HIPAA 5010 & ICD-10Compliance Program

Impact on Physician Practices

Luis E. Taveras, Ph.D.

December 2010

Executive Overview Agenda

Background

The Migration to 5010

The Migration to ICD-10

Impact on Physician Practices

Q & A

Background

Healthcare Providers must implement the new HIPAA 5010 Transaction Standards and must upgrade from ICD-9 to ICD-10 by the federally mandated deadlines:

5010 – January 2012; ICD-10 – October 2013

Available diagnosis codes: 14K to over 68K

Procedure codes: Nearly 4K to over 72K

5010 Impact: Updated HIPAA transaction standards for electronic exchange of administrative and financial information with Payers

ICD-0 Impact: IT remediation, updated policies and procedures, all clinical forms, coding, extensive education and training in all departments

Expected outcome: Cost effective & timely compliance

The Migration to HIPAA 5010

The existing standards are over six years old and enhancements are needed to address current issues.

Objectives of HIPAA 5010Addresses shortcomings of 4010Prerequisite for ICD-10

Key differences between 4010 and 5010800+ modifications to the HIPAA transaction setsPrimary technical changes including adds, changes, and deletes

The Migration to ICD-10

The additional fields and characters used by the ICD-10 coding scheme enable greater detail and flexibility in describing diagnoses and procedures

Objectives of ICD-10•Provides richer detail regarding diagnoses and procedure codes•Greater ability to conduct research and innovation with broader code sets•Aligns the U.S. with the global community

Key differences between ICD-9 and ICD-10•ICD-10 codes are alphanumeric •The field length is longer – enables more codes•ICD-10 Codes150,000 versus 24,000 in ICD-9

Diagnostic Codes 13,000 to 68,000Procedure Codes 11,000 to 87,000

HIPAA 5010 & ICD-10Compliance Program

A Report to the ICD-10 Coalition

October 8, 2008

Study Conducted By: Nachinson Advisors, LLC

Study Results

Study: Scope of ICD-10 Implementation for Physicians and Clinical Laboratories

Study funded by: The American Academy of Dermatology

American Academy of Professional Coders

American Association of Neurological Surgeons

American Association of Orthopaedic Surgeons

American Clinical Laboratory Association

American College of Physicians

American Medical Association

American Optometric Association

American Physical Therapy Association

American Society of Anesthesiologists

Medical Group Management Association

Types of Provider Practices

A “Typical” Small Practice Three Physicians

Two Administrative Staff

A “Typical” Medium Practice 10 Providers

1 Full Time Coder

6 Administrative Staff

A “Typical” Large Practice 100 Providers

64 Coding Staff 10 Full Time Coders

54 Medical Records Staff

Study Results

Total Estimated Cost Summary

Typical Small Practice

Typical Medium Practice

Typical Large Practice

Education $2,405 $4,745 $46,280

Process Analysis

$6,900 $12,000 $48,000

Changes to Superbills

$2,985 $9,950 $99,500

IT Costs $7,500 $15,000 $100,000

Increased Documentation Costs

$44,000 $178,500 $1,785,000

Cash Flow Disruption

$19,500 $65,000 $650,000

Total $83,290 $285,195 $2,728,780

Study Results

Impact

Documentation Procedures

Record Keeping Procedures

Fee Schedules

Medical Review Edits Applied by Health Plans

Quality Measures to Access Performance

“It is not difficult to determine where the impact of the coding process begins for providers. While the codes may not be documented until the claim for payment is filed, the documentation for determining the appropriate code starts as soon as the patient visit starts.” (p. 9)

Study Results

Role of Documentation in the Conversion

“For documentation supporting diagnoses or procedures, physicians first must ensure that the services provided are consistent with the symptoms of the patient and that they satisfy generally accepted medical standards. Part of this effort requires that physicians understand and remain current on the relevant documentation standards. Physicians should strongly consider attending coding and documentation workshops on an annual basis to establish and to refresh their skills in documentation, and to master charging requirements.”

Procedures to improve your claims”, Jeffrey B. Miller, Esq. & Alice Anne Andress,

Physicians New Digest, October 2002.

Study Results

Super Bills

Will all Need to be Revised to Reflect New Way of Coding and the Additional Codes

Size: Approximately 5 Pages in Length – Practicality?

May Need Electronic Code Selection Software to Manage Paper Based and EHR-Enabled Practices

Paper Based practices may no longer be practical

Expect a Major Move to EHR-Based Practices Which Will Complicate the Transition and the Associated Costs

Study Results

Project Plan for Practice Compliance Training

Analysis of Internal Practices Business Processes

Patient Flow, documentation, billing

Contact Trading Partners

Vendors, health plans, device manufacturers, etc.

Determine Implementation Schedule to Minimize Disruptions

Update Systems and Documentation Process

Review Participation in Health Plans

Assess Staff’s Understanding and Ability to Implement the Required Changes

Manage Relationship with Trading Partners to Assure Transition is Moving According to the Plan

Testing Plan for all Changes

Testing Plan with all Trading Partners

Make the Final Transition

Questions & Answers