nicole d. harper, ph.d., mba, rhia, ccs-p, c-cdi director ... icd-10.pdficd-10 x . x extension an...
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Nicole D. Harper, Ph.D., MBA, RHIA, CCS-P, C-CDI
Director, Revenue Cycle
St.Vincent Health – Indiana
Pat Schmitter CPC, CPC-I
Senior Healthcare Consultant
Approved ICD-10-CM Trainer AHIMA/AAPC
VEI Consulting - Indiana
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Discuss expected industry impacts resulting from the ICD-10 implementation
Define a proactive approach to preparing for organizational success beyond Oct. 1, 2014
Summarize concurrent activities that can be used to support a positive implementation
Identify pitfalls to avoid as we approach go-live
201 DAYS… and counting!!!!
10%-50% decrease in coder productivity
DNFB and A/R – fourfold increase x9mos
$50-$100 million in productivity losses among physicians
Backlogs in adjustments and inquiries
Error rates up to 6%-10% (annual ICD updates)
10%-25% increase in denial rates
10+% of charts = documentation insufficiency
Potential 10%-25% increase in RAC/MIC take backs
Code set will increase to ~69,000 new codes
Physicians will have to document more information
The ICD-10 implementation date is NOT subject to change
• Greater specificity
• Need for improved documentation of clinical data
• Information relevant to patient care encounters
• Ability to document risk factors
• Efficacy of Physician peer-to-peer education
• Opportunity to recruit physician champions
ICD-10 Incorporates:
More-accurate payments for new procedures Fewer miscoded, rejected, and improper
reimbursement claims Better understanding of the value of new
procedures Improved disease management Better understanding of health care outcomes Higher quality information for measuring
healthcare service quality, safety, and efficiency
Expected Benefits of ICD-10
Education & Training ◦ Increased Documentation Costs** ◦Est. ~ $80k per Physician
Business Process Changes Health Plan Contracting IT System Changes Cash Flow Disruption
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• Group presentations
– General overview
– By specialty
• Classroom
– Increments of 1 hour or less
• Web
– Video vs. text vs. combination
• Internal vs. external training sources
• Use specific examples of relevance to audience
– Documentation gap analysis can help identify problem areas
• Focus on areas that represent change – Guideline change – Change in desired specificity • Focus on high‐volume, problem‐prone topics -- May not be your top 50 DRGs/Diagnosis -- Have you considered your NOS/NEC
volume?
Accountability ◦ Make sure stakeholders
clearly understand responsibility to ICD-10..
◦ How does MY ROLE impact the organization?
◦ Take time to enjoy what you are doing right!!
Physician Education & Training
Specialty specific Physician education
Impact to Medical Decision Making
Commercial Insurance Plans ◦ Value based purchasing
◦ Contracting
Physician Score Cards
Health Information Exchanges
Meaningful Use
Documentation leads to identification of diagnoses and procedures
Resource utilization (quality management, patient outcomes, etc)
Support the length of stay, medical necessity & continuity of care
Morbidity and mortality scores Increase communication (i.e. physician documentation,
coding updates/guidelines, Case Management) Appropriately Represent Case Mix Index Precise data capture for public reporting (i.e.
Healthgrades, Care Science, WebMD) Audits may occur years after the patient was in the
hospital – ‘documentation has to stand up to the test of time’
Outcome of defaulting to ‘NOS’ codes
Physician Staffing/Interruption to Office Process & Flow ◦ Time associated with reworking/researching
information needed to adjust claims
Identification of problems that lead to claims being rejected
Educating the provider/entity on data elements necessary to fix a rejected claim
Unable to translate ICD-9 to ICD-10 ◦ What about GEMS mapping??
Key Strategies for Compliant Documentation • Helping the provider understand what is
necessary. • Keeping the lines of communication open
between providers and relevant staff.
• Ensure that providers/staff have access to current documentation education and materials.
• Encourage networking between peers.
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Pre-registration, scheduling & registration
Understanding the process
Provider/Hospital Staff/Coding Communication
(Encounter) Form/Smart Set Updates
Insurance verification/eligibility requirements ◦ Prior Authorization
◦ Medical Necessity (LCD/NCD/ABN)
◦ ICD Codes vs Narrative Diagnosis
◦ Financial Counseling
An example of structural change
ICD-9
X X X X X . Category Etiology, anatomic site,
manifestation
X X X X X . Category Etiology, anatomic site,
manifestation
ICD-10
X X . Extension
An example of (1) ICD-9 code being represented by multiple ICD-10 codes
2 5 0 1 6 . Diabetes mellitus with neurological Manifestations type I not stated as uncontrolled
E 1 0 0 4
E 1 0 1 4
E 1 0 4 4
E 1 0 9 4
.
.
.
. Type I diabetes mellitus with diabetic neuropathy, unspecified
Type I diabetes mellitus with diabetic mononeuropathy
Type I diabetes mellitus with diabetic amyotrophy
Type I diabetes mellitus with other diabetic neurological complication
The Basics of the ICD-10 Change
A glimpse at ‘specificity’ ICD-9-CM
821.01 Fracture of femur, shaft, closed ICD-10-CM
S72301A Unspecified fracture of shaft of right femur, initial encounter for closed fracture
S72322A Displaced transverse fracture of shaft of left femur, initial encounter for closed fracture
S72326A Nondisplaced transverse fracture of shaft of unspecified femur, initial encounter for closed fracture
S72301G Unspecified fracture of shaft of right femur, subsequent encounter for closed fracture with delayed healing
S72322G Displaced transverse fracture of shaft of left femur, subsequent encounter for closed fracture with delayed healing
S72326G Nondisplaced transverse fracture of shaft of unspecified femur, subsequent encounter for closed fracture with delayed healing
S72302A Unspecified fracture of shaft of left femur, initial encounter for closed fracture
S72323A Displaced transverse fracture of shaft of unspecified femur, initial encounter for closed fracture
S72331A Displaced oblique fracture of shaft of right femur, initial encounter for closed fracture
S72302G Unspecified fracture of shaft of left femur, subsequent encounter for closed fracture with delayed healing
S72323G Displaced transverse fracture of shaft of unspecified femur, subsequent encounter for closed fracture with delayed healing
S72331G Displaced oblique fracture of shaft of right femur, subsequent encounter for closed fracture with delayed healing
S72309A Unspecified fracture of shaft of unspecified femur, initial encounter for closed fracture
S72324A Nondisplaced transverse fracture of shaft of right femur, initial encounter for closed fracture
S72332A Displaced oblique fracture of shaft of left femur, initial encounter for closed fracture
S72309G Unspecified fracture of shaft of unspecified femur, subsequent encounter for closed fracture with delayed healing
S72324G Nondisplaced transverse fracture of shaft of right femur, subsequent encounter for closed fracture with delayed healing
S72332G Displaced oblique fracture of shaft of left femur, subsequent encounter for closed fracture with delayed healing
S72325A Nondisplaced transverse fracture of shaft of left femur, initial encounter for closed fracture
S72333A Displaced oblique fracture of shaft of unspecified femur, initial encounter for closed fracture
S72321A Displaced transverse fracture of shaft of right femur, initial encounter for closed fracture
S72325G Nondisplaced transverse fracture of shaft of left femur, subsequent encounter for closed fracture with delayed healing
S72333G Displaced oblique fracture of shaft of unspecified femur, subsequent encounter for closed fracture with delayed healing
S72321G Displaced transverse fracture of shaft of right femur, subsequent encounter for closed fracture with delayed healing
Outsource assistance
Coding Policies & Procedures
◦ Injury Codes (Y Codes) What about Quality/Risk reporting??
Productivity
◦ Estimated 40% - 50% decrease
Potential Loss of staff
Process/Workflow Changes ◦ Billing, denials, other..
Clinical Documentation Improvement Vendor/Payer Readiness Review/recognize patterns & trends Reimbursement simulation Data Analysis What is your back end NOT telling your front end?
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Software Vendors ◦ Verify Software Versions
◦ Expected dates of installation/transition
◦ Impacts to contracts & future upgrades
Billing Services
Clearinghouses
Healthplans ◦ Changes in format for data submission
Policy & Operational Changes
What does ‘upgrade’ really mean ◦ Codes only?
◦ Templates/Smart Sets/Interfaces?
Will there be additional costs associated with the transition?
Is there any education included in the system upgrade?
‘0’ vs ‘O’
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Testing ◦ Unit/Component Basic System Functionality
◦ Internal vs External Process
Information Exchange
◦ End-to-End High $$
High Volume
Entire Cycle
◦ Regression Testing Identify Errors
Testing crucial to ensuring systems actually work
Minimize risks to reimbursement
Issues should be mitigated PRIOR to go-live
Necessary stage to ensure a smooth transition
Are your Health Plans openly offering testing?
What is your community doing?
HIMSS/WEDI Testing Pilot
End-to-End vs 5010
Develop Your Own Pilot!!!!
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Industry vs Organizational Changes
Contingency Planning
Volume vs Cash ◦ Service Line Impact
◦ Specialty Impact
◦ Top 10 Diagnosis & Procedures??
Managed Care Contracting
Awareness of Clinical/Quality reporting & its impact on reimbursement ◦ Physician participation
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How will you know when something is going wrong?
◦ Content vs Process
Increase in claims processing errors
◦ Determine Baseline
Significant decrease in productivity logs
◦ Expected vs Catastrophic
Influx of inaccurate codes
◦ Common vs New
◦ Increased use of unspecified codes
Track * Resolve * ReEducate
Identify all of the processes you currently employ that involve an ICD-9 code
Connect with your customers/vendors/payers
Are there things you need to improve TODAY that will help ease the transition?
Budget accordingly
Prepare & train your staff
(End-to-End) Test, test & test again….
◦ Even if CMS doesn’t support it Implement – Convert & Monitor
Recommend adding Post Go-Live Phase to your plan!
Evaluating IT systems, interfaces, and customers that currently use ICD-9 codes and developing a transition plan
Strategizing on ways to improve data capture and how to use that data
Assessing training needs and developing programs to support both the initial and any ongoing training
Managing expectations regarding productivity loss
Appropriate budgeting for implementation resources, as well as the short and long term impacts on cash driven by reduced productivity and increased A/R
Potential revision of work flows/processes
1. Everyone will be affected 2. Private and public health plans will
not accept and pay based on ICD-9 codes used after DOS 10/01/2014
3. Automated conversions are not possible (forward & backward mapping of codes)
4. ICD-10 cannot wait for Electronic Health Records & other health IT initiatives
5. ICD-10 is more than a compliance activity
Five Points of Preparation
Preferred Proactivity
Do you have the right people doing the right job?
Do your ‘experts’ have everything they need?
What resources do you have lined up to support go-live?
Are you prepared to provide training POST go-live?
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Lack of Preparation Hurry up and Wait (Anticipate –
Act – Adjust) Your EMR won’t save you!!! Collaborate/combine efforts to
maximize resource utilization Who is your ICD-10 Champion?
Preventable Pitfalls
Nicole D. Harper, Ph.D., MBA, RHIA, CCS-P, C-CDI
Director, Revenue Cycle Management
St.Vincent Health – Indiana
317-583-4171
Pat Schmitter CPC, CPC-I
Sr Healthcare Consultant
VEI Consulting-Community Health Network
317-621-7187
Contact Information
American Health Information Management Association (AHIMA)
Hay Group, Inc. Healthcare Information Management Systems
Society (HIMSS) RAND Robert E. Nolan Company Pricewaterhouse Coopers http://www.cms.hhs.gov/TransactionCodeSetsS
tands/02_TransactionsandCodeSetsRegulations.asp
http://www.cms.gov/ElectronicBillingEDITrans/18_5010D0.asp
3M Solutions 2011 www.wedi.org www.mgma.org www.precyse.com
References