ICD-10 Changes Everything in the Revenue Cycle

1
ICD-10 Changes Everything in the Revenue Cycle

• Presented by
• Day Egusquiza, President
• AR Systems, Inc.
• Karen Kvarfordt, RHIA, AHIMA ICD-10 Certified
  Trainer
• President, DiagnosisPlus, Inc.

2
ICD-10 Implementation

• WHO ?
• What ?
• When ?
• Why ?
• How ?

3

• Its on your doorstep! The biggest change to
  happen in Health Information Management and
  Revenue Cycle in more than 30 years.
• Preparation is the KEY!
• Will you be ready?

4
ICD-10

• WHO (World Health Organization) owns publishes
  ICD (International Classification of Diseases).
• WHO endorsed ICD-10 in 1990 members began using
  ICD-10 or modifications in 1994.
• U.S. is only industrialized country not using
  ICD-10, for morbidity reporting (coding diseases,
  illnesses, injuries in a healthcare setting).
• The U.S. has used ICD-10 for mortality reporting
  (coding of death certificates by Vital Statistics
  offices) since 1999.

5
Countries Using ICD-10 For Case Mix

• United Kingdom (1995)
• Denmark, Finland, Iceland, Norway, Sweden (1994
  1997)
• France (1997)
• Australia (1998)
• Belgium (1999)
• Germany (2000)
• Canada (2001)
• U.S. (2015) (Reimbursement Case Mix HIPAA
  Standard Transaction, 2003)
• Thats
  why!

6
Coordination Maintenance Committee

• ICD-9-CM Coordination and Maintenance Committee
  is made of 4 parties
• National Center for Health Statistics (NCHS)
  responsible for diagnoses (Volumes 1 2)
• Centers for Medicare and Medicaid Services (CMS)
  responsible for procedures (Volume 3)
• American Hospital Association (AHA)
• American Health Information Management
  Association (AHIMA)

7
CMS grants Part B/provider 1 yr transition period
with provisions

• CMS granted Part B/provider 1 year transition
  period for Medicare and Medicaid claims.
• Conditions
• Denials not made based solely on dx as long as
  the code is in the family of codes.
• No penalty for the provider in the Quality
  reporting/Value based as long as code is in the
  same family of codes.
• If payment is disrupted during the transition,
  CMS will advance payments.
• CMS will establish a communication center (ICD 10
  Ombudsman) devoted to triage doctor issues.
• Will all payers allow this 1 year transition for
  Part B?
• When requesting ICD 10 specific codes for
  hospital claims push back?

8
Why Should We Do ICD-10?

• What is the benefit to the provider?
• Dramatic improvement in the assignment of costs
  to procedures performed.
• ICD-10 will allow us to develop meaningful
  estimates about what a disease state or a
  procedure costs us, while ICD-9 is limited in
  what it can do in this regard.
• Identify opportunities to avoid cost improve
  lives.
• Additional information in an ICD-10 diagnosis
  code includes severity and specific comorbidity,
  but it can also include information about
  demographics and some of the underlying reasons
  for the diagnosis.

9
Additional Benefits

• Share higher-quality data with other health care
  providers.
• ICD-10 increases the amount of specific
  information in every diagnosis code and makes
  this more valuable to other providers.
• For example, ICD-9 has a code for laceration of
  an artery.
• ICD-10 lets you know if that artery was in
  someones finger or in their heart.

10

• Reimbursements will better align with activity
  cost.
• Payers will reimburse severe complex cases
  better and simple cases at lower rates.
• How? By the diagnosis codes!

11
Heres an Example

• Imagine you had a patient who was noncompliant
  with their medical therapy.
• In ICD-9, the only code we have available is
  V15.81 (personal history of noncompliance with
  medical treatment).
• Is the patient noncompliant because of their own
  personal reason? Or something else?

12
How Will it Look in ICD-10?

• Z9111 (Patients noncompliance with dietary
  regimen)
• Z91120 (Patient's intentional underdosing of
  medication
• regimen due to financial
  hardship)
• Z91128 (Patients intentional underdosing of
  medication
• regimen for other reason)
• Z91130 (Patients unintentional underdosing of
  medication
• regimen due to age-related
  debility)
• Z91138 (Patients unintentional underdosing of
  medication
• regimen for other reason)
• Shows whether or not the patients noncompliance
  was intentional, but also identifies if the
  patient needs some form of assistance from social
  services, etc.

13

• What is ICD-10-CM
• and
• ICD-10-PCS?

14
What is ICD-9-CM?

• International Classification of Diseases, 9th
  Revision, Clinical Modification (ICD-9-CM) is
  based on the WHO ICD-9 standard diagnostic
  classification system.
• Volumes 1 2 (diagnosis codes) applies to ALL
  settings.
• Volume 3 (procedure codes) applies to inpatient
  hospital only.
• ICD-9-CM diagnosis codes are required under HIPAA
  for uniform claim submission (2003).

15
What is ICD-10-CM/PCS?

• Department of Health and Human Services (HHS)
  mandated that HIPAA covered entities must update
  medical coding sets, effective October 1, 2015.
• Diagnosis code set changes from ICD-9-CM to
  ICD-10-CM.
• Hospital inpatient procedure code set changes
  from
• ICD-9-CM (Volume 3) to ICD-10-PCS.
• No impact on CPT and/or HCPCS codes. Yeah!
• We will still report CPT codes for all outpatient
  procedures/services physician hospital visits
  to Observation and Inpatients (EMs).

16
The ICD-10 Impact!

• ICD-10-CM (Diagnoses)
• Will be used by all hospitals, providers,
  clinics, lab, radiology, psych, rehab, nursing
  homes, etc.
• ICD-10-PCS (Procedures)
• Will be used only for hospital claims for
  inpatient hospital procedures
• CPT/HCPCS No change!
• Procedures for Hospital Outpatients, Physician
  Visits, Lab and Radiology Outpatients, etc.

17
ICD-10 Implementation Span Date

• CMS clarifies policy for processing split claims
  for hospital encounters that span the ICD-10
  implementation date.
• MLN (Medical Learning Network) Matters Number
  SE1408/UPDATED June 27th, CR 7492
• NO longer split claims with inpt accounts.
• Bill type 11x if the hospital claim has a
  discharge and/or thru date on or after 10-1-15,
  then the entire claim is billed using ICD -10
• Bill type 13x split claims so all ICD -9 codes
  remain on one claim with dates of service thru
  9-30-15 and all ICD-10 codes placed on the other
  claim with DOS beginning 10-1-2015. (Think OBS!
  Recurring/series discharge and readmit)
• All healthcare types have rules identified in the
  Med Learn.

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Huge potential issue with Med Learn/SE 1408- Dual
processing/updated June 27, 2015

• Will CMS allow for dual processing of ICD 9 and
  ICD 10 codes (accepted and process both ICD 9 and
  ICD 10 codes for dates of service on or after Oct
  1, 2015)?
• No, CMS will not allow for dual processing after
  ICD 10 implementation on Oct 1, 20915. Many
  providers and payers, including Medicare have
  already coded their systems to ONLY allow ICD 10
  codes beginning Oct 1, 2015. The scope of
  systems changes and testing needed to allow for
  dual processing would require significant
  resources and could not be accomplished by Oct 1,
  2015, implementation date. Should CMS allow for
  dual processing, it would force all entities with
  which we share data, including our trading
  partners, to also allow for dual processing. In
  addition, having a mix of ICD 9 and ICD 10 codes
  in the same year would have major ramifications
  for CMS quality, demonstration, and risk
  adjustment programs!
• FAQ CMS/Aug CMS webpage- Will providers be able
  to use ICD -10 CM/PCS codes on claims prior to
  Oct 1, 2015?
• No. Providers may only use ICD -10 codes for
  services furnished on or after Oct 1, 2015.
  Claims that contain ICD 10 CM/PCS codes for
  services furnished prior to Oct 1, 2015 will be
  returned as unprocessable. You must submit
  claims for services furnished prior to Oct 1,
  2015 with the appropriate ICD 9-CM code. For
  more information refer to the MN above.

19

• Non-HIM Uses For ICD-9-CM-
• Preparing for ICD-10-CM as we move from 15,000
  codes to over 70,000 codes

20
ICD -10 Continues the Documentation Enhancement
Story

• Along with focusing on enhanced documentation to
  support inpt level of care, the expanded
  narrative to support ICD 10 conversion continues
  the story.
• Support team to make this happen
• Integrated CDI with feedback from coders
• PFS /denial busters with feedback to CDI
• Payer new edits PFS monitors and advises
• IT with ability to test, submit, and maintain
  both ICD 9 and ICD 10 post go live.
• Eyes in the record nursing/24-7.

21
Ideas for Physician Engagement

• Rollout monthly dedicated specialty specific
  audit and training.
• EX) Sept is ER month. Coders dual code an
  identified sample of ER claims. Identify at
  risk documentation by provider. Turn into easy
  to implement documentation.
• EX) If the facility has a CDI team, work
  cooperatively with the coding team to coach/que
  the ER providers thru their month.
• EX) Do an month end dual coding show
  improvement or challenges.

22
Exploring new partnerships with provider offices

• Physician dictates, hospital coders code, UB is
  created.
• NEW Why not share the codes with the providers
  who are attached to the account? Why repeat the
  same coding process in the office?
• NEW Brown bag coding luncheons with the
  provider offices. Office brings samples to code,
  hospital coders code while teaching ICD 10
  concepts. (TX Lunch Learn weekly)
• NEW Hospital becomes the outsourcing company to
  assist small practices with coding.

23
Non-HIM Impact Areas(HINT Denial Busting)

• Scheduling precerts, eligibility.
• Claims submission with scrubber both ICD 9 and
  ICD 10 codes ( Min-1 yr ability to rebill, do
  duality with IT systems.)
• Medical necessity CPT codes software, manual
  processes, cheat sheets
• Recurring accounts will need new precerts
  recoded after 10-1-2015
• Payer acceptance of new ICD 10 codes PLUS ICD 9
  codes 2 batches
• Payer contract language Dx codes
• Payer remark codes/denial codes
• CDM Hardcoded RT/LT needs to match with the
  soft coded RT/LT ICD10
• Trauma/Tumor registry - translated
• All IT systems within the organization

• 837/835 HIPAA transaction sets new for ICD 10
  locators
• Quality of care indicators translated
• P4P indicators/Outcome Measures translated
• Decision Support, utilization patterns,
  benchmarking translated
• Medical care review by provider, by dx, by LOS
  
• New business plan research/future healthcare
  trends translated
• Monitoring and analyzing the incidence of disease
  other health problems translated new
• Embedded dx attached to CPT codes
• Population Health History vs Current
• Revise forms to include new ICD 10 codes.

24
Departments who are impacted by ICD -10 changes

• 1st point of contact provider offices/dx to get
  pre-certifications with payers.
• Pre-auth with payers internal staff, UR
  (Historically 6 denials for no prior auth/HFMA
  conference/David Hammer)
• Medically necessary edit diagnosis to screen
  diagnosis against CPT tests to determine if
  Medicare or other payers will allow. ABN
  completed with Medicare pts prior to the test.
• Internal IT, scrubber company, payers IT systems
  prior to go live and post go live.
• Concern Workers Comp and Liability not covered
  entities/HIPAA Standard Transaction. Maintain
  both ICD 9 ICD10??

25
More areas impacted by ICD 10

• Lab, Chemo, Imaging, Cardiology, Specialty
  services all usually require medically
  necessary payer screening prior to the
  procedure. Cheat sheets gone!
• Doctor offices new encounter forms.
• Rehab Work comp pre certs. (? ICD 9 10)
• PFS new rejections, new return to provider
  edits, potential new denials
• HIM/the clean up crew all payer rejections due
  to coding, internal issues, more?
• IT decision support historical to current codes
• Others? any area tracking by Dx codemore!

26
Who Needs to Understand ICD-10?

• Beyond the coders
• PFS leadership as payers may reject based on ICD
  -10 coding and medical necessary codes denial
  software.
• PFS leadership and contracting to ensure
  contracts can accept both ICD-9 and ICD-10 on the
  UBs post go live.
• UR and all care mgt as payers will need to be
  able to do pre-certifications and concurrent
  review with ICD-10.
• Decision support and all areas using ICD-9/10
  coding for tracking, reporting, etc. (Trauma
  registry, Tumor registry, outcome comparisons,
  contracting, etc.).
• IT leadership must be involved to ensure all
  impacted areas are ready. A team leader or
  leaders are identified.

27
Payer Readiness - Letters with timelines to get
started, test, dialogue

• UB submissions with ICD-9 and ICD-10 -
  conversion dates
• Denials with new reasons as ICD-10 is far more
  specific
• Contract language that addresses ICD-10
  inclusions/exclusions
• Claim scrubbers/payer scrubbers ABN issues
  (LCD/NDC dx codes), if rules, edits
• Pre-authorization process/coverage
• WC and Liability are not subject to HIPAA
  standard transactions. Will they convert? Most
  are as mandatory within their state..but ask!

28
More Payer Issues

• Will they deny unspecified dx? Most are
  saying-not to begin with.
• How many digits will they require to have a pre
  authorization match?
• Testing test pt type, create claim, thru
  scrubber, to payer to payment. When start?
• Post go live? Accept DOS with ICD 9 after go
  live?
• If delayed, notify CMS/HIPAA Standard Transaction
  2003.
• Track and trend all payer issues report to
  hospital association.

29
More On LCD/NCD Diagnosis Codes Under ICD-10

• The Challenges
• What? For each Lab NCD, the ICD-9-CM codes and
  descriptions will have to be translated to
  ICD-10-CM versions.
• When?
• Prepare ICD-10-CM versions for full ICD-10-CM
  implementation in 2015
• HEY look at MLN Matters MM8197 3-15-13
• ICD conversion from ICD 9 to related code
  infrastructure of the Medicare shared systems as
  they relate to CMS NCDs. (Watch for more on
  this!)

30
LCD/NCD Objectives and Goal

• Translate all ICD-9-CM codes and descriptors in
  each Lab NCDs table of covered codes to the
  ICD-10-CM equivalent(s).
• Provide these translated tables to the CMS
  contractor, so that the tables can be
  incorporated into the codelist spreadsheet
  which will be processed for use by the shared
  systems for claims processing. (update 2/13-NCDs
  available)
• TESTING UPDATE Watch for updates! (CMS
  announced end to end to continuing-started inJan
  2015) Other payers? Optional!!

31
Results of Nov ICD-10 Acknowledgement Testing week

• Each MAC reported their success with testing.
  CMS reported a 76-87 acceptance rate during the
  week of testing.
• CMS reported more than 500 providers, suppliers,
  billing companies, and clearinghouses
  participated in the Nov round of testing.
• While providers are welcome to submit
  acknowledgement test claims anytime, during the
  Nov testing week, testers submitted almost 13,700
  claims.
• Tested with a valid ICD-10 dx that matched the
  DOS, National Provider Identifier/NPI and an
  ICD-10 companion qualifier code to allow for
  processing of claims. Majority of
  physician/professional claims rejections were
  related to an invalid NPI.
• Testers intentionally included errors in their
  claims to make sure the claim rejected, a process
  referred to as negative testing.

32
Duality of Systems

• Will payers, vendors (claim submission and
  scrubber) and other IT systems be able to handle
  ICD-9-CM as well as ICD-10-CM and ICD-10-PCS at
  the same time?
• Rebills of pre-conversion, medical necessity
  software, scrubbers, ensuring all payers are
  ready to convert AND test with each payer
  critical to the successful conversion.
• P.S. Dont forget all payers (Medicaid too!
  Funded to keep both ICD 9 and ICD 10 live?)

33
Hot Spots

• Make a master list of all vendors who currently
  support any ICD-9 activity. (Think Y2K)
• Look at all items /ordering tools where ICD-9
  codes are present. Need reviewed and revised
• Lab requisitions
• Online ordering of services that also requests
  ICD-9 codes
• Physician super bills/encounter forms with
  pre-printed ICD-9 codes
• Dept specific cheat sheets for covered dx.
  (Yep we know you have them!)

34
Example of 200 Bed Hospital IT list

• 3M or other encoder
• Main frame /main IT system
• Radiology-doc billing, radiologys own system
• Clearing house/claims
• Hospital employed doctors software for billing
• SNF/RUG software for grouper
• HH/HHRG software for grouper
• Lab pathology doc billing, labs own system
• Internal electronic medical record used for
  coding
• Software used for Trauma Tumor registry

• Decision support
• Scheduling software
• All tied Medical Necessity software in different
  areas main frame, bolt on software, individual
  areas screening
• Infection Control software
• Cardiology EKG system
• Itemized statements with dx as needed by the
  payer/pt
• Clinical quality reporting software
• Cheat sheets in each dept!
• OR software
• Occupational Med software

35

• Diagnosis Coding
• (ICD-10-CM)
• Building a code

36
ICD-9-CM vs. ICD-10-CM

• ICD-9-CM
• 3 - 5 digits or characters
• 1st character is numeric or alpha (E or V codes)
• 2nd 5th characters are numeric
• Decimal placed after the first 3 characters
• 17 Chapters and V E codes are
  supplemental
• 14,000 diagnosis codes

• ICD-10-CM
• 3 - 7 digits or characters
• 1st character is alpha (all letters used except
  U)
• 2nd 7th characters can be alpha and/or numeric
• Decimal placed after the first 3 characters (the
  same!)
• 21 Chapters and V E codes are not
  supplemental
• 69,000 diagnosis codes

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ICD-10-CM (Injury and External Cause Extensions)

• A Initial encounter
• D Subsequent encounter
• Q Sequelae (disease progression)
• Coders will need to look for the episode of care.
  Is this the patients 1st visit for treatment or
  is it for routine follow-up? Is it clearly
  documented in the medical record?

38
ICD-10-CM Format

• X X X ? X X X X

Category
Etiology, anatomic site, severity
Extension
39
Examples of ICD-10-CM Emergency Room

• I10 Essential (primary) hypertension
• S01.02xA Laceration with foreign body of scalp,
  initial encounter
• S01.02xD Laceration with foreign body of scalp,
  subsequent encounter
• S02.2xxA Fracture of nasal bones, initial
  encounter for closed fracture
• H65.01 Acute serous otitis media, right ear
  (CDM too)
• H65.02 Acute serous otitis media, left ear
• H65.03 Acute serous otitis media, bilateral

40
Quirky ICD-10-CM Codes

• On any given day, anything can happen!
• W17.82xA Fall from (out of) grocery cart,
  initial encounter
• V94.4xxA Injury to barefoot water-skier,
  initial encounter
• W61.43xA Pecked by turkey, initial encounter
• Y93.C2 Activity, handheld interactive
  electronic
  device, i.e., cellular phone
• Are we querying providers? Who wants it -payers?
• Have internal discussions, payer research, and
  make
• final decision.

41
Why Are There So Many Diagnosis Codes?

• Greater specificity and detail in all diagnosis
  codes!
• Butis there supporting physician documentation
  in the medical record?
• 34,250 (50) of all ICD-10-CM codes are related
  to the musculoskeletal system
• 17,045 (25) of all ICD-10-CM codes are related
  to fractures
• 10,582 fracture codes will distinguish right
  vs. left
• 25,000 (36) of all ICD-10-CM diagnosis codes
  will now distinguish right vs. left

42
Cross Walking - GEMs

• CMS has created GEMs (General Equivalence
  Mappings) to assist hospitals with cross walking
  ICD-9-CM ?ICD-10-CM/PCS forward mapping
  ICD-10-CM/PCS ? ICD-9-CM backward mapping. The
  correlation between the 2 code sets for some
  codes is fairly close, but not a straight
  correlation for others, i.e. OB, etc.
• Not always 1 to 1 crosswalk from ICD-9-CM to
• ICD-10-CM (www.cms.gov/ICD10/11b15_2013_ICD10
  PCS.asp)
• Available on CMSs website

43
GEMs
ICD-9-CM Code Diagnosis ICD-10-CM Code
V20.2 Routine infant or child examination Z00.129 (Encounter for routine child exam without abnormal findings). Z00.121 (Encounter for routine child exam with abnormal findings). Use additional code(s) to identify abnormal findings.
250.00 DM w/o complications, type II or unspecified E11.9 (Type II DM without complications)
V04.81 Need for prophylactic vaccination and inoculation Z23 (Encounter for immunization). At this time in ICD-10-CM there is only one code for immunizations.
401.1 Hypertension, benign I10 (Essential primary hypertension). ICD-10-CM does not differentiate between hypertension that is controlled or uncontrolled, benign or malignant and there is only one code.
427.31 Atrial fibrillation I48.0 (Atrial fibrillation) I48.1 (Atrial flutter)
786.50 Chest pain, unspecified R07.0 (Chest pain, unspecified). ICD-10-CM expands upon chest pain symptoms and unspecified code may no longer be necessary.
465.9 URI J06.9 (Acute upper respiratory infection, unspecified)
724.2 Lumbago M54.5 (Low back pain)
466.0 Bronchitis, acute J20.0 (Acute bronchitis, unspecified). ICD-10-CM includes 10 choices for acute bronchitis.
729.5 Limb pain M79.604 (Pain in right leg)
44
Now Lets Take a Look At ICD-10-PCS!
45
ICD-10-PCS Structure(Characters and Values)

• A character is a stable, standardized code
  component
• Holds a fixed place in the code
• Retains its meaning across a range of codes
• A value is an individual unit defined for each
  character
• Section Body Root Body
  Approach Device Qualifier
• System Operation Part

46
Case 1 Diagnostic Colonoscopy

• This 44-year-old male patient is known to have
  diverticulitis of the colon. He has noticed
  melena occasionally for the past week. The
  initial impression was that this is acute
  bleeding from diverticulitis. Patient was
  scheduled for colonoscopy. Colonoscopy
  identified the cause of the bleeding to be
  angiodysplasia of the ascending colon.

47
Case 1 ICD-10-CM Coding

• K55.21 Angiodysplasia of colon with
• hemorrhage (569.85)
• K57.32 Diverticulitis of large intestine without
• perforation or abscess without
• bleeding (562.11)

48
Case 1 ICD-10-PCS Coding

• 0DJD8ZZ Inspection of Lower Intestinal
  Tract, via Natural or Artificial
  Opening Endoscopic (45.23)

49

• What Will ICD-10 Cost?

50
Estimated Costs

• CMS estimates cost to the private sector for
  implementation of ICD-10 will exceed 130
  million.
• Hay Group White Paper in 2006 estimated cost for
  hospitals ranged from 35K - 150K for lt 100
  beds, to 500K to 2 million for 400 beds.
• AAPC indicates current documentation 50 could
  be coded.
• AHIMA indicates after ICD 10- coders will be 50
  slower for up to 3 months 50 more physician
  queries.

51

• Potential Hidden Costs

52
Potential Hidden Costs

• Back log of uncoded claims with ICD-9 while
  trying to get coders ready for ICD-10.
  Remote/outsourced coding may need to occur as
  well as OT.
• Rejected claims from payers who are not ready to
  accept UB-04 with ICD -10 PLUS ICD-9 as
  necessary.
• Vendor software rejecting ICD-10 or edits not
  working correctly thus slowing claim submission.
  Manual intervention to ensure claims are
  submitted and accepted.
• New software if existing software for related
  ICD-10 work is not compatible.

53
More Hidden Costs

• Cost to conduct a risk assessment to assess
  current documentation patterns for providers and
  care givers.
• Potential salary adjustments for the coders.
• Cost to conduct training for providers and care
  givers on enhanced documentation.
• Cost to review EMR or other software to adapt to
  enhanced documentation requirements.
• Cost to conduct a readiness assessment pre go
  live to determine readiness of coders,
  documentation and vendors.
• Cost of moving related work from the coders
  during training period. (EX Drug
  administration/charge capture)

54
And More .

• Loss of productivity rebills, denials,
  rejections, EOB work, medical necessity
  rejections/follow up (PFS)
• Loss of productivity excessive physician
  queries, coder slow down with new coding process
  (HIM)
• Growth in the discharged not final billed
• Potential impact to the Case Mix Index
• Cost of a project manager (1 yr contract staff to
  coordinate all the IT, testing, training,
  documentation assessments)
• Cost of implementing a clinical documentation
  improvement program
• Cost of EMR changes and training of all impacted
  staff
• Cost of any changes to the functionality of the
  any software and training costs

55
Shortage ProjectionsAHA AHIMA
Type ICD 9/minutes ICD 10/minutes
Inpt acute care 8.99 15.99
Outpt acute care 4.18 9.03
Physician practice 3.04 6.70
Free standing ASC 2.27 4.82
Nursing/SNF 6.71 12.98
Rehab facility 4.97 10.94
Additional time projected by CMS 2 minutes additional for each encounter 30 estimated loss in productivity
56
Shortage Strategies

• Mentorship program /formal
• 30 less productive alternatives?
• Back fill with remote coding
• Explore Computer Assisted Coding uses natural
  language processing, cost analysis
• Outpt ancillary high potential usage. (MN
  screening)
• Other outpt areas depending on how well the
  provider is documenting new elements of ICD 10.
  (Queries)

57
Education

• AHIMA estimates approximately 16 hours of coding
  training is needed for outpatient coders and 50
  hours for inpatient coders.
• Additional time may be needed to refresh anatomy
  physiology fundamentals.
• Learn foundational knowledge before more
  intensive training.
• Allow time for practice, practice, practice
  (key!)
• Down time during training and practice time.
• And dont forget the NON-HIM training needs

58

• Whats Next?

59
Developing an ICD-10 Implementation Team

• When ? By late 2014 (Already done, right?)
• Who? Key leaders in the revenue cycle/IT and
  HIM. Will a designated project leader need
  identified?
• What? Create master list of all revenue cycle
  areas, IT, HIM and physician issues
• How? Identify timelines for when components will
  be done, who does it, results reviewed, testing,
  with ownership and timelines for completion
• Key benchmarks for completion done beginning
  1st Q 2015 or once final go live date is
  established
• After go live, complete a 2nd set of benchmark
  assessments with barriers, delays, more
  education, etc.

60
Develop Phase 1 and Phase 2 Attack Plan

• Phase 1 Goal 3rd Q 2014 (if not already done)
• Awareness training of leadership
• Awareness training of coders inpt/all
  others/providers
• Conduct a risk assessment of current
  documentation patterns
• Track and trend ALL queries for a defined period
  of time.
• Using the query, develop provider education with
  structured rollout time frames
• Develop master list of impact areas coders,
  PFS, IT, providers, etc.
• Develop structured coder education based on type
  of pt.

• Phase 2 1st Q of 2015 and after go live.
• Conduct a readiness assessment audit of
  documentation, testing of coders/per pt type,
  review of all IT functions, new forms, software
  testing, payer, contracting, etc.
• Coding comparison for case mix impact, MS-DRG..
• Aggressively code all pending ICD-9 prior to Oct,
  2015.
• Remote/outsourced coding before/during transition
  and training needed
• Contract coding company should have a
  preparedness plan
• Contract ICD-10 program manager or dedicated
  staff (Think Y2K)

61
Steps to Implementation - Communication

• Make a master list of all software where ICD-9 is
  being used. This will be essential to the
  seamless implementation of ICD-10 (or less
  anguish).
• Contact each vendor NOW to identify their roll
  out plan for compliance and when they will be
  ready to test.
• Test with each vendor early in 2015 or as soon as
  they are available for testing. HUGE CONCERN!
• Keep Sr. Leadership well aware of the status of
  ALL software testing and compliance. Be prepared
  to make changes if compliance is not achieved
  with testing 9 months prior to go live.

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Audits of Course!

• Documentation Audits
• Your CDI (Clinical Documentation Improvement)
  department can start now conducting ICD-10
  documentation audits this year risk assessments
  of current documentation practices.
• Audit top 25 ICD-9-CM principal diagnosis codes
  and map to ICD-10-CM codes and begin auditing to
  determine whether the records contain the
  necessary clinical information to support the
  ICD-10-CM principal diagnosis code.
• Coding Audits
• Target certain inpatient cases for review based
  on the MS-DRG assignment or the CCs because both
  of these IP PPS components will undergo changes
  when reconfigured with the ICD-10-CM codes.

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October 2013 Beyond

• Possible decrease in cash flow due to
• Increase in time to code medical records
• Learning curves, potential increase in errors
• Decreased coder productivity, when, or will it
  recover
• System, vendor or software issues
• Potential reimbursement impact due to payer
  systems, claim edits or processing issues
• Expect denials and underpayments
• Lower DRGs or IP lack of severity of illness
  due to nonspecific documentation and unspecified
  diagnosis codes

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• Defense for 2015

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Defense for 2015

• Never too late to start!!
• Provide adequate system and coding resources for
  go live
• Will you need additional coding support?
  Contracted coders? Who will handle the coding of
  prior to accounts vs. go live accounts?
  Possible concurrent coding?
• Post go live auditing monitoring of
• Coding Documentation coding queries!
• Systems, data, reports
• Claims (UB 1500), payments, denials
• Audit and then more auditing from a RISK to a
  READINESS environment
• Remember, we are ALL in this
  together!!

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Accreditation for Coders

• AAPC (American Academy of Professional Coders)
• Certified coders will have opportunity to take
  the ICD-10 proficiency exam starting in October
  2012 and must successfully complete the test by
  September 30, 2014.
• AAPC will require its certified coders to pass
  this test to retain their certification.
• AHIMA (American Health Information Mgmt.
  Association)
• Continuing education hours with ICD-10-CM/PCS
  content will be required based on the specific
  AHIMA credential(s).
• RHIA - required to have at least 6 CEUs dedicated
  to ICD-10-CM/PCS
• 12 for the CCS-P credential
• 18 for the CCS credential, etc.

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Resources

• www.ahima.org/icd10
• www.cdc.gov/nchs/about/otheract/icd9/abticd10.htm
• www.cms.hhs.gov/ICD9ProviderDiagnosticCodes/08_ICD
  10.asp
• www.cms.gov/ICD10
• www.who.int/classifications/icd/en
• www.cms.gov/ICD10/Te110/itemdetail.asp?filterType
  nonefilterByDID99sortByDID1sortOrderdescendi
  ngitemIDcms1246998intNumPerPage10
• CMS Sponsored Teleconference Case Study in
  Translating Lab NCD
• (5-18-11) PowerPoint slides 23 24

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AR Systems Contact Info

• Day Egusquiza, President
• AR Systems, Inc
• Box 2521
• Twin Falls, Id 83303
• 208 423 9036
• daylee1_at_mindspring.com
• Thanks for joining us!
• Free info line available.
• NEW WEBPAGE www.arsystemsdayegusquiza.com
• Thank you for allowing us to participate in your
  continuing commitment to excellence!

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• Physician Documentation

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Biggest Challenge?

• Documentation Physicians!
• Begin providing them education now so that they
  are fully prepared on what will be required for
  appropriate documentation for correct ICD-10 code
  assignment and MS-DRG assignment.
• Customize the training for physicians based on
  their medical specialty.
• Do not just focus on inpatient diagnoses and/or
  procedures but also on outpatient diagnoses as
  this will require beefed up documentation from
  your docs as well to support the codes.

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Coders Role

• As a basic awareness
• Coders are required to code to the highest degree
  of specificity, but the quality of the physician
  documentation HAS to be there in the medical
  record.
• Coders are bound by many rules/guidelines for
  application of the translation process of
  narratives to numerical codes, which generates
  the bill/claim.
• Coders are not licensed to make the diagnoses, so
  if it is not stated, it cannot be coded!

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Top 10 Documentation Tips

1. Laterality (side) i.e., left or right 25,000
   codes!
2. Stage of Care, i.e., initial, subsequent,
   sequelae
3. Specific Diagnosis
4. Specific Anatomy
5. Associated and/or Related Conditions
6. Cause of Injury
7. Documentation of Additional Symptoms or
   Conditions
8. Dominant vs. Non-dominant Side
9. Tobacco Exposure or Use
10. Gustilo-Anderson scale

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Fracture Coding

• A 35-year-old man suffered open displaced tibia
  and fibula fractures of the right leg as the
  result of an automobile accident. In addition,
  he lost a lot of blood, also from the right leg.
• To assign the correct ICD-10-CM codes, coders
  will need to know
• Which leg and which specific bone(s) the patient
  injured (in this example, its the right tibia
  and fibula)
• Whether the fracture is open or closed (in this
  case, open)
• Whether the fracture is displaced (in this case,
  displaced)
• For open fractures, coders will also need to know
  what type of trauma the patient suffered to
  choose the appropriate character based on the
  Gustilo-Anderson classification system.
• The 7th character identifies open fractures using
  the Gustilo-Anderson classifications, which are
  the most commonly used classifications for open
  fractures. The Gustilo-Anderson classification
  identifies the severity of the soft tissue damage.

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What is Gustilo-Anderson scale?

• Classification of fractures may be new to
  your coders and physicians
• Type I Wound is smaller than 1 cm, clean, and
  generally caused by a fracture fragment that
  pierces the skin (low energy injury).
• Type II Wound is longer than 1 cm, not
  contaminated, and w/o major soft tissue damage or
  defect (low energy injury).
• Type III Wound is longer than 1 cm, with
  significant soft tissue disruption. The
  mechanism often involves high-energy trauma,
  resulting in a severely unstable fracture with
  varying degrees of fragmentation.

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Physician Documentation Challenges

• Weaknesses
• Lack of understanding of what will be required
  for specificity of documentation.
• Need to ensure detailed documentation is present
  in the medical record.
• Will see a significant increase in the of
  coding queries coming their way for further
  clarification and/or specificity of diagnoses as
  documented in the medical record.
• Need to be part of the TEAM as they will
  drive the coding process.
• Docs will now be affected in their own offices
  and must change how they document, i.e.
  superbill, lab requisitions

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Examples of GOOD Documentation

• Fracture (type, site, cause)
• Closed fracture, right arm, due to osteoporosis
• Additional Symptoms or Conditions
• Extremity atherosclerosis with
• Intermittent claudication
• Rest pain
• Ulceration
• Gangrene
• Diverticulitis or diverticulosis with
• Peritonitis/abscess
• Perforation
• Bleeding
• Location, i.e. small or large intestine

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And A Few More

• Bucket, handle tear of lateral meniscus, current
  injury, right knee
• Internal bleeding hemorrhoids
• Barretts esophagus with low grade dysplasia
• Pressure ulcer of right ankle, stage II
• Mild persistent asthma with status asthmaticus
• Alzheimers disease, early onset
• Benign neoplasm of right ovary
• Strain of right Achilles tendon, subsequent
  encounter

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Coding Queries

• Expect a significant increase in the of queries
  that will be generated from ICD-10.
• Existing coding queries will most likely have to
  be updated as you will be asking for different
  documentation to capture specificity.
• Make sure they are not leading the physician to
  document one way or another.
• Consider making the query part of the permanent
  medical record physician addendum.
• Track and trend for patterns. Then do more Ed!

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Reduce Rework, Engage At Time Of Coding, Think
Outside The Box!

• Think concurrent inpt coding.
• Immediate interaction with the provider and other
  caregivers on weak or incomplete documentation.
• Have coders on the floor with the care team.
  Back office coding results in chasing the
  provider delay in coding delay in cash.
• Expand the CDI teamto include both UR
  needs/severity of illness intensity of service
  PLUS specificity/laterality/ and other unique
• ICD-10 needs as identified thru queries and risk
  audits.

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What Impact Will ICD-10 Have On MS-DRG Payments?

• Lack of specificity for a certain diagnosis as
  documented in the record, could have the
  potential of not capturing the CC/MCC which could
  result in a lower paying MS-DRG.
• MS-DRG shifts could occur due to improper
  training of the coding staff.
• Example Coder selects the improper root
  operation for a code, i.e. excision vs.
  resection.
• This incorrect code assignment could also
  potentially cause changes within the MS-DRGs
  resulting in payment increases or decreases.