icd-10 - optum · icd-10 physician education — engaging your physicians for a smooth transition...

Coding services: Your ace in the hole for ICD-10

Presented by: Terry Santana-Johnson, Coding Services Product Manager, Optum

In this session, you will gain a deeper understanding of concerns about keeping up coding productivity through the transition to ICD-10. You will learn how to:

• Figure out how much coverage you may need in coding services

• Choose a worthy partner for your coding needs and how technology can help

• Evaluate the quality of services you are receiving

ICD-10 education — Strategic considerations for how to educate your organization

Presented by: Deena Kerr, ICD-10 Education Director, Optum

In this session, we share guidelines and best-practice considerations that will help your organization execute a solid approach to ICD-10 education. We offer insight on how to better leverage the corresponding activities that can accompany and enhance the education process, and we’ll discuss:

• Areas of impact: Which groups to focus on, and how to address their varying educational needs

• Timing considerations: When to start educating people in their various roles

• Process: How to develop and implement a training program that meets your organization’s specific educational needs

Radical thinking… “Let’s let doctors be doctors!”

Presented by: Cecilia Guardiola, JD, RN, Associate Director, CDI Consulting, Optum

Lynn Probert, Optum CDI Product Specialist, CDI Subject Matter Expert, Optum

In the current environment of ever-changing documentation requirements from CMS, reductions in payments for services rendered and increased public reporting of performance statistics, it is imperative that the medical record completely capture an accurate reflection of the patient and treatments rendered.

In this session, you will learn how the Optum CAC/CDI Single solution will facilitate the efficient screening of cases for those conditions that are undocumented or need to be specified more clearly in the medical record. You will also learn how the NLP and LifeCode bring the cases to the users, allowing for specific case finding in the first-of-its-kind method in the CDI environment.

ICD-10 physician education — Engaging your physicians for a smooth transition

Presented by: Deena Kerr, ICD-10 Education Director, Optum

One aspect of your ICD-10 transition plan that must not be overlooked is physician training and education. Provider documentation is as important as coding when it comes to successful ICD-10 implementation. Hospitals need to develop a strategy now to ensure that physicians are ready, willing and able when ICD-10 coding becomes a reality in 2014. Learn more about strategies and approaches to consider when constructing your own physician ICD-10 transition plan.

ICD-10Big changes bring big opportunities.Comprehensive ICD-10 solutions to help you strengthen organizational performance

BOOTH#1238BOOTH#1238

Thank you for joining Optum™ at this year’s AHIMA Convention and Exhibit. As the ICD-10 transition approaches, we invite you to download our presentations from the show to learn how we can support you in taking on new challenges and making the most of new opportunities.

ICD-10 preparedness: Countdown is on … are you on track?

Presented by: Emily Rafferty, Vice President, ICD-10 Provider Consulting, Optum

Is your organization applying best practices to transition to ICD-10? In this session, an ICD-10 industry thought leader will explore various ICD-10 strategies, including vendor/ payer readiness and contingency planning, communication and awareness campaigns, revenue mitigation strategies, mapping and translation methodologies, and coder productivity mitigation strategies. At the end of this session, you will have an understanding of the key strategies leading organizations are implementing to mitigate their risk with the transition to ICD-10.

Concurrent CAC with computerized CDI at UPMC: Lessons learned from implementation

Presented by: Julie Truver, MSIS, RHIA, Vice President of Operations, UPMC Technology Development Center

Adele Towers, MD, MPH, Medical Director, UPMC Health Information Management

This presentation focuses on the challenge that the University of Pittsburgh Medical Center (UPMC) faced with their CDI program and how they are evolving their program (as we speak) into a more automated initiative, utilizing natural language processing at its core. Presenters will discuss their data outcomes from the concurrent CDI.

Objectives: After this session, you will be able to:

• Explain the CDI challenge at UPMC

• Identify how technology can improve the CDI process

• Describe how a natural language processing (NLP)-driven CDI can enhance staff productivity, coding accuracy and compliance

• Highlight lessons learned and opportunities discovered from CDI implementation

• Review the transition from post-discharge CAC to concurrent CAC

NLP innovation for CAC and CDI — An update on new technology

Presented by: Mark Morsch, Vice President of Technology, Optum

In this session, you will learn about recent advances in NLP technologies for CAC and CDI. The Optum LifeCode NLP engine includes new patent-pending capabilities to identify detailed clinical information within medical records. This new technology will transform CDI programs by automatically marking cases with documentation deficiencies. For ICD-10, new capabilities in compositional

NLP will be key to recognizing the greater specificity of the new coding system. You will also learn how compositional NLP combines elements from across the medical record to follow complex coding guidelines.

The benefits of automating compliance management

Presented by: Lee D. Valenta, Executive Vice President, Optum

Providers, health plans and payers are subject to a regulatory environment today that is becoming more and more complex. With audits expanding and serious financial penalties being enacted, health care companies need a better way to handle compliance requirements. Optum Compliance Suite is a flexible, cloud-based solution that offers an integrated, unified approach. Find out how guided workflow with automated tools reduces the time, effort and resources involved in multiple compliance processes and audit preparation. Understand how you can be in a continuous state of audit readiness while actually lowering your costs for compliance management.

How to improve physician relationships using CAC and concurrent coding — A case study from Mission Health

Presented by: Susan Hoyle, CCS, Mission Health System

Mission Health chose to implement a computer-assisted coding solution to increase coding productivity and accuracy, in preparation for ICD-10. But they soon determined that their new CAC system could also enable concurrent coding and strengthen not only their coding accuracy but also their physician relationships. Mission Health’s coding and revenue cycle leaders decided to move from a post-discharge coding process to a concurrent coding process. Learn how Mission Health worked with its computer-assisted coding system to enable its concurrent coding process, and how the results helped the hospital system and the system’s affiliated physicians.

ICD-10-CM mapping: Reasons, rules and restrictions

Presented by: Anita C. Hart, RHIA, CCS, CCS-P, Product Manager for ICD-9-CM and ICD-10-CM/PCS, Optum

Mapping is a very useful tool when undergoing the change to ICD-10-CM/ PCS. It can be especially beneficial when transitioning coding practices, converting reports, and validating software and clinical documentation practices. Download the presentation to learn how to wisely use mapping in combination with other resources in order to effectively transition from ICD-9-CM to ICD-10-CM/PCS by identifying and resolving issues, setting decision-making rules and planning for change. You’ll walk away knowing the benefits of mapping and rules to follow, as well as understanding what mapping was not designed to do.

Coding Services: Your Ace in the Hole for ICD-10

1 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

Forging ahead to ICD-10 Hospitals continue preparation

• Evaluation of current electronic medical records

• Evaluation of current coding software

• Reducing redundancy of systems

• Continuing physician education toward ICD-10 documentation

• Review of current coding functions

– Review of current processes

– Workflow re-engineering

• Evaluate educational requirements


Evaluate and revise coding workflow

Evaluation of current coding software

• Grouper evaluation – Products – Features

• New technology – CAC

Review of current coding functions

• Review of current processes

• Workflow re-engineering

Education of staff

• Baseline

• Who, what, where?


The coder shortage Impacts to coding professionals

• CDI

• EMR data extraction

• Regulatory environment – Core measures – POA – RAC – ICD-10

• Shortages – Lack of experienced, credentialed coders – Lack of qualified coding management – Retirement!


Medical records professionals aging population

Source: http://cew.georgetown.edu/healthcare, Georgetown University Center on Education and the Workforce; Healthcare, 2012, Carnevale, Smith, Gulish, Beach; accessed 7/19/2012

0

5

10

15

20

25

30

18-24 25-34 35-44 45-54 55-64 65-74

Age Distribution of Medical Records & Health Information Technicians (includes Coders)

% Population

48% of HIM professionals

are greater than 45 years of age


Considering purchased services

Company Size • Tenure in health care

Experienced • How many years are required?

Credentialed • AHIMA, AAPC, clinical credentials

Committed to medical coding • Recognized in the coding space

Ability to provide remote services • Secure connectivity

Technology company • Workflow, CAC

Global resourcing pricing advantages


Considerations What is the end goal?

• Reduce DNFB

• Fill for vacancy

• Fill for medical leave

• Fill for vacations

• Transition current staff to new roles


Issues addressed

Quality issues with current staff

• Maintaining an audit program

• Education and re-education

Unable to find qualified coders

• Serious competition for resources

Want technology but funds are limited

• CAC is what it’s all about!

• Other code assist technologies??

Lack of coding management resources

• Shortage of prepared management/ coding abilities


Temp coders

Onshore and offshore

Onsite services

Remote-only services

Coding service options:

ON DEMAND


Service line or department outsourcing

Onsite services

Remote-only services


STEADY STATE


Complete HIM coding department outsourcing

Company takes on management of coding-related functions


FULL OUTSOURCING


Pricing considerations

Costs

• By coder

• By hour

• By chart – Chart type

How much support will you need?

• Estimating productivity losses

• Vacation leave

• Anticipated medical/ maternity leave

• Vacancy backfill

Thank you.

Terry Johnson, RHIT, CDIP, CCS, CCS-P — Solutions Architect 434-963-2519 [email protected]

Can managing compliance be automated?


What we’ll review today

Compliance and risk management

Cost of compliance

Successful automation

Compliance automation: ROI

Proactive compliance management


Compliance affects all levels of the organization

2

How do we interpret and manage compliance across an enterprise?

Complex, manual and spreadsheet-based workflows, changing regulatory standards delay response and increase cost

Monitoring compliance-related business process s involved in day-to-day work is incredibly time consuming

Ensuring the organization complies with regulations and standards so that we can focus on business without incurring high costs of non-compliance

Compliance visibility across the organization and changing regulations are senior executive challenges


Compliance management: Processes of many tasks

Compliance assessment and corrective-action plan

Continuous monitoring of compliance elements in business process

Incidents and complaints management

Third-party vendor compliance management

Mock audits and reports

Staff awareness and training

Identify compliance requirements

Identify business process elements to monitor

Develop methods to collect and report incidents and complaints

Identify specific areas and frequency of due diligence

Identify key audit areas for mock audits

Identify training needs

Develop assessment methodology

Develop rules for process monitoring

Review, assess risks associated with incidents and prioritize

Set up and schedule due diligence

Prepare audit protocols

Provide new employee and refresher training courses

Conduct assessment Collect data and compare with rules

Investigate and provide resolutions

Collect and review compliance data from third parties

Collect information, sample data and documents

Customize training for organization roles

Report findings and recommendations

Identify gaps, risks and alerts Manage resolutions

Report to management and provide CAP suggestions

Review and provide findings report

Test and confirm the understanding

Develop and implement CAP

Provide feedback to mitigate risks

Report incidents and compliance risks and resolution

Contractual decisions based on diligence report

Fine-tune audit response and be prepared

Document training provided for audit requirements

Continuous oversight: policies, procedures, controls

Continuous oversight on gaps and risks

Continuous oversight on incidents and complaints

Continuous oversight on third-party compliance adherence

Continuous review of audit findings and risks

Generate reports for management, external auditors


Provider Focused Condition Tracking /

HIPAA

PHI / Research

Data Integrity & Filtering

Abstraction & Tracking

Compliance & Reporting

Stark Law

Conflict of Interest Reporting

Clinical Decision Support Malpractice Medication Management

Health Data Access & Interoperability Outcomes Measurement

CMS Compliance Audits / RAC Reviews Performance-based Reimbursement/P4P

Clinical Coding Integrity

Meaningful Use /

Patient Privacy

Contract

Adherence Legal & Other

Joint Commission Accreditation

Clinician Education / Certification

Charity Care Reporting

Referrals / Pr-e Authorizations

Eligibility Verification

Demo - graphics /

Clinical

Compliance

Financial Administration

Compliance

Stimulus Qualification

Clinical Auditing

Population Health

Management

Analytics / Reporting

Education

Medication Adherence

PHM Program Delivery

Incentive Management Participant Engagement / Outreach

Fraud

Claims Editing Payment Integrity

Data

Population Stratification & Patient Identification

Overpayment Detection

Auditing / Investigations Subrogation

ICD -10

Data

Overpayment

Member

Chart Extraction

Clinical Coding

Co -morbid Condition

Identification

Management Reporting

Payer Focused

Preparedness Mining & Analytics

Recovery / Collection

Targeting

Health care compliance requirements: Increasingly complex!

Triple Tree report on health care compliance, 2010

Regulatory compliance

Payment integrity

Clinical compliance

Meaningful-use stimulus

qualifications

Revenue cycle management

HIPAA Privacy and

Security

Medical necessity

The Joint

Commission

Clinical quality measures

Clinical safety

RAC audits

Coding compliance

FWA

ICD-10

Payer Contracts

Medications

Decision support Medications

STARK




Cost of compliance





Non-compliance is not an option Studies show that non-compliance is less costly than compliance

Source: Ponemon Institute Cost of Compliance Report 2011

Compliance cost

Policy

Communications

Program management

Data security

Compliance monitoring

Enforcement

Non-compliance cost

$9,368,351 $3,529,579 AV E R AG E C O S T

Activity-based costing model

Indirect costs

Opportunity costs

Direct costs

Business disruptions

Productivity loss

Revenue loss

Fines and penalties




Cost of compliance





Successful compliance management automation

Dashboards and decision-making tools

Content and workflow tools

Optimizing the compliance capabilities

Reduced cost of compliance

Automation Reduce cost and risk

Translating complex regulations into simple business processes

Compliance management-guided workflow to increase efficiency

Automate day-to-day compliance manage-ment process and tasks

Identify incidents, events and processes that affect compliance as they happen

Be proactive

Early identification of risks to mitigate them

Timely regulator response to reduce penalties

What is our compliance posture?

What are the vulnerabilities?

How are we managing risks?

Awareness Understanding Managing ROI

Visibility Simplification


Visibility: Identify, understand the risks

Dashboard to display risks, compliance posture and incidents that need attention

Compliance management activities data

Compliance-related incident data

Regulations database

Policies and procedures

Compliance posture and risks are identified using

an analytical engine


Simplification and automation

Monitor compliance • Investigate and manage incidents • Monitor vendor compliance • Identify compliance events that could become non-compliance issues

Compliance status, alerts, decisions

and risk protection

Audit and preparedness

Internal Audits

External Audits

Workflow for compliance management • Identify gaps and take corrective actions • Manage policies and procedures • Identify vulnerabilities and risks

Compliance requirements summation Translating regulations to easy-to-use content and workflow tool



Cost of compliance






Return on investment

• Automated process to reduce time, resources involved • Increased collaboration with intelligence-based system, less duplication

Significantly reduce time and effort of managing compliance

Cost of non-compliance • Business disruption: loss of revenue • Financial penalties: now in millions of dollars • Legal and other related costs with high business impact

Reduce risks of regulatory penalties

Suspension from doing business; publicized compliance events may result in loss of customers

Prevent reputational damage

Automation is highly cost-effective, optimizes compliance productivity



Cost of compliance






Be proactive in managing compliance

Compliance Automation

Regulatory compliance

Payment integrity

Clinical compliance

Meaningful-use stimulus

qualifications

Revenue cycle management

How can we more effectively monitor compliance incidents?

What are the financial, operational and administrative compliance requirements for our organization?

Can we reduce the cost of compliance? How can we be

prepared for an audit?


Questions Answers

ICD-10 Preparedness: Countdown is on…are you on track?

Communication and awareness

Education and training

Revenue mitigation

Coder productivity/retention

Report remediation


Q1 2013 Q2 2013 Q3 2013 Q4 2013 Q1 2014 Q2 2014 Q3 2014 Q4 2014

Report remediation

Education

Revenue mitigation



Report/Form Identification

Crosswalk Strategy

Report/Form Remediation

Convince Clarify Involve

System Identification

System Remediation

360° Testing

KPI Benchmarking

Denials Management/ Payer Contingency

Contract Review

CDI Program Review

CAC Implemented

Coder Backfill and Retention Strategy

Compliance Date: Oct. 1, 2014

3

Vendor selected

Coder CDI/physician champion

All learners Practice coding

System remediation

Inform

Start of process Decision point

Section I



Revenue mitigation


Report remediation

5

ICD-10 communication stages

Broad awareness campaigns

(to the masses)

Department meetings: change management

Role-specific training

Workflow optimization

Inform Clarify Convince Involve

“How will ICD-10 affect my job, roles and responsibility?”

“How do I use ICD-10 in my job?”

“When are we moving to ICD-11?”

“What is ICD-10 and how do I get more information on how we are addressing it as an organization?”

Awareness Understanding Acceptance Commitment

6

ICD-10 communication and awareness

Don’t be afraid to have some fun.

Get creative!

Section II



Revenue mitigation


Report remediation

8

Methodology to approach physicians

• Includes both employed/non-employed providers • Focus is on acute-care clinical documentation requirements

All affiliated providers

• Includes employed providers within medical group • Focus is on documentation and coding requirements in the physician

practice (professional) setting

Employed providers only

• Includes all non-employed community providers affiliated with the hospital • Focus is on awareness/education of both impacts and potential remediation

activities

Community providers



Revenue mitigation


Report remediation

Section III

10

Revenue mitigation: Creating a baseline

Key Performance Indicators

Case Mix Index

(CMI)

Coding productivity and quality

Denials Discharged

not final billed (DNFB)

Reimbursement by service line

What metrics should we be

collecting?

Who will be accountable

for taking action?

How should we report the information?

When should we start benchmarking

our data?

11

Contingency planning: Be prepared

• Will you be able to proactively identify the payers that will not be ready/compliant by Oct. 1, 2014?

• If so, do you want to take a proactive or reactive approach, i.e., let the claims deny or map/code to ICD-9 before submitting?

• Will you dual-code claims or map from I-10 to I-9?

• Which department will be responsible ― HIM or PFS?

• Do you have workflows within your application to support your strategy?



Revenue mitigation


Report remediation

Section IV

13

Coder productivity mitigation plan

• You can always hire more coders, right? • Transition to computer-assisted coding • Be creative ― consider a coder career

ladder program • Remote coding (retention vs. productivity

mitigation strategy?) • Considerations:

– While coders are in training (minimum 40 hours for IP coder, but likely more)

– Through dual-coding period – Post-transition (learning curve) – Retention

Anticipated coder productivity impact of ICD-10*

Long-term

Short-term

50% 25%

*http://library.ahima.org/xpedio/groups/public/documents/ahima/bok3_005558.hcsp?dDocname=bok3_005558



Revenue mitigation


Report remediation

Section V

15

Forms and report remediation

Remediate Develop

consistent mapping strategy

Prioritize Inventory

• Select an organization-wide mapping and translation tool

• Identify HIM analysts and support

• Compliance (regulatory, state, CMS, other)

• Quality

• Financial

• Frequency, prevalence

• Review with end user

• Survey

• Meet with business impact areas

• Determine vendor vs. internal

• Charge tickets

• Vendor reports

• Ad hoc/ custom reports

• Order sets

• Clinical templates

• Cheat sheets

Reports and

forms are everywhere!

Questions

Thank you.

NLP innovation for CAC and CDI — An update on new technology

Mark Morsch Vice President Technology


New technology for ICD-10-PCS Compositional approach to NLP Opportunity to leverage partial information Advantage of partial PCS coding

NLP advancements transforming CDI Case finding automation Clinical information model Linkage between CAC and CDI

CDI example

Q&A

AGENDA


Compositionality

ICD-9 38.93 “Venous catheterization, NEC” maps to 185 ICD-10 PCS codes.

02HS03Z Insertion of infusion device into right pulmonary vein, open approach

02HS33Z Insertion of infusion device into right pulmonary vein, percutaneous approach

02HT03Z Insertion of infusion device into left pulmonary vein, open approach

05H003Z Insertion of infusion device into azygos vein, open approach

Basic concept Side Location Approach


Compositionality Example: 0FB40ZZ partial gallbladder removal, open approach OPERATIVE REPORT PRINCIPAL DIAGNOSIS: Cholecystitis with cholelithiasis with history of emphysematous cholecystitis. PROCEDURE: Open cholecystectomy with intraperitoneal drain placement and removal of cholecystostomy tube. … PROCEDURE … We then did identify the gallbladder, and we were able to grab with a Kelly clamp and lift it up. It was very inflamed. The cholecystostomy tube did go through the liver and into the gallbladder as we had anticipated. … We then did a dome-down technique to take the gallbladder down. … Therefore, I felt the best thing to do was piecemeal remove the gallbladder and then keep the back wall intact where we could. Actually this area was quite small, so therefore we took out several pieces of the anterior wall of the gallbladder, and then we had a lip of posterior wall of the gallbladder that we could sew the gallbladder back closed just at the infundibulum. There was maybe 0.5 cm of gallbladder remaining. … Therefore, we closed the approximately 2 cm and 0.5 cm depth of gallbladder with Vicryl sutures. … We irrigated this several times, and there was no bile coming from the gallbladder remnant whatsoever. …

Procedure (removal) Removal (gallbladder) Removal (partial) Approach (open)

Partial removal — 0FB Gallbladder — 4 Open approach — 0 No device/qual — ZZ


ICD-10-PCS code structure

PCS codes consist of seven alphanumeric slots, each slot assigned a specific meaning

Section 0

Slot 1 Section Medical & surgical, imaging …

Slot 2 System Gastrointestinal, lower bones …

Slot 3 Root procedure Bypass, alteration …

Slot 4 Body part Esophagus, stomach …

Slot 5 Approach Open, percutaneous …

Slot 6 Device Drainage, infusion …

Slot 7 Qualifier Syngeneic, zooplastic …

Fully specified PCS where information for all seven slots identifiable.

0W9F0ZZ Abdominal wall drainage, open approach

Partially specified PCS where confidence in information for some slots only.

0W9F_ZZ Abdominal wall drainage, approach not specified


Leveraging partial information in PCS codes

A diagnostic bronchoalveolar lavage (33.24) was performed, but the physician did not adequately specify the location for ICD-10.

0: Medical & surgical

B: Respiratory system

9: Drainage

_: Body Part?

8: Opening, endoscopic

Z: No device

X: Diagnostic


Partial CD-10-PCS code: Interaction with book coding

• All possible selections for each character are presented

• Drop-down list and segment selection allow coders to adjust PCS code


Advantage of partial PCS coding

Supports clinical documentation improvement where specificity increases from ICD-9 to ICD-10

NLP suggested codes need not be all or nothing

Provides for PCS code auto-complete capability


Natural language processing (NLP) is transforming HIM and coding with computer-assisted coding (CAC) solutions

• Benefits: Productivity, accuracy, efficiency, transparency, manageability

• CDI programs share these same goals

However CAC is not the same as CDI

Not limited to finding only “code-able” facts, but clinically significant facts that are evidence of an information gap

Transformation opportunity for CDI


Factors aligning NLP with CDI

Accurate abstraction of medical evidence to automate case-finding

Clinical information model that supports

consistent query decisions

Compositional approaches to NLP

to recognize complex query scenarios

1 2 3


NLP can extract the clinical evidence that indicate gaps in documentation

Like in CAC, recall and precision are important measures of accuracy

• High recall ensures that a high proportion of relevant facts are captured

• Capture important facts that can escape manual processes

• High precision means CDI specialists don’t waste time reviewing cases that don’t have gaps

Comparing CDI evidence to CAC results provides automated validation

Case finding automation with LifeCode® NLP


Three-tier information model MARKER • Marker Source = CDI • Marker Label = Condition or Procedure • Marker Type = Type of Marker • Confidence = High, Medium, Low • SNOMED Concept ID = simple or complex

SNOMED representation

SCENARIO: Group of indicators specifying the reason for a Marker • Scenario label • Confidence • SNOMED Concept ID

INDICATOR • Indicator label • Indicator type • Finding or lab or vital or meds or supplies with full inherited output • SNOMED Concept ID

Marker

Scenario Scenario

Indicator Indicator Indicator


CDI example — Congestive Heart Failure


CDI Marker — Acute Systolic Heart Failure


• NLP for CDI cannot be limited to narrative text — should have capability to handle structured data

• Structured and semi-structured data are an important source of clinical evidence – Vital signs – Laboratory order and results – Medication orders

• NLP for CDI should have high-accuracy coding capability to create effective ICD-10 queries

Key requirements of NLP for CDI

• NLP for CDI should have access to the complete record — or as much as possible

Clinical evidence + No ICD-10 code Physician query

Clinical evidence + ICD-10 code No query


New NLP technology for ICD-10-PCS and CDI

Advantage of partial PCS coding • NLP results are not all-or-nothing • Integrates with references for quick completion

Transforming CDI • Case finding automation • Clinical information model

Compositional NLP is key to both CDI and ICD-10-PCS

Conclusions

ICD-10-CM Mapping: Reasons, rules and restrictions

Anita C. Hart, RHIA, CCS, CCS-P OptumInsight Product Manager, ICD-9-CM and ICD-10-CM/PCS AHIMA-Approved ICD-10-CM/PCS Trainer


Reasons The WHEN, WHERE and WHY to employ Mapping

Rules The BEST PRACTICES to follow when using Mapping

Restrictions The CAUTIONS and LIMITATIONS of Mapping

Readiness The PLAN assessment

AGENDA How to develop an applied mapping

Decision-making process for choosing translation alternatives applied for a specific purpose

Reasons


REASON 1

To establish focus of coding training

Key factors

Code set expansion

Body system code count differences

Coding guideline and instructional changes

Major classification axes changes in specific coding areas


REASON 1 — To establish focus of coding training

Examples:

Code set expansion

ICD-10-CM MAPPING: REASONS, RULES AND RESTRICTIONS

Body system code count differences

Chapter ICD-9-CM ICD-10-CM Infectious & Parasitic 1,270 1,049

Circulatory 474 1,239

Respiratory 254 324

Pregnancy 1,103 2,145

Injury & Poisoning 2,544 39,761

ICD-10-CM (2014 Draft) codes = 69,367 vs.

ICD-9-CM (Vol.1) FY 2014 codes = 14,568


REASON 1 — To establish focus of coding training

Example: Coding guideline and instructional changes

ICD-9-CM: Aftercare Codes Aftercare visit codes cover situations when the initial treatment of a disease or injury has been performed and the patient requires continued care during the healing or recovery phase, or for the long-term consequences of the disease. [ICD-9-CM CG Oct 1, 2011 Sect I.C.18.d.7]

ICD-10-CM MAPPING: REASONS, RULES AND RESTRICTIONS

ICD-10-CM: Subsequent Encounter vs. Aftercare Subsequent Encounter: • Extension “D” subsequent encounter is used for encounters

after the patient has received active treatment of the injury and is receiving routine care for the injury during the healing and recovery phase.

• Aftercare, Z codes should not be used for aftercare of injuries. [ICD-10-CM CG 2014 Draft Sect I.C.19.a]

Aftercare: • Aftercare visit codes cover situations when the initial treatment

of a disease has been performed and the patient requires continued care during the healing or recovery phase, or for the long-term consequences of the disease. [ICD-10-CM CG 20141 Draft Sect I.C.21.c.6]


REASON 1 — To establish focus of coding training ICD-10-CM MAPPING: REASONS, RULES AND RESTRICTIONS

Examples:

Major classification axes changes in specific coding areas • Method of detection for tuberculosis infection

• Legality status and completion of abortions

• Trimester vs. episode of care for pregnancy

• Hypertension

• Transient hypertension in pregnancy vs. gestational hypertension w/ and w/o proteinuria

• Underdosing of drugs and chemicals


REASON 1 — To establish focus of coding training ICD-10-CM MAPPING: REASONS, RULES AND RESTRICTIONS

• Identify facility-specific high-volume codes based on utilization/reimbursement

• Focus training based on code utilization and facility-specific coding issues

• Prepare real-time training coding in both code sets

• Compare coded results

• Test coding proficiency in specified code set

Key Action Items


REASON 2

To identify clinical documentation essentials

Key factors

New clinical concepts residing in ICD-10-CM should be identified and conveyed

Retired ICD-9-CM concepts

Expanded clinical specificity

Terminology changes


REASON 2 — To identify clinical documentation essentials ICD-10-CM MAPPING: REASONS, RULES AND RESTRICTIONS

New concepts/classification axes conveyed • Salter-Harris physeal fracture classification

system • Asthma classification • Categories of diabetes mellitus • Obstetrical trimester as secondary axis

of classification

Retired concepts/classification axes • Essential hypertension, malignant, benign,

unspecified • Obstetrical episode of care as secondary axis

of classification

Terminology revisions

Expanded clinical specificity • Anatomy and Physiology • Laterality: Left, Right, Bilateral

Intermediate Coronary Syndrome Unstable Angina

Septicemia Sepsis

Senile Cataract Age-Related


REASON 2 — To identify clinical documentation essentials ICD-10-CM MAPPING: REASONS, RULES AND RESTRICTIONS

• Identifying documentation needs concerning the clinical concepts and anatomical specificity for selected subset of codes

• Create training tools and modify templates

• Train providers, coders and other coded data users

Key Action Items


REASON 3

To evaluate software and coding resources

Key factors

Vendors apply software subjective decision logic and assumptions

Resources based on General Equivalence Mappings (GEMs) represent all valid alternatives, based on code descriptor information; not intended for all uses — not application-specific

Forms and reports represent coded facility-specific data requirements


REASON 3 — To evaluate software and coding resources ICD-10-CM MAPPING: REASONS, RULES AND RESTRICTIONS

Evaluate how well the software makes ‘good’ decisions based on: • Reasonable code translations of the code

(source code) • The “complete meaning” is based upon the

code set conventions and structure, coding guidelines, instructional notes, official coding advice, index entries and code descriptors

How does the software translate the following: • Coding of Injuries (800-900) in ICD-9-CM

is for initial encounter only; in ICD-10-CM 7th character defines the encounter; GEMs only map to “initial encounter” codes

• Aftercare vs. subsequent encounter issue: V54.16, Encounter for aftercare healing traumatic fracture of lower leg, maps to almost 4,500 ICD-10-CM alternatives

• The change in classification axis from outcome of delivery encounter to trimester

• ICD-10-CM utilizes terms such as dependence and abuse. ICD-9-CM utilizes the descriptors of continuous, episodic, in remission and unspecified


REASON 3 — To evaluate software and coding resources ICD-10-CM MAPPING: REASONS, RULES AND RESTRICTIONS

• Verify software decision logic

• Set decision-making parameters based on the specific data source and use

• Check training effectiveness

• Update forms, reports and analytics

Key Action Items


RULE 1

Use translations to facilitate conversion

Key factors Not “crosswalks” intended to be a 1:1 code match

May not provide complete clinical picture of coded data; based on code descriptor

Translations provide multiple alternative choices

Rules and assumptions applied not readily known

Not intended to be applied to all conversion needs

Key action items Identify the translated data use

Identify the source data used for the mapping

Identify the differences in clinical concepts, classification axes, coding practices and terminology for specific subset of codes

Develop selection criteria based upon facility-specific needs


RULE 2

Know coding guidelines and instructions differences and similarities

Key factors Structure and conventions changes

Classification axis revisions

Use additional code instructions

Application of appropriate guidelines

Key action items Start coding in the specific ICD-10-CM sections to identify issues

to be resolved

Identify the end use of the mapping data

Identify and resolve coding practice issues

Map according to coding in the target system


RULE 3

Use mappings bi-directionally

Key factors In some instances, one map may not include a code that is required

in coding a condition that is a combination code in one code set or the other

Glaucoma stages (365.70-365.74) have NODX forward map, yet backward mapping results in scenarios to accommodate the combination codes in ICD-10-CM

In some instances, one map may not include a code that is required in coding a condition or clinical concept that has been retired

Level of specificity difference between the code sets

Differences in the structure of the classification system

Key action items Identify the end use of the mapping data

Code “problem areas” in the coding conventions of the target system

Compare all results and document final decision logic assumptions

Restrictions


Key factors Based upon code (description), no supporting/additional

information Translations are based on concept(s) inherent to one

code set (source) Mappings can take specific concepts to more general

concepts, but cannot add specificity when the original information is general

Key action items Identify the end use of the mapping data Code “problem areas” in the coding conventions

of the target system Compare all results before and after mapping

RESTRICTION 1

GEMs designed as translators of coded data


Key factors GEMs provide all possible alternatives GEMs were not developed with specific application

decision logic GEMs not developed to reflect facility-specific data use

Key action items Identify the end use of the mapping data Establish decision logic criteria and assumptions Document final decision logic Compare all results before and after mapping

RESTRICTION 2

Designed for multi-purpose use


Key factors GEMs will include “No Map” results Level of specificity difference between the code sets Differences in the structure of the classification system In some instances, one map may not include a code that

is required in coding a condition that is a combination code in one code set or the other

Key action items Analyze coding results before and after mapping Adjust coding practices to account for concept

differences Improve clinical documentation to minimize coding

accuracy issues Compare all results before and after mapping

RESTRICTION 3

Classification system concept differences

Assess your readiness


Listed top high-volume code set

Coded in both code sets

Compared the coded results

Review those mappings that have conflicts

READINESS 1

Top coding issues identified


Decisions must be made as to how to translate, which concept takes priority (reimbursement, clinical, etc.)

Test and revise assumptions and rules in decision making

Documented rules applied

READINESS 2

Set decision-making rules


Develop procedures to review all changes periodically

Develop procedures to update applications of data

Refresh coding training

READINESS 3

Plan for changes


ICD-10-CM Mapping: Reasons, rules and restrictions

Reasons Rules Restrictions Readiness

• Coding training focus

• Clinical documentation improvement

• Software and resource evaluation

• Use mapping to

facilitate conversion

• Understand classifications system similarities and differences

• Use mapping bi-directionally

• Designed as

translators

• Designed for multi-purpose use

• Mappings can take specific concepts to more general concepts

• Identify top-priority

coding issues

• Resolve and set decision-logic

• Plan for change

Assess … educate … execute Successful implementation on October 1, 2014 Thank you.

CONTACT INFORMATION Anita C. Hart, RHIA, CCS, CCS-P ICD-9-CM and ICD-10-CM/PCS Product Manager AHIMA-Approved ICD-10-CM/PCS Trainer [email protected]

ICD-10 education: Strategic considerations for how to educate your organization


Objectives Today’s topics and learning objectives:

Areas of impact: Identify the various areas of impact across your organization

Learner categories and educational needs: Plan when education should start for each

Educational program planning: Understand the specific educational needs and develop a training plan that takes all learning activities into consideration

Areas of impact


Business impact areas

• Registration (central; ED; ambulatory; ancillary)

• Scheduling

• Admitting/discharge/ transfers

• Prior-authorizations/ pre-certifications

• Medical necessity checks

• Bed management

• Physician and nurse documentation

• Ancillary and support services documentation

• Order entry and results

• Workflow within EMR

• Case management

• Clinical research

• Workflow and transfers between clinical units

• Coding and abstracting

• Deficiency tracking

• Claim edit work lists

• NCCI/LMRP edits

• Encoding and grouping

• Physician query

• Clinical documentation improvement

• Charge entry

• Payer and clearinghouse edits

• Contracting

• Facility and professional billing

• Follow up and denial management

• Claims status

• Quality/outcomes reporting

• Financial/revenue reporting

• Public health reporting

• Clinical registries

• Data warehouse

• ICD-9 to ICD-10 mapping and translation

• Compliance

• Implementation of new business and/or clinical systems

• Transition to paperless environment

• Opening of new facility

• Narrowing of IT vendor portfolio

• Implementation of computer-assisted coding

Patient access Clinical and ancillary

Health information

management Patient financial

services Analytics and

reporting Strategic initiatives

Organizational Support: Project Management — Education and Training — IT

People Systems


ICD-10 transition methodology

Learner categories and educational needs


Transitions learners from a structured learning environment to applying the knowledge obtained in Level 1/2 courses to their specific job function • Uses instance data from

the learner’s environment

Level 3: On-the-job

Learner categories: Skill building

Provides high-level education of ICD-10 mandate to ensure that the learner has baseline knowledge of why the industry is moving from ICD-9 to ICD-10 • Benefits • Challenges • Timeline • Impact to systems • Workflows

Delivers deeper understanding of the ICD-10 code set • Content will vary dramatically

by job function

Level 2: Knowledge-based/skill transfer

Level 1: Overview


Learner categories: Roles

Learner categories Typical roles/credentials Education levels

Coders CCS, RHIA, RHIT, CPC, etc.

Revenue cycle, IT and reporting/analytics

Claims, appeals, referral/prior authorization, billing, patient accounts, analysts, report writers, etc.

Providers, nurses, CDI specialists

MD, NP, PA, ancillary providers, therapists, RN, case managers, CDI specialists, etc.

Executives/ key stakeholders

CEO, CFO, CIO, CCO, CNO, COO, CMO, CMIO, etc.

1

2

3

Level 1: Overview

Level 2: Knowledge-based/skill transfer

Level 3: On-the-job

1 2 3

1 2

1 2 3

1


Prior Q3 2013 Q4 2013 Q1 2014 Q2 2014 Q3 2014

Executives/Stakeholders

Revenue Cycle

IT/Reporting

Coders/HIM

CDI Specialists

Providers/Nurses

Learner category: Timeline

* Depending upon dual-coding strategy

2

1

1

1

1

1

1 2

2*

2 3

3 2

To prepare for report remediation

Com

plia

nce

O

ctob

er 1

, 201

4

2 3

1

2

3

Level 1

Level 2

Level 3

2 3

2 3

2 3

Education program planning


Education program planning: Holistic education

ICD-10 education program

Consider education/training program coordinators or overall program management

Consider both eLearning and instructor-led content to provide a comprehensive and multifaceted program

Can you integrate your eLearning courses and content into your existing or pending technology, including CAC, CDI, mobile coding apps, etc.?

Program management

Content

Technology and integration


Education program planning: Strategy and philosophy

• Focus on the void/delta to meet the learner’s need • Offer flexibility in delivery methods

Inform without extraneous components

• Understand organizational needs • Leverage partnerships

Partner with the best | Use resources wisely | Use expertise wisely

Concise

Relevant

Accurate

Focus on learner retention


Education program planning: Key decisions

• Understand the needs across your entire organization

• Make it informative and relevant for the job role

• Determine strategy for employed vs. non-employed

• Address community physicians/other hospitals in the area

• Determine testing/attest requirements for each role

• Plan remediation/1:1 support for inadequate assessment results

• Determine delivery methodology that makes sense for each learner category

• Develop a dual-coding strategy (will impact the timeline)

Education must be concise, relevant and accurate


Educational program planning: Methodology for physicians

• Includes both employed/non-employed providers • Focus is on acute-care clinical documentation requirements

All affiliated providers

• Includes employed providers within medical group • Focus is on documentation and coding requirements in the physician

practice (professional) setting

Employed providers only

• Includes all non-employed community providers affiliated with the hospital • Focus is on awareness/education of both impacts and potential

remediation activities

Community providers


Educational program planning: Focus on provider needs

Focus on provider documentation What they need to know to document properly

Identify relevant concepts in documenting They need to know what to document, not how to code

Emphasize the differences from ICD-9 to ICD-9 Some documentation concepts are identical, others are not

Teach only the differences Providers do not need or want to be taught what they already know


Educational program planning: Interaction is important

Leverage train-the-trainer sessions Peer-to-peer education has proven to be the most effective

Identify physician champion(s): • Conduct education sessions at dept. meetings,

physician forums, physician lounge, etc. • Provide one-on-one coaching to “repeat offenders” • Be ICD-10 SME to physician community

Integrate with existing CDI programs

Prioritize education High-volume/high-impact diseases

Offer CME credits


Support physicians with technology: EMR tools

Getting documentation from here … … to here

Appropriate use of technology: electronic templates | prompts | pick lists


Questions? Thank you.

Concurrent CAC with computerized CDI at UPMC: Lessons learned from implementation University of Pittsburgh Medical Center UPMC | Technology Development Center

2

• Explain the CDI challenge at the University of Pittsburgh Medical Center (UPMC)

• Identify how technology can improve the CDI process

• Describe how a natural language processing (NLP)-driven CDI can enhance staff productivity, coding accuracy and compliance

• Highlight lessons learned and opportunities discovered from CDI implementation

• Review the transition from post-discharge CAC to concurrent CAC

Objectives

Presenters

JULIE TRUVER MSIS, RHIA Vice President, Operations UPMC | Technology Development Center

ADELE TOWERS MD, MPH Medical Director UPMC Health Information Management

Quick facts — University of Pittsburgh Medical Center

National leader UPMC is one of the leading nonprofit health systems in the United States, headquartered in Pittsburgh, Pennsylvania.

Employer UPMC is Western Pennsylvania’s largest employer, with more than 56,000 employees, including 3,200 physicians.

Inpatient facts Hospitals – 22 (Academic, Community and Specialty) Outpatient Facilities – 400 Average Daily Census – 3,250 Inpatient Discharges per Year – 253,000 Surgeries per Year – 174,000 ED Visits per Year – 600,000

5

• No concurrent CDI program in place

• 100% retrospective focus on record review

• Average of 550 inpatient medical records per day are coded

• 5% of the total discharges result in a query with revenue impact of $1M per month

• Creating, distributing, monitoring and resolving physician queries is labor intensive

• Queries that are not resolved quickly impact the DNFB

CDI at UPMC: The challenge

CONCURRENT

100% RETRO

5% = $1M/mo.

550 records/day

6

Staffing per the financial benchmarking report

Source: “Best-in-Class Clinical Documentation Improvement Programs.” Financial Leadership Council — The Advisory Board Company. 2010.

Performance LOW AVG HIGH

Total Beds Covered per CDI FTE

128 113 92

Total FTEs Required for 4,732 Beds

37 42 51

Salary Benefits Total

$2.7M $3.1M $3.8M

Assumptions: • Total Beds Provided from UPMC Finance

• Average Salary for CDIs $28.84/hour per Indeed.com

• Salary marked up 22% to add benefit costs to total salary $35.18/hour

• FTE of 2,080 hours per year

7

ICD-10 impact on productivity and revenue

$3.1M $3.8M

$8.1M

Productivity Denials Financial Impact Undercoding

Projected annual financial impact of ICD-10: UPMC Health System: 4,500 Licensed Beds

CAC Key CDI Key

Content derived from The Advisory Board Company. 2013

Balancing organizational approach with physician needs

HOSPITAL PHYSICIANS

DNFB SIMPLE

Clinically Relevant Concurrent

FTE-Neutral

Case Mix Index

Severity of Illness Risk of Mortality

Alerts within Workflow

Requirements for technology solution

10

The CDI case-finding conundrum

• Reviewing enough charts • Reviewing the right charts • Reviewing charts for the right reasons • Reviewing charts enough times

Reviewing enough of the right charts for the right reasons enough times

Appropriate Case Finding

11

ACDIS CDI Staffing Survey*:

• CDI specialists conduct 8 to 12 new reviews per day

• Each CDI specialist spends between 33 and 48 minutes per initial review

Case finding is often a wasted effort

*Source: ACDIS CDI Work Group. White Paper: CDI staffing survey provides estimates on record reviews, productivity considerations. HCPro, Inc., 200 Hoods Lane, Marblehead, MA. 2010

Percent of Reviews Resulting in a Query

Percent of Respondents

0–10% 7% 11–20% 22% 21–30% 36% 31–40% 15% 41–50% 7% 51–60% 6% 61–70% 2% 71–80% 2% 81–90% 1% 91–99% 0% 100% 0%

TOTAL 100%

87% of respondents <50% of reviews result in a query 36% of respondents 2 out of 3 reviews unnecessary

System-built queries vs. manually built

13

Types of documentation queries

Example 1: Specificity Example 2: Clinical Clarity

Physician documents “CHF improving.” Physician documents “fluid retention and shortness of breath improving.”

Physician Documentation • “CHF” in History and Physical • “CHF” in Progress Note • Code for Unspecified CHF

Clinical Indicators • Pulmonary Vascular Congestion in CXR • Ejection Fraction of <30% in Echo • BNP of 700 • IV Lasix in MAR

Approach to Query • Engage Physician to Provide

Specificity in CHF Diagnosis – Acute vs. Chronic – Diastolic vs. Systolic – Acute or Chronic

Approach to Query • Engage Physician to Clarify Clinical Facts • Ascertain if there is a diagnosis that could be added to reflect the clinical

picture for treatment of this patient • Subsequent query for specificity in diagnosis, if indicated

The reason we need a CDI program is to assist physicians when they do not document something well OR when they neglect to mention a diagnosis or condition at all.

14

Common ways physicians downplay severity of illness

We document … We SHOULD Document …

Urosepsis UTI with Sepsis

“Wet,” “CHF,” “rales, give Lasix” Acute Systolic CHF (or Diastolic, etc.)

Troponin Possible SEMI

H/H Acute Blood Loss Anemia

Dry, Creat Dehydration, Acute Kidney Injury

15

Physician documentation

Impression: 1. Urosepsis 2. CHF-IV Lasix 3. Pleural Effusion

Impression: 1. Sepsis d/t UTI 2. CHF-IV Lasix 3. Pleural Effusion

Impression: 1. Sepsis d/t UTI 2. Acute on Chronic Diastolic

Heart Failure 3. Pleural Effusion

80-year-old female, fever, AMS, dysuria and elevated white count, CXR pulmonary shows vascular congestion

MS-DRG MS-DRG RW SOI ROM MS–DRG $

690 0.7810 1 1 $4,842

Note: Severity and Mortality are both level 1

MS-DRG MS-DRG RW SOI ROM MS-DRG $

872 1.0988 2 2 $6,812 Note: Severity and Mortality levels increased to 2 and RW increased to 1.0988 by documenting the Sepsis d/t UTI. Reimbursement increased.

MS-DRG MS-DRG RW SOI ROM MS-DRG $

871 1.8803 3 3 $11,657

Note: Severity and Mortality levels remained at 3 and RW increased to 1.8803 by documenting the Sepsis d/t UTI and Acute on Chronic Diastolic Heart Failure. Reimbursement increased.

16

Physician query

17

Physician query

18

Physician query

19

Physician query

20

OptumTM CDI — Hard ROI

$1.8M $2.2M $2.3M $2.4M $3.5M

$4.3M

$2.7M $2.2M

$21.5M

$1.0M $0.8M

$1.0M $1.0M

$1.2M $1.2M $1.2M

$1.1M $1.1M

$1.3M $1.4M

$1.3M

$1.7M

$1.8M

$2.0M

$2.2M

$10.2M

$11.3M

$69,000 ÷ 500 cases = $138/case

83% of cases found by Optum CDI module

Existing manual program

Incremental revenue after CDI marker validation

$28K

$41K

$69K

Impact of more accurate documentation

UPMC Case Study Projected Annual Income $21.5M

3 Facility 6 Month Limited Pilot Increase in revenue of $4.5M

Presbyterian 31,133

McKeesport/ Horizon/

Northwest 19,315

Mercy 16,669

Hamot 16,279

St. Margarets 13,378

Passavant 16,311

Magee 17,470

Shadyside 25,322

All UPMC 155,877

21

DRG impact

316

243

107

20 8 18 4

81

366

99 62 51 35 22

A (<1) B (1-2) C (2-3) D (3-4) E (4-5) F (5-6) G (>6)

DR

G C

ount

DRG Weight Scale

Original DRG Weight

New DRG Weight

CDI codes consistently and accurately. This shifts originally coded cases to higher DRGs due to severity.

• Physician satisfaction with query process – Within workflow; requiring little hand-holding

or follow up – Focus beyond revenue cycle

• SOI/ROM Lever

• Confidence in ICD-10 preparation – Ability to measure and monitor performance – Rules engine provides safety net

• Staff satisfaction – Improved communication among physicians,

CDIS and HIM coders

• Administrative oversight and agility to act

Soft ROI

ICD-10 physician education: Engaging your physicians for a smooth transition


Objectives Today’s topics and learning objectives:

Create focused training

Support physicians with technology

Integrate CDI processes into ICD-10 strategies

Create focused training


Educational program planning: Strategies

Education needs to focus on specifics and not generalities

Eliminate the fear Emphasize only the differences from ICD-9 to ICD-10

Identify relevant concepts in documenting They needs to now what to document, not how to code

Minimize additional workflows/processes Utilize tools instead of provider time to get things done

Make education time appropriate Not all specialties require the same amount of training


Create focused training: Delivery

Make education a priority

Select a content partner with flexible curriculum

Determine appropriate delivery channel eLearning vs. instructor-led or a combination

Instructor-led eLearning

Support physicians with technology


Support physicians with technology: Analytics

Prioritize educational focus with analytics Identify high-volume/high-impact diseases • Hospital inpatient: Identify potential impact to reimbursement • Hospital outpatient: Identify high-impact codes moving from ICD-9 to ICD-10

CODING & REIMBURSEMENT IMPACT/RISK IDENTIFICATION


Support physicians with technology: EMR tools

Getting documentation from here … … to here

Appropriate use of technology: electronic templates | prompts | pick lists


Support physicians with technology: Portable tools

Put information in physicians’ hands

Mobile applications providing: • Physician Documentation Guidelines • Automatic monthly updates • Mapping content • User notes • Favorites

Job aids Flash cards with top 10 diagnosis by specialty

Reference material



Mitigate risk + leverage opportunity = CDI a must for ICD-10

Primary objectives Critical success factors

• Improve physician documentation

• Improve Case Mix Index (CMI)

• Enhance compliance

• Document for appropriate reimbursement

• Identify and track core and other quality measures

• Executive sponsor and accountability

• Physician liaison

• Robust reporting and metrics

• Adequately trained clinical documentation specialists

• Effective physician query process



• Effective documentation standards

• Severity-adjusted documentation practices

• Demonstrate how documentation improvement opportunities support professional billing and reporting of patient acuity (severity of illness and risk of mortality)

• Case scenarios that illustrate differences in improved documentation — from both a clinical/quality and reimbursement perspective

Education options

• Digital videos (4 to 8 minutes) on each of the CDI markers presented by specialists

• Onsite or webinar instructor-led

• CBT learning


Summary

• Think BIG ― ICD-10 changes more than the codes for providers

• Focus training • Leverage technology • Integrate with other initiatives

Data Action Accountability

Susan Hoyle, CCS | Coding Manager, IP/Obs

Concurrent coding with CAC helps Mission Health improve physician relationships

About Mission Health • Based in Asheville, North Carolina

• North Carolina’s sixth largest health system

• Tertiary care regional referral center for Western North Carolina and adjoining region

• Main hospital: 730 beds on two adjoining campuses

• Medical staff includes more than 750 physicians

• 6,000 employees and nearly 700 volunteers

• Centers of excellence include Pediatrics, Cancer, Heart, Neurosciences, Orthopedics, Women’s Health, and the region’s dedicated Level II Trauma Center

The move to computer-assisted coding • Primary Driver: ICD-10 ‒ Mitigate coding productivity loss ‒ Prepare for limited coding resources

• Ensure appropriate revenue/reimbursement ‒ Capture all codes that may impact DRG/Case Mix Index ‒ Reduce DNFB

CAC helped enable Mission Health’s concurrent coding • CAC reviews all text documents, including electronic notes progress notes

• Natural Language Processing (NLP) ‒ The brains of the CAC system ‒ Review electronic documents and suggests codes in near real-time ‒ NLP technology that can “understand” medical terminology and context is

recommended

The move to concurrent coding • Originally to encourage physicians to use electronic progress notes

• Benefits for physicians ‒ Use the progress notes to provide codes for physician billing ‒ Identify situations where their documentation could be improved ‒ Increase concurrent queries while reducing post-discharge queries

Benefits of concurrent coding • Coding queries to physicians have resulted in $297,000 average increase per

month in DRG reimbursement over the same three months in 2012

• Discharge Not Final Coded >5 days for Inpatient and Observation cases has decreased 30% from $6.9 million to $4.3 million

• Clinical Documentation Specialists have been able to increase their review of cases by 43%

• Diagnosis codes are being used to generate system alerts to physicians to drive treatment protocols (example: AMI and no aspirin) tied to quality indicators and the value-based purchasing program, reducing “false alarm” alerts by more than 5000%. Prior to concurrent coding, these alerts were firing off of clinical indicators that were typically “false alarms”

Benefits of concurrent coding • The calculation of a working DRG at admission is providing an estimated LOS

for Care Managers, resulting in a decrease in unnecessary chart reviews

• The calculation of a working DRG is allowing for identification and prioritization of discharge planning on cost outlier cases

• Implementation of ICD-10 will result in the need for greater documentation specificity. Concurrent coding will identify these documentation needs early on in the admission, generating concurrent queries to the MD. Providing that feedback to the MD prior to ICD-10 implementation will position Mission for a more successful ICD-10 implementation

Queries: Financial impact $550,000

$500,000

$450,000

$400,000

$350,000

$300,000

$250,000

$200,000

$150,000

$100,000

$50,000

$0 J F M A M J

Financial Impact from MD Queries

FY13

FY12

Case mix index

1.58

1.6

1.62

1.64

1.66

1.68

1.7

1.72

1.74

October November December January February March April

FY 2013

FY 2012

Average FY 2012 CMI: 1.6542

Average FY 2013 CMI (through seven months) : 1.6943

2012–13 increase: 2.4%

Thank you

Radical thinking…“Let’s let doctors be doctors”

Supportive physician communication

Providing time-of-service support for clinical documentation improvement Supporting physicians in this rapidly changing environment

Why now?

In the current environment, it is imperative that the medical record completely capture an accurate reflection of the patients SOI, ROM and all treatments rendered.

The perfect storm on the horizon

• Pay for performance

• Accountable Care Organizations (ACO)

• ICD-10, arriving October 1, 2014

• Denials

• Changes in reimbursement

5

• Optum CAC/CDI Single solution will facilitate the uniform efficient routing of cases for those conditions that are undocumented or need to be specified more clearly in the medical record.

• Currently, our competitors rely on the clinician’s individual knowledge and ability to search through the records in a random method to find relevant clinical elements.

Solutions

6

Optum Enterprise CAC: A comprehensive coding solution

Enterprise CAC • Powered by LifeCode NLP technology, suggests and assigns traceable codes for coder review.

• Unifies hybrid medical records by presenting the coder with one consolidated view of the case, including all electronic medical records and scanned image documentation.

• Provides a comprehensive play for for all hospital inpatient and outpatient coding needs within a single integrated solution.

• Dashboard view for managers’ full transparency of coding operations.

Coding & Reimbursement Module • Logic- and book-based encoder

includes all supporting encode components, clinical references, edicts, reimbursement library an coding and reimbursement.

• When paired with Enterprise CAC, a fully integrated product for all coding needs within one single solution.

Workflow Module • Automates case

assignment.

• Reduces steps in coding processes.

• Build and maintain work queues.

CDI Module • Automates the entire CDI process, including

clinician query.

• Includes traceability of colder and CDI specialist efforts for improved communications and tracking.

• Provides the opportunity to address any documentation issues to support quality and coding efforts much earlier in the workflow.

7

Ease transition to ICD-10 • Helps mitigate anticipated reduction in

productivity (and resulting revenue cycle impact)

Increase coder productivity • Reduce or eliminate coding backlogs, overtime

and contract coding services dependencies

Improved coding accuracy • Identify and capture ICD-9-CM and CPT® codes

based on clinical documentation • Correctly capture Case Mix Index (CMI) • Decrease external audit dependency and costs

Increased revenue and reduced expenses • Shorten revenue cycle • Decrease number of denials and re-bills • Reduce administrative costs

More consistency • Less room for coder interpretation • Improve quality of less experienced coders

bridging the coder experience gap

Traceability • Complete traceability of codes to document

for internal and external auditing • Unifies hybrid records

Optum Enterprise CAC benefits

8

• Clinically invalid queries • Ever changing regulatory landscape • EMR • Opportunity/case finding challenges • Clinical verbiage vs. CMS verbiage • Physician time for education • Variable coder and CDIS knowledge base

Current challenges

9

Connected functions/processes are critical to success

Coding and CAC

ICD-10 Meaningful Use

CDIP and CDI technology

Education and feedback drives improved clinical documentation

Clinical documentation allows for: • Increased specificity and accuracy • Better compliance, patient safety • Typically increases CMI • Increases quality report card • Drives accurate coding

Computer-assisted coding enables: • Increased accuracy and efficiency • Mitigate ICD-10 productivity impact

Both clinical documentation and coding with be impacted by ICD-10 and require organization-wide education and intersect with Meaningful Use initiatives

10

NLP LifeCode case finding

CDI markers

Integrated solution with coding

Configurable worklist

Consistent query process/templates

Functionality

11

• Most accurate case finding in the industry • Use of the LifeCode NLP engine • Automates case finding/routing • Standardizes the query process • Embedded clinical references in the query process • One-step query creation to the physician

CDI solution

12

• The integrated solution with the coders allows the same query solution to be launched both in the concurrent and post discharge environment

• The same query method and embedded clinical references are utilized for consistency to the providers

Integration with coding

13

Process improvement

This is a demonstration of a typical workflow

Physician process CDI specialist Coder

• Document clinical findings

• Review queries routed directly to appropriate physician

• Add requested response/specificity information to the chart

• Review charts with CDI markers

• Send queries as appropriate

• Monitor for query response

• Ensure case is optimized if able, prior to reaching coder

• Review optimized cases

• Send query if needed using same process

• Send final bill

• Minimal DNFB due to concurrent process

Thank you.

Contact information: Lynn Probert , RN CDI Product Specialist Cecilia Guardiola, Associate Director, CDI Consulting [email protected] [email protected]

icd-10 - optum · icd-10 physician education — engaging your physicians for a smooth transition...

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