and report thefts immediately Do NOT open suspicious e-mail attachments Do NOT respond to Spam Do NOT post patient PHI to Social Media sites Do NOT text PHI via unsecured means

132. 132 Curiosity can be a normal human trait … however accessing health information or disclosing PHI on family members, friends, co- workers, persons of public interest or any others that is not related to your work responsibilities is … VIOLATION of HIPAA Computer use is monitored.

133. 133 It is a violation of CH policy for an associate to look up their own medical record Associates may file a written request with Health Information Management for their medical record information OR Associates are encouraged to utilize the Patient Portal for direct secured access to their medical information.

134. 134 Fraud and Abuse Fraud Defined: An intentional deception or misrepresentation that could result in some unauthorized benefit to a person or Catholic Health Abuse Defined: Practices that are inconsistent with sound fiscal, business, or medical practices, and result in unnecessary cost, or in reimbursement of services that are not medically necessary or that fail to meet professionally recognized standards for health care

135. 135 Inaccurate, incomplete, or missing Documentation Improper billing and coding Offering or receiving kickbacks, bribes, or rebates A service has not been rendered by the identified provider, to the identified person, or on the identified date Failure to comply with government rules and regulations affecting healthcare

136. 136 Lack of integrity Ethical incidents Theft or misuse of services Improper political activity Breech of corporate confidentiality Improper use of proprietary information Environmental health and safety issues Dishonest communication (spoken or documents) Improper business arrangements Failure to follow Record Retention policy Receipt of incentives for patient referrals The Associate Guidebook or your supervisor can provide additional info.

137. 137 Immediate supervisor or appropriate department Higher level manager Compliance Officer Leonardo Sette-Camara, Esq. 821-4469 Also available 24/7 Compliance Line 1-888-200-5380 Confidential. Anonymous (if desired)

138. 138 Behavior issues Human Resource policy violations Union contract matters Any of above should be reported to Human Resources HR Policies on Compliance 360 include: Corrective Action Fair Treatment Review

139. 139 Protects associates from adverse action when they do the right thing and report a genuine concern Reckless or intentional false accusations by CH associates are prohibited Reporting the possible violation does not protect the constituent from the consequences of their own violation or misconduct Associates have a duty to report HIPAA/Compliance concerns

140. 140 Upholding CH Mission and Values Adhering to Code of Conduct, Policies and Procedures and the Law Completing education and employment requirements Constant monitoring for concerns Duty to report concerns and support non-retaliation During an investigation Be truthful Preserve documentation or records relevant to ongoing investigations

141. 141 For CH associates Fines and Prison sentences Corrective action Includes possible termination of employment for violations or failure to report concerns For Catholic Health System Exclusion from government funded insurance programs (Medicare/Medicaid) Fines

142. 142 Putting words into action … “ We judge ourselves based on our intentions … others judge us based on our actions.” Adhere to the CH code of conduct, policies and procedures, and other standards. Uphold Catholic Health Values.

143. 143 Duty to report Compliance/HIPAA concerns as soon as aware of situation Do the right thing … Apply ethical decision making If uncertain … Always Seek Knowledge (A.S.K.) Use Associate Booklet on CH website as a reference

144. 144 Corporate Compliance and HIPAA Privacy Officer Leonardo Sette-Camara, Esq. 821-4469 CH HIPAA Hotline 862-1790 Compliance Hotline 1-888-200-5380 (available 24/7) All reports are confidential.