Better Late than Never: How to catch up with ICD-10-CM/PCS
Better Late than Never: How to catch up with ICD-10-CM/PCS in 2012 Or BGYBIG What Does it Really Take? Prepared by: Rose T. Dunn, RHIA, MBA, CPA, FACHE, FHFMA, FAHIMA ©2012 © 2010 Disclaimer • Information contained in this presentation has been presented at VHA, HFMA, AHIMA, and other professional and healthcare organization meetings. 2 © 2010 AGENDA • Brief overview of 5010 and its ties to ICD-10 • ICD-9cm vs. ICD-10cm • Department/Function Impacts and Considerations • What you need to do • Resources 3 © 2010 Where Are You? 1. Identified sponsor(s) and/or steering committee 2. Conducted awareness education 3. Started/completed system and other inventories 4. Vendor discussions underway 5. Testing upgrades for ICD-10 6. Initiated a new job search 4 © 2010 What You Need to Do 1. Champion/Steering Committee a) Senior leader(s) who will make organization wide decision b) Senior leader(s) who will remove roadblocks 2. Project Team a) YOU CAN’T DO IT ALL YOURSELF b) IT, HIM, CDI, PFS, CM, MD, Decision Support 5 © 2010 Another Federal Mandate Effective 10/1/2013 6 © 2010 Effective 10/1/2013 • Not dead, not going to die: Going full steam ahead – Well until Valentine’s Day came – AMA Spoke Up 7 © 2010 HHS Proposed Rule Published 4/9/12 • Buried in a Proposed Rule that includes: – Unique Health Plan Identifier and Other Entity Identifiers – Expanding the National Provider Identifier Requirements • Identifies that the delay will serve certain providers including physicians, small hospitals, trading partners, and vendors • Acknowledges that larger hospitals and payers have incurred costs to be prepared • Recognizes that the delay will cost providers, payers, and others estimated up to $6.5 billion © 2010 Whenever It’s Effective • Affects any provider who uses ICD-9 codes for billing or reimbursement purposes • All health plans must accept ICD-10 codes – Some may accept earlier 9 © 2010 For Purposes of This Session: ICD-10 Will Be Effective 10/1/2013 • Use any extra time to refine your processes © 2010 Significant Change • 33 years • 18 years • Failure to comply by 10/1/2013 may cause cash flow interruption or no reimbursement • Coding granularity • Major change in documentation requirements • Direct Tie to 5010 11 © 2010 5010 was Effective 1/1/12 • What is 5010? – The electronic data standards that allow healthcare organizations and health plans communicate with one another electronically 12 © 2010 5010’s Benefits &Tie to ICD-10 850+ changes Accommodates the attributes of ICD-10 codes • Allows for 25 diagnoses (up from 9 diagnoses) and 25 procedures (up from 6 procedures) – Severity and Complexity – Distinguish your care and outcomes from others 13 © 2010 What You Need To Do • Validate that your payers are accepting the 25/25 • Confirm your HIM coding team is taking advantage of the 25/25 • When: NOW © 2010 Healthcare Reform Other Internal Competing Projects Source: HIMSS 15 © 2010 Fiscal Contraints, Demand for the Same Labor, Competing Priorities will Stretch Your Existing Resources © 2010 What You Need To Do • Hold on to your existing resources • Staff upIt’s temporary; Attrition • Spice up your recruitment process • When: Now and through 2014 © 2010 Comparing ICD-9 & ICD-10 18 © 2010 ICD-9cm vs. ICD-10cm • International Classification of Diseases, 9 Edition, Clinically Modified for the United States (I-9) • I-9 since January 1979 – What’s the problem? 33 • Space limitations for new codes • Lack of detail • Inability to compare data internationally 19 © 2010 ICD-9cm vs. ICD-10cm/PCS • International Classification of Diseases 10th Edition (developed by WHO) – Clinically Modified for the US (I-10cm) and • Updated annually by National Center for Health Statistics – Clinically modified: Includes additional subsections – ICD-10CM = Diagnosis Coding System – Procedural Coding System (I-10 PCS) 20 © 2010 ICD-9cm vs. ICD-10cm/PCS • I-10 since 1994 – For Morbidity-99 countries and Mortality-138 countries – For Reimbursement/Case Mix: United Kingdom, Norway, Belgium, Finland, Iceland, Denmark, Sweden, France, Canada, Australia and Germany • US-Only industrialized country not using I-10 21 © 2010 ICD-9cm vs. ICD-10cm • 3 Volumes – Diagnosis – Procedure (v.3) – Index • Diagnosis – ~13,700 codes – Up to 5 characters – Alpha-Numeric • 3 Volumes – Diagnosis – Rules and Guidelines – Index • Diagnosis – ~70,000 codes 1:5 – Up to 7 characters – Alpha-Numeric • Not case sensitive – Placeholder “x” Source: MLN SE0832 22 © 2010 ICD-10cm ICD-9cm Comparing Attributes •496 – Chronic airway obstruction not elsewhere classified (NEC) •511.9 – Unspecified pleural effusion •V02.61 – Hepatitis B carrier •O9A●311 – Physical abuse complicating pregnancy, first trimester •S42.001A – Fracture of unspecified part of right clavicle, initial encounter for closed fracture Source: AHA I-10 Overview © 2010 One for All of Us •Z63.1: – Problems in relationships with In-Laws! •Z59.2: 24 – Problems in relationships with neighbors © 2010 What You Need To Do • Inventory reports – Customized • • • • Field length for ICD-10 descriptions 50250 Not high on the priority list When: April-June 2013 – System edits • Alpha characters throughout the code • When: During Testing (December 2012-August 2013 25 © 2010 Structure 3% to 30% • ICD-10 CM – – – – – Category (3) Etiology Anatomic Site Severity Extension • Pros • Cons ICD-9 ICD-10 26 © 2010 What You Need To Do • Ask the question! • When: NOW • Consider: – – – – Contracts Retention Bonuses Recruitment Grow your own 27 © 2010 Where Do You Find Those To Grow? • • • • • Permanent Light Duty Clinical Staff Military Medics Outpatient Coders Transcriptionists HIM Program Students • Assign to HR 28 © 2010 Specificity HAC or Potentially Preventable Condition/Event • 50 different codes for “complications of foreign body accidently left in body following a procedure” – ICD-9: only one code • Who is interested in this? Source: AHIMA ICD-10 Primer 29 © 2010 HAC/PPC-E Identification-20 Categories • Misadventures to patients during surgical and medical care (Y62-Y69) 6 (not 8) categories • Y62: care • Y63: • Y64: • Y65: • Y66: • Y69: Failure of sterile precautions during surgical and medical Failure in dosage during surgical and medical care Contaminated medical or biological substances Other misadventures during surgical and medical care Non-administration of surgical and medical care Unspecified misadventure during surgical and medical care 30 © 2010 Detail of Category Y62 Y62Failure of sterile precautions during surgical and medical care • • • • • • • Y62.0 Failure of sterile precautions during surgical operation Y62.1 Failure of sterile precautions during infusion or transfusion Y62.2 Failure of sterile precautions during kidney dialysis and other perfusion Y62.3 Failure of sterile precautions during injection or immunization Y62.4 Failure of sterile precautions during endoscopic examination Y62.5 Failure of sterile precautions during heart catheterization Y62.6 Failure of sterile precautions during aspiration, puncture and other catheterization • Y62.8 Failure of sterile precautions during other surgical and medical care • Y62.9 Failure of sterile precautions during unspecified surgical and medical care 31 © 2010 Detail of Category Y63 Y63Failure in dosage during surgical and medical care • Y63.0 Excessive amount of blood or other fluid given during transfusion or infusion • Y63.1 Incorrect dilution of fluid used during infusion • Y63.2 Overdose of radiation given during therapy • Y63.3 Inadvertent exposure of patient to radiation during medical care • Y63.4 Failure in dosage in electroshock or insulin-shock therapy • Y63.5 Inappropriate temperature in local application and packing • Y63.6 Underdosing and non-administration of necessary drug, medicament or biological substance – Y63.61 Underdosing of necessary drug, medicament or biological substance – Y63.62 Nonadministration of necessary drug, medicament or biological substance – Y63.8 Failure in dosage during other surgical and medical care – Y63.9 Failure in dosage during unspecified surgical and medical care 32 © 2010 Detail of Category Y65 • Y65 Other misadventures during surgical and medical care – – – – Y65.0 Mismatched blood used in transfusion Y65.1 Wrong fluid used in infusion Y65.2 Failure in suture or ligature during surgical operation Y65.3 Endotracheal tube wrongly placed during anesthetic procedure – Y65.4 Failure to introduce or to remove other tube or instrument – Y65.5 Performance of inappropriate operation – Y65.8 Other specified misadventures during surgical and medical care 33 © 2010 HAC/PPC-E Identification-20 Categories – Y70-Y82: Breakdown or malfunctioning of medical device (during procedure) (after implantation) (ongoing use) – Y83-Y84: Surgical and medical procedures as the cause of abnormal reaction of the patient, without mention of misadventure at the time of the procedure 34 ~115 codes in 20 categories © 2010 HAC/PPC-E Identification-20 Categories Y70-Y82: Breakdown or malfunctioning of medical device (during procedure) (after implantation) (ongoing use) • Y70 Anesthesiology devices associated with adverse incidents • Y71 Cardiovascular devices associated with adverse incidents • Y72 Otorhinolaryngological devices associated with adverse incidents • Y73 Gastroenterology and urology devices associated with adverse incidents • Y74 General hospital and personal-use devices associated with adverse incidents • Y75 Neurological devices associated with adverse incidents • Y76 Obstetric and gynecological devices associated with adverse incidents • Y77 Ophthalmic devices associated with adverse incidents • Y78 Radiological devices associated with adverse incidents • Y79 Orthopedic devices associated with adverse incidents • Y80 Physical medicine devices associated with adverse incidents • Y81 General- and plastic-surgery devices associated with adverse incidents 35 • Y82 Other and unspecified medical devices associated with adverse incidents © 2010 What Do You Need To Do • Look back at your existing experience • Expect an expansion of HACs from all payers – Lower Reimbursement • • • • High Transparency Anticipate the Ambulance Chasers Consider a financial reserve When: August 2012-October 2012 (Budget) © 2010 What You Need to Do 1. Risk Management and Clinical Teams need to address exposure 2. Revenue impact needs to be addressed • Steering Committee or Sub Committee 3. How will coders obtain information 4. Compliance involvement? 37 © 2010 General Equivalence Mappings (GEMS) • ICD-9 to ICD-10 • ICD-10 to ICD-9 38 © 2010 GEM Excerpt 1-1 ICD-9 • • • • • • • • • • • • 2229 2230 2231 2232 2233 22381 22389 2239 2240 2241 2242 2243 ICD-10 D299 D3000 D3010 D3020 D303 D304 D307 D309 D3140 D3160 D3150 D3100 ICD-9 to ICD-10 Source: http://www.cms.hhs.gov/ICD10/ 39 © 2010 One to One Source: CMS GEMS 40 © 2010 ICD-9 to ICD-10 GEMS 1 to Many • • • • • • • • • • • • ICD-9 24950 24950 24950 24950 24950 24950 24950 24950 24950 24950 24950 24950 ICD-10 E09311 E09349 E0939 E0936 E09359 E09351 E09341 E09339 E09331 E09329 E09319 E09321 • • • • • • • • • • • • ICD-9 24951 24951 24951 24951 24951 24951 24951 24951 24951 24951 24951 24951 Source: http://www.cms.hhs.gov/ICD10/ ICD-10 E09341 E09351 E0939 E09359 E09349 E09331 E09329 E09311 E09321 E0936 E09319 E09339 41 © 2010 Specificity -- Cause • ICD-9-CM: Aphasia due to previous CVA. 438.11 • ICD-10-CM codes: – I69.020…Aphasia following non-traumatic subarachnoid hemorrhage – I69.120…Aphasia following non-traumatic intra-cerebral hemorrhage – I69.220…Aphasia following other non-traumatic intra-cranial hemorrhage – I69.320…Aphasia following cerebral infarct – I69.820…Aphasia following other cerebro-vascular disease – I69.920…Aphasia following unspecified cerebro-vascular disease 42 © 2010 Example – One-to-Many; Laterality Fracture of femur… ICD-9-CM ICD-10-CM S72.001A – Fracture of unspecified part of neck of right femur, initial encounter for closed fracture 820.8 – Fracture of unspecified part of neck of femur, closed S72.002A - Fracture of unspecified part of neck of left femur, initial encounter for closed fracture S72.009A - Fracture of unspecified part of neck of femur [unspecified], initial encounter for closed fracture Unspecified exists in ICD-10 43 © 2010 Examples – Combination Codes Diabetes Codes in ICD-9 Diabetes Codes in ICD-10 249.70 - Secondary diabetes mellitus with peripheral circulatory disorders, not stated as uncontrolled 785.4 - Diabetic gangrene 443.81 - Diabetic peripheral angiopathy E09.52 - Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy with gangrene 250.60 - Diabetes with neurological manifestations, type II or unspecified, not stated as uncontrolled 355.9 - Mononeuritis of unspecified site E11.41 - Type 2 diabetes mellitus with diabetic mononeuropathy 249.40 - Secondary diabetes mellitus with renal manifestations , not stated as uncontrolled 585.9 - Chronic kidney disease, unspecified E08.22 - Diabetes mellitus due to an underlying condition with diabetic chronic kidney disease http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_038084.hcsp?dDocName=bok1_038084 44 © 2010 GEMS Fog ICD-10 J869 J90 J90 J910 J918 J920 ICD-9 ICD-10 to ICD-9 5109 5119 51189 51181 5119 5110 http://www.cms.hhs.gov/ICD10/ 45 © 2010 New Clinical Concepts Inclusion of clinical concepts that do not exist in ICD9-CM T45.526D, Underdosing of antithrombotic drugs, subsequent encounter Z67.40, Type O blood, Rh positive Trimesters rather than episodes of care NO MATCH Recognize the limitations 46 © 2010 When Will You Use the GEMS? • Transitional – – – – Trended Data Preparing for Managed Care Contract Negotiations Converting Forms with ICD-9 codes Identifying Documentation Opportunities • When: Now through 2014 47 © 2010 Start Your Internal Comparison Mapping between I-9 and I-10 www.cdc.gov/nchs/about/otheract/ICD9/ICD10CM.h tm CM http://www.cms.gov/ICD10/11b14_2012_ICD10C M_and_GEMs.asp#TopOfPage PCS http://www.cms.gov/ICD10/11b15_2012_ICD10PC S.asp#TopOfPage 48 © 2010 What You Need to Do 1. Look at top 10-30 conditions by patient care area or physician practice (map to ICD-10) a) Define the documentation requirements b) Assess documentation weaknesses i. Case review c) Address through documentation improvement 2. When: June 2012-August 2012 (templates) 49 © 2010 What You Need to Do: Physician Offices • Look at your superbills for your common Diagnoses • Update the superbills – Examples at AHIMA.org/ICD10 – Assume 2 pages • When: July 2013-August 2013 (training) 50 © 2010 NCPD Recommendation • National Coalition of Pharmaceutical Distributors – Effective 3/1/2013 – E-Prescriptions sent to Retail Pharmacies • Include an ICD-10 Code 51 © 2010 What You Need to Do • Ask your pharmacist to do some research • Check with your e-prescribing application vendors • Figure out how you’re going to be I-10 Ready 7 months before you need to be! • When: Now….until? 52 © 2010 ICD-10cm-PCS Procedure Coding System • Procedure – Up to 4 digits – Numeric – ~3,800 codes • ICD for Inpatient Procedures • CPT for Outpatient and Physician Services • Procedure – Up to 7 characters – Alpha Numeric • Not case sensitive 1:18 – ~72,000 codes • ICD-PCS for Inpatient Procedures • CPT for Outpatient and Physician Services 53 © 2010 Comparing Attributes ICD-9 V. 3 • 43.5 – Partial gastrectomy with anastomosis to esophagus • 44.42 – Suture of duodenal ulcer site • 0FB03ZX – Excision of liver, percutaneous ICD-10 PCS approach, diagnostic • 0DQ107Z – Repair, esophagus, upper, open with autograft • No decimal point 54 Source: AHA ICD-10 Overview © 2010 Structure ICD-10-PCS-Each position of the code has a specific meaning › › › › › › › Section Body System Root Operation Body Part Approach Device Qualifier 55 © 2010 Documentation • Procedure specificity – Operative Reports Source: Ann Zeisset 2010 56 © 2010 Specificity Comparison Source: AHA ICD-10 Overview 57 © 2010 What You Need to Do 1. Identify top 10-30 surgeries (Map to ICD-10) a) Define the documentation requirements b) Assess documentation weaknesses i. Case review c) Address through documentation improvement 2. When: June-August 2012 58 © 2010 What You Need to Do 1. Review reports (customized) a) b) c) d) Size of field System edits for decimal point System edits for alpha numeric characters Testing plan 2. When: April-June 2013 59 © 2010 What Do We Need To Do • • • • Identify sources of documentation Link to other documents Auto-populate Physician authentication • When: June-August 2012 (templates) 60 © 2010 What and Where Hospital Inpatient Outpatient (Hospital/Office) ICD-10 CM for diagnoses ICD-10 CM for diagnoses ICD-10 PCS for procedures CPT-4 for procedures DSM IVDSM5 for Behavioral Health DSM IVDSM5 for Behavioral Health ICD-O for Cancer Registry ICD-O for Cancer Registry Source: First Class Solutions 61 © 2010 Resources • Complete Versions of ICD-10-CM and ICD-10PCS • Available at: www.cms.gov/ICD10 62 © 2010 Are There Any Benefits? Increased granularity › Improve cost analyses within organization › Improved resource utilization management › Enhances ability to compare to others Volume Cost Morbidity/Mortality › Facilitates identifying quality improvement opportunities › Improved revenue stream as a result of documentation improvement › Enhances disease management and development of protocols › Supports Meaningful Use CQMs › Facilitates strategic positioning and contracting value discussions (innovative contracting) 63 › Facilitates epidemiological and bio-surveillance activities © 2010 What You Need to Do 1. Direct the Steering Committee to evaluate impact and how to collect and utilize the data effectively 2. When: Now until….. 64 © 2010 Education across the organization • • • • • • • • • • • Coders (hosp./phys. Off.) Other HIM staff Case Management Clinicians MDS Coordinators Senior Management Information Systems QM/PI Utilization Review Accounting Patient Financial Services • Clinical Department Managers • Documentation Improvement Professionals • Data Analysts • Home Health • Researchers • Epidemiologists • Software Vendors • RM and Compliance • Data Quality/Security • Decision Support • Access/Ancillary Registrars Source: Adapted from AHIMA 2007: http://www.ahima.org/icd10/ICD-10PreparationChecklist.mht 65 © 2010 Education….but when? • Physicians—documentation: Sooner than later • Case Managers and CDI Specialists: Sooner than later • Coders: – Refresher coursework: 2012 (all year) – ICD-10 Specific EducationLate 2012/early 2013 • Ideal if both codes can be captured in system • Give some history in your decision support data bases • Role-based: One size does not fit all 66 © 2010 Coder (CDI, Some Physician Office Staff, Others) Education • First: Refresher courses: Anatomy, Physiology, Pharmacology, Pathophysiology, Surgical Procedures, Surgical Devices • Then: ICD-10: 6-10 days for experienced coders (for both I-10cm and PCS) • For understanding the structure • Coder learning curve (6+ months) • DNFB • Loss of coders • Contract coders 67 © 2010 What You Need to Do 1. Conduct a Skills Assessment – When: Yesterday 2. Consider refresher training needed a) b) c) d) e) A&P Pharmacology Pathophysiology Medical terminology Surgeries/Surgical Devices a) When: 12 months Now-March 2013 68 © 2010 What You Need to Do 3. Consider training options a) Using internal staffs (Pharmacist, Surgeons/OR team, Educator) b) Using You Tube c) Community colleges/technical schools d) Apprentice programs e) College f) On-line programs g) State/professional associations h) Professional journals i) Sharepoint/websites j) Surgical supply firms 69 © 2010 What You Need to Do 4. Consider direct training hours and backfill a) b) c) d) e) Basic: Awareness ~2 hours Moderate: 4 hours Detailed: 40 hours GEMs: 8-10 hours Physician: 4 hours How best to do physician training One on One? Groups or Medical Staff Meeting? NOT 70 © 2010 Coding Time/Productivity • Additional labor time projected by CMS-up to 2 minutes additional for each encounter • 24 inpts/day to 22 inpts/day • However………….. Just the facts 71 © 2010 AHA/AHIMA’s Productivity Study Record Type ICD-9cm Minutes ICD-10cm Minutes Short-term Acute Care Inpatient 8.99 15.99 Short-term Acute Care Outpatient 4.18 9.03 Clinic/Community Health Center 2.42 5.05 Physician Practice 3.04 6.70 Free Standing Ambulatory Surgery Center 2.22 4.62 Home Health/Hospice 10.76 13.31 Nursing Home 6.71 12.99 Long-term Care Hospital Inpatient 18.22 28.74 Rehabilitation Facility 4.97 10.94 Behavioral Health Inpatient 6.33 12.89 Behavioral Health Outpatient 3.08 9.71 “ICD-10-Field Testing Project. Report on Findings: Perceptions, Ideas and Recommendations from Coding Professionals Across the Nation” 72 © 2010 Lessons Learned from Canada Source: ICD-10 Lessons Learned from Canada 12/09 ICD-10 Task Force 73 © 2010 What You Need To Do • Ensure Coders Practice • Evaluate other coding productivity enhancement tools: CAC, Get rid of the non-coding duties • Identify other physician documentation enhancement tools: Slang translators, Intelligent Dictation, etc. • When: July 2012 until…. © 2010 It’s All About the Data • Meaningful Use, PQRI, CQMs • ICD-10 data will drive clarity in outcome definitions • ACOs-Outcomes-Value based purchasing • ICD-10 coding is dependent upon physician documentation 75 © 2010 Documentation: Baseline Assessment • What condition is your documentation in today? • Share findings with clinicians – Physician champion and coding leadership address findings with clinical service meetings • Monitor efforts to change documentation practices 76 © 2010 Assess Documentation • Which diagnoses now are source of queries • Identify top 30 diagnoses and top 30 procedures • Convert (Map) diagnoses and procedures to ICD-10 and identify the details required • Create drop-down ladders to accurately define the top diagnoses and procedures using EHR’s drop downs • Review documentation to determine if documentation supports ICD-10 diagnoses/procedures (all fields) • Segregate issues by physician and specialty • Physician champion and coding leadership address findings with clinical service meetings • When: August 2012---until 77 © 2010 Queries • The Medical Staff will: – Experience more queries for clarification • Helpful Options: – Short form documents (H&Ps and Discharge Summaries) discontinued? – Dictated reports (increased expense) – Templated documents will require more qualifying components (drop down selections) • ADR invitations 78 © 2010 Today vs. Tomorrow Today House Tomorrow Two story house with Rough sawn cedar siding 3500 square feet All electric Source: First Class Solutions, Inc. 79 © 2010 Staffing • Alert Human Resources – More staff in certain areas: Case Management, Clinical Documentation Improvement, Coding, Access, Physician Offices, IT, PFS • Temporarily? Permanently? • Consider light duty staff 80 © 2010 What You Need to Do • Decide when new staff will be added – JIT • Will they exist • September 2012…. • Recognize your competition – Other Providers --Payers – Vendors --Others • Contracts/Retention Bonuses – When: Now (Lock ‘em in) • Apprentice Program – When: Now (12-16 months) 81 © 2010 Payers • Same HIPAA Mandate – By 10/1/2013 • 5010 by 1/1/2012 – More detailed data on all providers – Profiles will be more specific • Including quality evaluations (P4P) 82 © 2010 Healthcare Reform Source: HFMA 3/31/10 83 © 2010 Payers • System changes – Phase In – Testing • Adjudication challenges – Two coding systems in use during transition for claims “before” and “after” • “Potential” reduction of “attachments” • Facilitate validating “medical necessity” 84 © 2010 Payers • Will Medicaid be ready? • Not Required to use I-10 – Workers Compensation – Automobile Insurance (no fault) • 8-12 month overlap period for claims to clear your system • How many coding databases will be required to be maintained? – Consider complexity of claim edits 85 © 2010 What You Need To Do • Inventory and Contact Payers – When will they be ready for ICD-10? – When will you be able to test their readiness? – How will they pay you when you submit ICD-10 codes? (reverse map) – When will new Advisories and LCDs/NCDs be issued – Will Medicaid be ready – Will state Workers Comp accept 5010/ICD-10 • When: April 2012-June 2012 86 © 2010 Managed Care Contracts • Contracts: – Any based on DRGs? – Any fee schedules based on I-9 codes? • Need to map DRGs/Codes and align healthcare costs to ICD-10 – Anticipate educating Provider Relations Contract staff – Start re-negotiating no later than 1Q2013. • Need data • Dual coding in 2012/2013 87 © 2010 What You Need to Do 1. Understand your managed care contracts a) Inventory the contracts i. Understand the basis for payment ii. Define renegotiation activity required b) Prepare for potential mapping efforts 2. When: May 2012-July 2012 88 © 2010 MS-DRG Conversion Project • HHS MS-DRGs conversion to I-10cm – http://www.cms.gov/ICD9ProviderDiagnosticCodes/ 03_meetings.asp#TopOfPage – http://www.cms.gov/ICD10/17_ICD10_MS_DRG_ Conversion_Project.asp • Which diagnosis to choose to trigger principle diagnosis Which Dx/Px? 89 © 2010 MS-DRGs mapped to ICD-10 ICD-10 MS-DRG conversion project website -- new information now available • The ICD-10 Medicare Code Editor v27 and a text version of the ICD-10-CM/PCS Medicare Severity-Diagnosis Related Group (MS-DRG) v28 Definitions Manual are now posted on the Centers for Medicare & Medicaid Services (CMS) website at http://www.cms.gov/ICD10/17_ICD10_MS_DRG_Conversion_Project.asp in the “Downloads” section. There are also links to order the MS Grouper with Medicare Code Editor ICD-10 Pilot Software Version 28 on CD-ROM from National Technical Information Service (NTIS) in the “Related Links Outside CMS” section of the Web page. • This update is part of the ICD-10 MS-DRG conversion project. In the conversion project, CMS is using the General Equivalence Mappings (GEMs) to convert CMS payment systems. CMS is sharing information learned from this project with other organizations facing similar conversion projects. Please note that the final ICD-10 MS-DRGs will be subject to formal rulemaking. • 3/17/11 First Coast 90 © 2010 Contract Management Software • Is vendor/application ready to accept new codes? • Allow more than 1 contract per payer for different years and store ICD-9 and ICD-10 codes? • Staffing efforts required to ensure payments are made correctly after new codes are initiated 91 © 2010 Physicians/Other Providers • ICD-10cm ONLY • Continue to use CPT for services • Revise Superbills/Encounter Forms – http://www.ahima.org/icd10 • Coding Education – Billing – ABNs 92 © 2010 Physicians/Other Providers • More SPECIFICITY in coding – Enhance profile/severity index – Profiles will be more specific and transparent • Including quality evaluations (P4P) – Facilitates research – Facilitates “medical necessity” checking • 5010 may help on physician office denials – If they document and code the cases • Documentation education 93 © 2010 What You Need To Do • Assess Physician Office Documentation – Identify 25 most common diagnoses – Map to ICD-10 – Assess whether documentation would support complete coding – Address findings with practitioners • One on one • When: June-July 2012 (templates) 94 © 2010 Physicians/Other Providers • Practice Management Software updates (all installed?) • Clearinghouse readiness • Less demand for attachments--Later • Fee schedule changes-minimal – (CPT driven) • Reimbursement changes-?major--Profile • Report changes 95 © 2010 What You Need To Do 1. Find out if your owned physician practices have updated their software 2. Contact software vendor for readiness 3. Contact clearinghouse for readiness 4. Schedule upgrades 5. Schedule testing 6. Update superbills/encounter forms and requisitions 7. Schedule training for physician office staff a) Your cost or theirs? 8. Buy educational resources for the office – When: Throughout 2012 96 © 2010 Access/Patient Financial Services • Forms – Facesheet fields • ABNs – Education (Access, Lab, Cardiology, Radiology) – Updated LCDs/NCDs • Clearinghouse readiness – Claim transaction sets • UB-04 and CMS-1500 – Already incorporated larger fields and indicator for I-9 vs. I-10 97 © 2010 Access/Patient Financial Services • Access or Scheduling’s use of I-10 to validate eligibility, pre-certs/auths, and verification • Anticipate delayed or lost payments • Contract management system changes – Accommodate both coding systems • Billing system modifications (larger and alpha numeric fields) • Impact on A/R due to “attachments” and potential lack of readiness by the Payers • CDM (embedded ICD-9 Procedure Codes) 98 © 2010 Decision Support and Information Technology 99 © 2010 Decision Support/IT • Assessment and Inventory House of Y2K – Which systems capture, store, use: • ICD codes • ICD descriptions – – – – Databases Standalone Research Interfaces When: April 2012July 2012…. • EHR (does it use ICD-9 to trigger alerts, rules, reminders etc.) • Credentialing data modifications 100 © 2010 Don’t Forget • Third party products integrated in your information system – ABN applications When: AprilJuly 2012 • Web-based applications – Code Look Ups – Eligibility 101 © 2010 Decision Support/IT • Updates will require coordination with: – Application/System vendors – Payers • Parallel systems to accommodate phasing in of Payer Modifications – External Data Exchange Entities • Field sizes (Character Attributes) – Printed reports 102 © 2010 Decision Support/IT • Management Reports-Mapping – – – – Top 25 DRGs Cost Reports-Analytics Cancer Registry Managed Care, Grant, Registry Analyses • Mapping effort [When: 2013-2014] – Between various systems – Between historical records using I-9 • Data repositories – Use a dual-code strategy 103 © 2010 Information Systems • IT Can’t Do “It” Alone: – Need an organization wide approach – Need a cross-functional team • Prioritize and Test system upgrades • Modify Interfaces • When: December 2012-August 2013 – Build test environment October 2012-December 2012 104 © 2010 Information Systems • Consider I-10’s impact on any new systems or applications being considered – Add question to capital request process – Query vendors – Delay new applications? 105 © 2010 Systems Likely to be Affected • • • • • • • • • • • • • • • • Encoders Case mix Medical record abstracting Billing systems DRG/HHRG/Rehab grouper Scrubbers Registration and scheduling systems Advance Beneficiary Notice software Financial applications Claim submission Decision support Clinical Applications Utilization Management Quality Management Pharmacy Clinical Documentation Integrity • • • • • • • • • • • • • • • Cost accounting Case management Clinical protocols Test ordering Clinical reminder Performance measurement Disease management Provider profiling Compliance checking Aggregate data reporting Registries-State and Internal State reporting UHDDS Managed Care Eligibility Patient assessment data sets (e.g. MDS, PAI, OASIS) Managed Care reporting (HEDIS) Adapted from: AHIMA 2007 Checklist www.AHIMA.org/ICD10 106 © 2010 Vendor Assessment • Check with vendor on their readiness (See AHIMA website for sample Vendor Letter) – When: May 2012….until they answer! • Will the update be part of the standard maintenance contract? (regulatory change) – When: Now • Renewing contracts – Price tags for updates – Timetable for testing • Will there be any charges for interface changes or testing? • Will vendor offer any education? 107 © 2010 Don’t Forget! • Trading partners (external data exchange entities-EDEEs) – Send data to: – Receive data from: • • • • • • • Registries Providers’ billing services Contract coders/registrars Reference laboratory State DOH Physician offices Etc……. • Interface changes/costs • Testing 108 © 2010 Information Technology Considerations • Additional staff for: – – – – – – Inventory effort Implementation/Updating efforts Multiple systems -- parallel period Testing Mapping ??? 109 © 2010 Next Phase of IT Mega-Expenditures • I-10 • ARRA-EHR Incentives 2009-2013 2011-2015 110 © 2010 Next Phase of IT Mega-Expenditures • I-10 • ARRA-EHR Incentives 2009-2013 2011-2015 111 © 2010 What will this cost you? • Look at Your Y2K History – AHA est. $8.2 Billion in 1999 for Y2K Source: www.milbank.org/reports/990725y2k.html 112 © 2010 What will this cost you? • Human – – – – – – – – – Steering committee Inventory/Investigation Implementation team Vendor management System modification Parallel testing/Validation Conversion team Education Back up resources-Coding, Access, IT, PFS, Documentation Improvement, Case Mgmt – Data conversion – Consultant Services • Non-Human – New interfaces – New modules/updates (not covered by contract) – More robust hardware – Replacement of systems no longer supported – DNFB/Cashflow – Mis-adjudication efforts-delayed payments – Books/reference materials – Reprinting of superbills, LCDs, NCDs – Encoders (if non-existed) – Bugs…. See AHIMA & HIMSS Resource too 113 © 2010 What will it cost? • HayGroup White Paper (10/12/06) by Thomas Wildsmith – 400+ beds $500,000-$2,000,000 – 200-400 beds $250,000-$1,000,000 – 100-200 beds $150,000-$500,000 – <100 beds $ 35,000-$150,000 ================================================== – 21+ Physician Group $50,000-$100,000 – 11-20 Physician Group $20,000-$40,000 – 6-10 Physician Group $10,000-20,000 – 3-5 Physician Group $ 5,000-$10,000 – 1-2 Physician Group $ 2,000-$8,000 114 © 2010 At the Physician Office 2008 http://nachimsonadvisors.com/Documents/ICD-10%20Impacts%20on%20Providers.pdf 115 © 2010 Owned Practices •Will you adjust physician contracts to address the extra effort? © 2010 Monitor Impacts • Baseline 10/1/12 or 1 Year Prior--Document: – – – – – – Coding productivity DNFB Average Days in A/R CMI Days in Cash On Hand Denials 117 © 2010 Insurers • • • • Small plans (<1M members): Medium Plans: Large Plans(>5M members): Per Member: $99 million $293 million $1.3 billion – Small Plans: $38/per member – Large Plans: $11/per member • Cost will trickle back to all of us in premium increases Source: www.ahip.org/SurveyICD-10CostsSept2010/ 118 © 2010 What We’re Hearing • $1-$2 million for every 100 beds 119 © 2010 Budgeting • Time to inventory systems, interfaces, trading partners (the initial gap analysis) • Time and Cost to Build Test System • Time to Install and Test System upgrades • Time/Cost to Modify and Test Interfaces • Cost of upgrades • Implementation fees • Additional Staff and Backfill 120 © 2010 Budgeting • • • • • Integrated Testing Replacement Systems Modifying Reports Coder assessment and refresher education ICD-10 Education – Role based • Initial ICD-10 system glitches 121 © 2010 Budgeting • • • • • • • Loss of staff/Developing new staff Physician training Update and Reprint Superbills Encoder upgrade Consider CAC Documentation Reviews DRG Shift Analysis 122 © 2010 Budgeting • • • • • Denials, HACs, PPC-Es DNFB Days in A/R Increased litigation Increased labor – – – – Attachments Verifying payments Edits/rejections Coding 123 © 2010 AHIMA/HIMSS Tools 124 © 2010 HIMSS/AHIMA Tools 125 © 2010 Entire Organization Make A “To-Do” List! 126 © 2010 What You Need to Do • Appoint Steering Committee • Appoint Project Team • Provide General Awareness Education – To whom? • _________________________ • _________________________ • _________________________ • Communication Plan – PR • Medical Staff • Employees 127 © 2010 What You Need to Do • • • • • Evaluate maintenance contracts Evaluate managed care contracts Itemize upgrades (system and interfaces) Itemize system replacements/terminations Delegate! – Contact Vendors – Contact Payers – Contact Trading Partners 128 © 2010 Entire Organization Impacted • Checklist (Resources) • Budget • Anticipate some chaos – Work disruptions • Fees for updates and/or mapping applications • Conversion resources – Staff for installing updates – Staff for testing updates – Labor to maintain parallel systems 129 © 2010 Entire Organization Impacted • Billing/Clearinghouse rejections – DNFB/Accounts Receivable • Education costs and time • HHS anticipates significant short-term productivity losses during the first 6 months of implementation – DNFB/Accounts Receivable 130 © 2010 ICD-10 – 532 days (+?365) 131 © 2010 On the horizonICD-11 • ~2015-2019 worldwide • US clinical modifications – ~2020 132 © 2010 Fast Forward • If the delay doesn’t occur – Use the AHIMA-HIMSS Document • If the delay does occur……. © 2010 To Do: 2012 • Implement coding apprentice program (Grow Your Own) • Refresher education for coders • Study CAC • Build your test environment – Populate with upgrades when available • Vendor and payer readiness defined 134 © 2010 To Do: 2012 • Modify maintenance contracts • Modify managed care contracts – Do mapping efforts (different DRGs) • Analyze your DRG exposure – Intensify your documentation improvement efforts (ALL payers) – Modify templates, drop downs to ease documentation pressures – Acquire HLI, IMO and other physician friendly documentation software • Use of IMO (cross links vocabularies) and HLI (Health Language-mapping of SNOMED to ICD codes) to assist physicians to select the correct code 135 © 2010 To Do: 2013 • Continue to monitor Payer, Vendor, & Trading Partner readiness • Modify interfaces and test • Schedule your upgrades and tests with vendor – Sooner than later • Schedule your tests with payers – Sooner than later © 2010 To Do: 2013 • Obtain LCDs from Medicare and Advisories from Commercials – Assess your exposure for outpatient denials • Validate Medicaid’s readiness – Develop plan for Medicaid’s non-readiness • Develop plan for Workers Comp and Motor Vehicle Insurers • Assess readiness for CAC – Install if appropriate • Evaluate Intelligent Dictation Systems 137 © 2010 To Do: 2013-2014 • Acquire additional coding staff (employed/contracted) • Late 2013: Trading partner readiness defined – Schedule testing in 2013 with trading partners • Late 2013: Install latest grouper and software in Encoders – ICD-10 ready? – Training – Bookshelf resources (anatomy, devices, drugs, etc.) • Late 2013 or early 2014 – ICD-10 Education for Coders and CDI – Practice Coding • Coders to code 5 records per week using ICD-10 • Mid 2014: ICD-10 Education for others (Access, Scheduling, etc.) 138 © 2010 To Do: 2014 • Reassess readiness for CAC and Intelligent Dication Systems…and….implement if indicated • Continue adding any new upgrades and testing • Test interfaces between systems and with trading partners • Testing with payers • Update contract management system • Educate PFS on revised managed care contracts • Ready by 8/1/14! • Go Live 10/1/14! 139 © 2010 Questions Check out the resources >> © 2010 Resources • Preparing for ICD-10 Checklist: http://library.ahima.org/xpedio/groups/public/documents/ahima/bo k1_048737.pdf • Medicare Learning Network (MLN) Matters-SE 0832, 10/3/08, CMS • ICD-10 Overview, CMS http://www.cms.hhs.gov/ContractorLearningResources/Downloads /ICD-10_Overview_Presentation.pdf • ICD-10 Implementation-What’s Next, AHIMA http://www.ahima.org/icd10/documents/Implementation.pdf • Webinar-AHIMA http://www.ahima.org/icd10/index.asp • AHIMA Study http://www.ahima.org/icd10/documents/FinalStudy_000.pdf. 141 © 2010 Resources • Barta, A., et al. “ICD-10 Primer.” Journal of AHIMA 79, no.5 (May 2008): 64-66. • Where to look for ICD-10 Guidance & Info.: – AHIMA • http://www.ahima.org/icd10/index.html – AHA • http://www.ahacentraloffice.com/ahacentraloffice_app/I CD-10/ICD-10.jsp • HIPAA Code Set Rule: ICD-10 Implementation (An Executive Briefing) – HIMSS (ICD-10 and 5010)-Budget Thoughts • http://www.himss.org/ASP/topics_FocusDynamic.asp?f aid=220 • Training Recommendations – http://www.ahima.org/icd10/role-based-model.html 142 © 2010 ICD-9cm vs. ICD-10cm Resources • Medicare dedicated webpage to ICD-10: – http://www.cms.gov/ICD10 • Medicare’s training manual – http://www.cms.gov/ICD9ProviderDiagnosticCodes/08_IC D10.asp • AHA and AHIMA have dedicate webpages as well – www.AHIMA.org/ICD10 – www.AHAcentraloffice.org • Clinical Modifications: http://www.cdc.gov/nchs/icd9.htm 143 © 2010 Speaker Information Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, FAHIMA Rose.Dunn@FirstClassSolutions.com First Class Solutions, Inc. St. Louis, MO (800) 274-1214 144 © 2010
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