Nicole D. Harper, PhD, RHIA, CCS-PDirector of Training&Development/Process Improvement, St.Vincent Health - Indiana

2

Reduce ICD-10 anxiety Help identify what you need to know for ICD-10

implementation. Provide tips on the training needed for ICD-10 future

success. AGENDA

◦ Background◦ Benefits/Consequences◦ Project Timelines◦ Budget◦ Estimated System/Implementation Costs◦ Code Comparison◦ Plan of Action

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??? DAYS……….And counting!!!!

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January 1, 2011 – begin testing 5010 with trading partners

October 1, 2011 – ICD-9/10 code freeze October 2012 – Stage 2 MU criteria takes

effect March 1, 2012 – full compliance with

5010 October 1, 2013 – ICD-10-CM-PCS

effective****

5

The October 1, 2013 date for implementation should be considered a

flexible date

6

Unnecessarily detailed medical record documentation will be required.

PolandPoland

ThailandThailand

United StatesUnited States

IcelandIceland

DenmarkDenmark

BrazilBrazil

New ZealandNew Zealand

ArgentinaArgentina

AustriaAustria

NorwayNorway

AustraliaAustralia

FinlandFinland

SingaporeSingapore

CanadaCanada

SwedenSweden

ChinaChina

JapanJapan

VenezuelaVenezuela

GermanyGermany

SwitzerlandSwitzerlandItalyItaly

SpainSpainPortugalPortugal

ColombiaColombia

BelgiumBelgium

UKUKIrelandIreland

Czech RepublicCzech RepublicThe NetherlandsThe Netherlands

FranceFrance

Costa RicaCosta Rica

Source: 3M Information Systems, Inc.

8

ICD-10 Sits Among the Top Issues the Industry Has to Weigh

Economic

recovery

by 2011?

ICD-10

(2013)

EMR

Adoption

HIPAA 5010

(2011)

Reform

(2013/2014)

Access to

Finite

Resources

Source: Deloitte, July 29, 2010

9

 

ICD-9-CM ◦ Current coding classification system◦ Introduced 30 years ago◦ No longer fits with 21st century health system

ICD-10-CM & ICD-10-PCS ◦ International standard - diagnostic classification for

all general epidemiological and many health management purposes

◦ Track, report and compare morbidity and mortality◦ Supports achievement of EHR benefits◦ Transition to ICD-10 required by federal regulation

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Soon…. the United States will move from the ICD-9 system to ICD-10

It is the first major change in diagnostic and procedural coding in the U.S. in over 30 years◦ The “most significant overhaul of the medical coding system

since the advent of computers.” –The WEDI Workgroup◦ Encompasses moving from 5 digit numeric codes to 7 digit

alphanumeric codes with embedded logic in the new code structure and a different decision tree

◦ Approximately 9 times more ICD-10 codes than ICD-9 codes (16,000 ICD-9 codes and 155,000 ICD-10 codes)

A complex, time-consuming and expensive compliance challenge ◦ More complex than HIPAA compliance◦ Will touch most operational and IT processes and dramatically

influence data and financial reporting strategies

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Comparison of the two systems:◦ Expansion of codes

13,000 diagnosis codes in ICD-9-CM / 69,000 unique diagnosis codes in ICD-10-CM

ICD-10-CM allows for new code expansion within the code category, ICD-9 does not have that capability Example: Adverse Effect and Poisoning codes

4,000 procedure codes in ICD-9-CM/ 72,000 procedure codes in ICD-10-PCS

◦ Different code structure, diagnoses for example ICD-9-CM: 3 - 5 digits / limited alpha characters ICD-10-CM: 3 - 7 digits / additional alpha

characters

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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

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Increased claims rejections and denials Increased delays in processing

authorizations and reimbursement claims

Improper claims payment Coding backlogs Compliance issues Decisions based on inaccurate data

Problems can be mitigated with proper advance preparation

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Organize the Implementation

Effort

Develop & Launch Communication Plan

Assess the Impact of ICD-10

Implementation

Estimate Budget Requirements

Complete Gap Analysis

Implement Systems and/or Software

Upgrades

Update/Implement Internal Processes

Conduct Internal/External

Testing

Conduct Training

Implement ICD-10

Change Management

Evaluate Success of Implementation

Monitor Coding Accuracy and

Reimbursement

Evaluate Training Needs

Data Analysis

Identify New Data and Process Opportunities

Celebrate

Activities

Delive

rables Risk Ranking

Organization-wide Implementation Plan

Integrated, Resource-Load

Project Plan

Program Budget

Governance Model / Resource Alignment

High-level Timeline

Communication Plan

Impact Assessment Tools

Risk and Impact Readiness

Assessment

Organization-wide Go-Live and Post Go-

Live Plan

ICD-10 Infrastructure

Lessons Learned

Ongoing Training & Education Plan

Coding Best Practices

Regulation -- On January 15, 2009,

the HSS published a final rule

establishing ICD-10 as the new national

coding standard

Project Monitoring & Controlling

Develop ICD-10 Roadmap

Develop Project Schedule

Budget for Implementation

Costs

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------ MARCH !!

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Budget $$’s◦People◦Process◦Technology

◦Other…

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20

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POTENTIAL BUDGETING CATEGORIES

2010 2011 2012 2013 2014

PEOPLE (HUMAN RESOURCE)

# FTEs/ Contract Workers

Program Manager w/ Admin Support x x x x x

Staff to review payer contracts/ renegotiate

x x x

HIM temporary during cross over period

x x

PFS temporary during transition x x

PROCESSES (not including potential process improvement gains)

Assessment/ Gap Analysis (internal +/or external )

x x

Documentation Improvement x x x x

Dual Systems? X X

Decision Support /Home Grown System Remediation (and/or Translation Software)

X

Payer Integration and/or Readiness (mitigation)

x x x x

Communications to internal/ external constituents

X X X X

TECHNOLOGY X X X X

Vendor Systems (ICD-10fees? x x x

Vendor Interface charges? X X X

New Vendors? x

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An example of structural change

ICD-9

X X X XX.Category Etiology, anatomic site,

manifestation

X X X XX.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 16.Diabetes mellitus with neurological Manifestations type I not stated as uncontrolled

E 1 0 04

E 1 0 14

E 1 0 44

E 1 0 94

.

.

.

. 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

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ICD-9-CM821.01 Fracture of femur, shaft, closed

ICD-10-CMS72301A 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

ICD-9-CM 414.02 Coronary

atherosclerosis of autologous vein bypass graft

AND 411.1

Intermediate coronary syndrome

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ICD-10-CM I25.710 Atherosclerosis of

autologous vein coronary artery bypass graft(s) with unstable angina pectoris

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Character 1 Section

Character 2

Body System

Character 3 Root

Operation

Character 4

Body Part

Character 5

Approach

Character 6

Device

Character 7 Qualifier

MEDICAL AND

SURGICAL

RESPIRATORY EXCISION LOWER LOBE BRONCHUS, RT

OPEN NO DEVICE

DIAGNOSTIC

0(zero) B B 6 0(zero) Z X

ICD-10-PCS

Early Preparation A well-planned, well-managed

implementation process will increase the chances of a smooth, successful transition.

Experience in other countries has shown that early preparation is the key to success.

An early start allows for resource allocation, such as costs for systems changes and education, process evaluation and change, as well as staff time devoted to implementation processes, to be spread over several years.

Potential Consequences of Inadequate

Preparation: Decreased coding accuracy Decreased coding productivity Increased compliance risks Increased claims rejection An adverse impact on patient care and

administrative decision-making26

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Assess Readiness – What is your ‘Current State’?

Identify Barriers/Challenges/Expectations/Needs

Introduce end-users to change (Buy-In) Milestone ReCap – How do you know

you were successful?

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ICD-10 Steering Committee Comprehensive assessment (including gap analysis and IT

Systems-System Inventory)◦ Decision Support◦ Case Management◦ Utilization Review◦ Managed Care/Payer Contracts◦ Quality Department◦ Functional Areas that use ICD-9 codes today that need translation (i.e.

superbills?) 5010 Readiness Educational Needs Within Organization Documentation Assessment Claims analysis to identify top specialties impacted the most Vendor readiness testing Schedule Managed care/payer contract readiness Implemented education/documentation improvement plan for ICD-

10 ◦ CDI Program w/ I-10 Concepts

Identified top specialties and education to physicians Roadmap completed for implementation

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1. Organization-wide education/awareness of ICD-10 and synergies with other entities (e.g. ARRA, CMS, ONC, etc)

Do functional areas understand ICD-10 implications for planning?How well are these plans integrated with other Initiatives?

2. Steering CommitteeAre clinical, operational and functional areas included?

3. ICD-10 Strategy/Plan: Comply/Optimize (including payer contracting)Discussion-ICD-10 overall plan/strategy

Does the strategy include taking advantage of the granularity provided by ICD-10 for improvements?Are you modeling contracts to negotiate with payers?

Have you planned for or thought about the impact of payment delays?

4. Functional/IT Opportunities/GapsDoes the scope include external vendor readiness?

5. Interdisciplinary Project ManagementScope of IT Plan: Is this end to end across the continuum?

6. Vendor & Assessment/PartnershipWill vendors be ready and what potential interim measures might they use (e.g. translations/maps)?

7. Systems Integration (end to end; internal/external)How will you assess end to end integration, interim dual coding, potential dual storage w/ transparent functionality?

8. Detailed training - function specificDo you have a detailed matrix type training plan through 2013 including function specific detail?

9. Simulate, Test and Manage ChangesHow and when will you implement within a step-wise process?

Have you reviewed encounter forms or electronic charging documents?

10. ImplementationThis is only the start….

2013 +++ Post Implementation ImprovementHow might you optimize and improve clinical, operational and financial systems to benefit

from ICD-10 detail?

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Audience Topic

HIM/Coding/CDI Coding structure and rules; A&P*

Information Technology Interface, internal systems, & database impact

Finance/Auditors/Compliance/Consultants Impact on reporting, cost accounting, grouping & payment

Clinicians Proper documentation to capture specificity of ICD-10

Quality Impact on reporting, databases & cost accounting

Utilization Review Proper documentation to capture specificity of ICD-10; impact on reporting & databases

PFS ICD-10 Basics, Impact on grouping and payment

C-Suite Awareness Training…..

Patient Registration Proper documentation, impact on medical necessity & POA

Ancillary Departments/Staff Proper documentation to capture specificity of ICD-10

Tra

inin

g S

ugge

stio

ns

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1. The date is not set (‘rule making period’ 30-60days…)

2. Everyone will be affected3. Private and public health plans will not accept and

pay based on ICD-9 codes4. ICD-10 is not an ICD-9 maintenance update5. Automated conversions are not possible (forward &

backward mapping of codes)6. ICD-10 cannot wait for Electronic Health Records &

other health IT initiatives7. Must implement both 5010 and ICD-108. ICD-10 is more than a compliance activity9. Planning and implementation must begin now10. The first step is a comprehensive Risk Readiness

Assessment followed by an Impact Analysis

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Knowledge transfer/education – were you able to provide education to key leadership/teams staged according to fully integrated program plan development and execution?

Complete and accurate ICD-9 and ICD-10 codified data – are you able to assign the appropriate codes regardless if native or translated/converted?

Enterprise-wide gap and impact analysis – were you able to identify every point of impact across the hospital or integrated health system?

Fully integrated IT and other systems – did you address all systems currently containing ICD-9 codes across all hospital, vendor, payer and other integrated systems (electronic and other)?

Comprehensive internal and external communication strategy/plan – Did you successfully implement your plan – is everyone ‘in the know’?

Detailed contracts with other providers, payers and vendors – did you provide your vendors with clear identification of timing, integration and conversion/translation applications?

Comprehensive modeling and integrated functional testing – were you able to test the plan across the continuum of care?

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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/TransactionCodeSet

sStands/02_TransactionsandCodeSetsRegulations.asp

http://www.cms.gov/ElectronicBillingEDITrans/18_5010D0.asp

3M Solutions 2011