AHIMA Approved ICD-10 CM/PCS Trainer · 2015-08-01 · AHIMA Approved ICD-10 CM/PCS Trainer Vice...

Peggi Ann Amstutz, MBA, CCS, CCS-P

AHIMA Approved ICD-10 CM/PCS TrainerVice President Revenue Cycle & HIM

Confluence Health

ICD-10

RegulationIs the Driver

Customer / Patients

InternalProcesses

Learning &Growth

HIPAA requirement

Documentation Driven

Expanded Reporting

Opportunities

Enhanced Specificity

Price Quality Availability Selection Service Partnership Brand

Organizational Capital

Human Capital

Information Capital

Culture Leadership Alignment Teamwork

ProcessReengineering

TrainingOrganizational

readinessEducation

EHR Systems Interfaces Testing

ReportingAnalytics KPIs Dashboards Public Reporting

Functionality

Operations

PhysiciansNurses

Facility Functions i.e. surgery,

radiology etc

Clinical & Care Management

Clinical InformaticsAmbulatory

Clinical Documentation

Managed Care

Contract AnalysisDRG’s Analysis

Contracts Negotiation

Reimbursements

Compliance

Coding HIM

OperationsPrivacy & Security

Revenue Cycle

BillingRegistrationCharge Data

Master

Proprietary & Confidential

What is the value of ICD-10? The improved clinical detail, better capture of medical technology, up-to-date

terminology, and more flexible structure will result in: Higher quality information for measuring healthcare service quality, safety, and

efficiency Greater coding accuracy and specificity Recognition of advances in clinical practice and technology Improved ability to measure outcomes, efficacy, and costs of new medical technology Enhanced review of medical necessity and fewer claims denials Improved ability to determine disease severity for risk and severity adjustment Global healthcare data comparability Improved ability to track and respond to public health threats Reduced need for manual review of health records to perform research and data

mining and adjudicate reimbursement claims Reduced need for supporting documentations to support information reported on

claims Reduced opportunities for fraud and improved fraud detection capabilities Development of expanded computer-assisted coding technologies that will facilitate

more accurate and efficient coding and alleviate the coder shortage Space to accommodate future code expansion

We are here today because… ICD-10 is only 67 Days away

ICD-10 appears to be happening whether we agree or not

ICD-10 is not just a coder / coding thing

ICD-10 impacts (not a complete list!)

•Scheduling •Policy & Procedures

•Registration •Coding

•Authorization •Billing

•Charge tickets •Reimbursement

•Medical Necessity •Reporting

•Registries •Forms

•Cash Flow •Staff Morale

Scheduling Do we currently use ICD-9 information in any of our

scheduling systems…….

Clinic Visits

OR Scheduling

PT/OT Scheduling

Imaging Scheduling

Cath Lab Scheduling

IR

Why do we ask? Many scripts in scheduling rely on diagnosis

information as they drives the time, equipment, space etc.

Medical Necessity checking for coverage (ABN)

Diagnosis may also direct ‘who’ a patient is scheduled to see

Diagnosis often drives additional work – i.e. a lab test might be needed prior to another service.

Registration & Authorization Insurance says…….

This service is only covered for XX condition

Prior Authorization…..

Some request codes

Some will request additional diagnoses

Who has a cheat sheet for staff?

Is it updated

Do you know where to look?

Health PlanICD10 code/description required on pre-auth requests submitted on or after*1:

ICD10 code/description can

be sent as early as

AsurisL&IRegenceCigna 07-01 07-01First Choice 07-03 07-03CHPW 08-01 08-01GHC 09-01 09-01Aetna 10-01 07-01AIM 10-01 10-01HCA-Medicaid 10-01 10-01Molina 10-01 08-05Premera 10-01 07-01United Health Care 10-01 10-01

Pre-Authorization RequestsDate Required for ICD10 Code/Description

On Pre-Authorization Requests submitted for services scheduled for 10-1-2015 and later …*1 – ICD9 codes/descriptions for services scheduled on & after 10-1 can be used before this date

Charge Tickets All paper tickets rounded up and revised?

What about ‘pre-printed’ orders for Imagining?

What about the lab?

DME

What will you do about the hoarders?

Have you checked to see if ICD-9 codes are ‘hidden’ within order ‘sets’?

Medical Necessity - CMS http://www.cms.gov/medicare-coverage-

database/overview-and-quick-search.aspx?list_type=ncd

Advanced Search: If searching by ICD-10, make sure that the date criteria field indicates a date of service after 10/01/2015 in order to receive valid results.

http://www.cms.gov/medicare-coverage-database/downloads/downloadable-databases.aspx

Medical Necessity - Payers http://www.onehealthport.com/icd10-information-

central

Direct Links to Health Plan ICD-10 Information Referrals

Lists, Clinical Guidelines & Forms!

Crossing the 10/01/2015 Boundary

Claims Processing

Contract Implications

Mapping

Outreach & Testing

Example of what is there… Is your pre-authorization policy AND/OR your

guidelines for requesting pre-authorizations now set for the implementation of ICD-10. If no, how will they change and when will the revised policy/guidelines be published?

Yes, Molina’s prior authorization policies and guidelines are set for the ICD10 implementation. Molina will begin accepting prior authorization requests with ICD9 OR ICD10 codes beginning in August. Only ICD10 codes will be accepted after the compliance date.

Registry and other Reporting Trauma -

http://www.doh.wa.gov/DataandStatisticalReports/InjuryViolenceandPoisoning/TraumaRegistry

Birth Defects – See Attachment

CHARS -http://www.doh.wa.gov/DataandStatisticalReports/HealthcareinWashington/HospitalandPatientData/HospitalDischargeDataCHARS

Notifiable Conditions – See Attachment

The questions to ask…. Have we identified all of our ‘outbound’ reports using

ICD-9 data?

Have we updated/cross walked this data?

Have we tested it up and down stream?

Have we verified our ‘triggers’?

Example, if a physician documents a phrase such as Cleft Palate – do ‘we’ have something automated based on this phrase which pulls the patient information into a report?

CMS developed General Equivalence Maps (GEMs) as interim step http://www.cms.gov/ICD10/11b14_2012_ICD10CM_and_GEMs.asp#TopOfPage

Backward and forward mapping between ICD-9 and ICD-10

Maps are not exact reverse images

Used by all stakeholders to convert: Payment systems

Payment and coverage edits

Risk Adjustment logic

Quality measures

Research applications

GEMs between ICD-9 to ICD-10

ICD-10 Examples Example: Laterality – Left versus Right

C50.1 Malignant neoplasm, of central portion of breast

C50.111 Malignant neoplasm of central portion of right female breast

C50.112 Malignant neoplasm of central portion of left female breast

• Example: Angioplasty

o 1,170 ICD-10-PCS angioplasty codes specifying body part, approach, and

device, including:

047K04Z Dilation of right femoral artery with drug-eluting intraluminal device,

open approach

047K0DZ Dilation of right femoral artery with intraluminal device, open

approach

047K0ZZ Dilation of right femoral artery, open approach

047K24Z Dilation of right femoral artery with drug-eluting intraluminal device,

open endoscopic approach

047K2DZ Dilation of right femoral artery with intraluminal device, open

endoscopic approach

Mapping between ICD-9 to ICD-10 There is no comprehensive map

Many maps have been developed but they are not precise

81.54 TOTAL KNEE REPLACEMENT in ICD-9, in ICD-10 there are 16 valid codes to chose from.

789.09 ABDMNAL PAIN OTH SPCF ST, in ICD-10 it is no longer “other specified” there are numerous codes to chose from to correctly specify

GEM example

Glossary of GEM Terms Approximate flag—attribute in a GEM that when turned on indicates

that the entry is not considered equivalent

No map flag—attribute in a GEM that when turned on indicates that a code in the source system is not linked to any code in the target system

Combination flag—attribute in a GEM that when turned on indicates that more than one code in the target system is required to satisfy the full equivalent meaning of a code in the source system

Scenario—in a combination entry, a collection of codes from the target system containing the necessary codes that when combined as directed will satisfy the equivalent meaning of a code in the source system

Choice list—in a combination entry, a list of one or more codes in the target system from which one code must be chosen to satisfy the equivalent meaning of a code in the source system

Source: Diagnosis Code Set General Equivalent Mapper (National Center for Health Statistics (NCHS))

CrosswalkingIn order to effectively interpret data across periods of time, crosswalks will be needed to associate ICD-10 codes with corresponding ICD-9 codes (and vice versa).

Crosswalks allow the retention of ICD-9 as the base scheme and enable organizations to convert from ICD-10 back to ICD-9, as well as ICD-9 to ICD-10. This helps:

Prevent loss of historical information for comparison and analysis – possibly!

Make accurate claims payments – only where one of the parties is not ready!

Continue fraud and abuse data audits and reviews

Crosswalking (cont.) Dual analysis and reporting systems will have to be

written and maintained for many years

Business analytics will be impacted because of the need to combine historical ICD-9 data with newer ICD-10 data

Major concern here is how to control wide range of reimbursement depending on which ICD-10 code is mapped to which ICD-9 code. This will require policy decisions to be made as part of the planning process.

Reimbursement Maps are a temporary but reliablesolution to map ICD-10 to the “reimbursement equivalent” ICD-9 codes

Used to aid conversion of legacy systems

One to one mapping of “most representative” ICD-9 and ICD-10 codes

Doesn’t account for clusters of ICD-9 codes

ICD-9 to ICD-10

Other places to review & x-walk Coding Summary

These are often exported

Physician Query

These are often tracked and trended

May also have “smart” text or phrases

Physician Attestation

Case Mix Reporting

LOS Reporting

DRG Reporting

About the CDM It contains thousands of individual charges and

procedures across all hospital departments

Each charge code is then associated with a revenue code

Every chargeable item in the hospital must be part of the CDM in order for a hospital to track and bill a patient, payer, or another healthcare provider

CDM includes a unique item number, technical description, CPT/HCPCS/ICD-9PX and revenue codes, the assigned price, and several other elements.

More details A percutaneous transhepatic cholangiogram for biliary drainage with low

osmolar contrast agent and radiological supervision and interpretation (S&I)

The CDM charges would include four separate CPT code components: 47500 – Injection for Percutaneous Transhepatic Cholangiogram 74320 – Cholangiography, Percutaneous transhepatic, S&I 47510 – Intro of Percutaneous Transhepatic catheter for biliary drainage 75980 – Percutaneous transhepatic biliary drainage with contrast monitoring,

S&I

Under ICD-10-PCS, only two codes—with very different descriptions—would be assigned; BF101ZZ – Fluoroscopy of Bile Ducts using Low Osmolar Contrast 0F9930Z – Drainage of Bile Duct, with Drainage Device, Percutaneous approach

The complexities of accurate charging and coding make thorough and precise clinical documentation.

Appreciating the Complexity In ICD-10-PCS, every detail of a surgical procedure must be

documented and coded, making coding exponentially more difficult. Several aspects of ICD-10 introduce additional complexity compared with ICD-9: A multitude of approaches, devices, episodes of care, and

major and minor body systems are all represented as digits within a single ICD-10-PCS code

Surgeries that were grouped together in ICD-9 must be broken out into multiple procedure codes for ICD-10

Outpatient procedure codes and quality indicator reporting will continue to use CPT, while inpatient procedures and all diagnosis codes must be in ICD-10-PCS

In the OR One of the most difficult steps in preparing operating

rooms (ORs) for ICD-10 is readying perioperativeclinical documentation. Assessments, template updates, and education are all required.

OR scheduling personnel depend on physician office staff for information and a complete medical diagnosis prior to surgery. Integrating physician office personnel into ICD-10 education and preparedness is essential to help prevent medical necessity denials and revenue take-backs.

OR Perioperative information systems typically allow each

member of the care team (pre-admission testing, pre-op, nursing, anesthesia, recovery, etc.) to document within the same system.

All perioperative charges must be captured, correlated with chargemasters, and correctly applied to the associated procedure codes.

Additional documentation from the surgical system may be needed across the charge interface and revenue cycle system to create correct “super-bills” under ICD-10.

Hot Spots Blood transfusions. Blood transfusions are essentially organ

transplants, and in ICD-10, the coding of them is far more specific.

Coding for the transfusion of packed red blood cells (PRCs) in ICD-9 is relatively simple: It consists of one code. However, ICD-10 requires that coders specify not only whether the red blood cells transfused were frozen, but also what specific site (peripheral or central vein or artery) and approach was used for the transfusion. Physicians and CDI and coding staff now must consider a total of eight codes for each transfusion event.

And Shifts in DRGs One example is Major Depression. Under ICD-9, the

principal diagnosis of Major Depression, unspecified, groups to MS-DRG 885. Under ICD-10, Major Depression groups to MS-DRG 881, which is a lower-weighted MS-DRG.

Two distinct types of patients—those diagnosed with major depression and those diagnosed with unspecified depression—will be captured with the same ICD-10 code, even though these conditions are different and involve different symptoms.

More Shifts

Discussion – Homework What reports need to be ‘re-done” at your facility?

_____________________________

_____________________________

Is payer testing complete and was it successful?

_____________________________

Chart tickets / Order forms

Reviewed? ____________

Revised? ____________

Distributed? __________

Discussion – Homework What data is sent to others electronically?

_____________________________

_____________________________

Is training complete and was it successful?

_____________________________

Policies

Reviewed? ____________

Revised? ____________

Distributed? __________

Discussion – Homework Back up plan?

_____________________________

_____________________________

Known reimbursement increase / decrease? _____________________________

Cash Flow Forecasted? ____________

DNFB Plan for keeping it low?

Productivity Known drop – what are you doing for backfill?

Thoughts? ___________________________________

___________________________________

___________________________________

The better prepared for the transition and the ‘what ifs’ the better your outcome will be!

Thank you!