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This material must be reviewed prior to attending your General Orientation class.
Please ask any related questions at your General Orientation class.
Welcome to the 2015 Catholic Health Online Orientation Component
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Risk Management
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What is "Risk Management?"
Risk Management is the
systematic review of events
that present a potential for
harm and could result in
loss for the system.
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Four Elements of Risk ManagementReview Identification
Review Occurrence Reports
Review Patient/Visitor Complaints
Participate in Root Cause Analysis
Review concerns expressed by CH staff
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Four Elements of Risk ManagementLoss Prevention
Educational programs through CH University
Department specific in-services
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Four Elements of Risk ManagementClaims Management
Investigating and reporting occurrences and claims made to insurance carriers
Assist with discovery requests for lawsuits
Process Summons, Complaints and Subpoenas
** NOTIFY RISK MANAGEMENT IMMEDIATELY UPON RECEIPT
OF A WORK RELATED SUMMONS OR SUBPOENA
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Four Elements of Risk ManagementClaims Management - Continued
Within CH, a process server is to be directed to Administration of the facility
in order to serve a Summons or Subpoena. (HIM may accept subpoenas for hospital records.)
*** INDIVIDUAL DEPARTMENTS SHOULD NOT ACCEPT, EVEN IF IT IS FOR SOMEONE IN THE DEPARTMENT.
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Four Elements of Risk ManagementRisk Financing
Obtaining and maintaining appropriate insurance coverage:
HPL (Healthcare Professional Liability)
GL (General Liability)
D&O (Directors and Officers)
Property and Casualty
Auto
Crime
Fiduciary (Finance)
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Occurrence Reporting
An occurrence is an event that
was unplanned, unexpected and
unrelated to the natural course of
a patient’s disease process or
routine care and treatment.
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What are Sources of an Occurrence?Patient harm/potential harm like falls, medication errors
Visitor injury
Patient related equipment “failure”
Security issues like elopement, crime, altercations
Lost or damaged property
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What is the Purpose of an Occurrence Report?
Enhance the quality of patient care
Assist in providing a safe environment
Quick notice of potential liability
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Who can Complete an Occurrence Report?
Any associate or physician who discovers,
witnesses or to whom an occurrence is reported,
is responsible for documenting the event
immediately by means of the
Occurrence Report.
Anyone who requires assistance should contact
the department manager.
DO NOT MAKE COPIES OF AN
OCCURRENCE REPORT.
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What Happens to the Occurrence Report?
The completed Occurrence Report
is to be forwarded to
the Department Manager
who will investigate the occurrence
and forward to Quality & Patient
Safety Department who will
forward to Risk Management.
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Patient and visitor safety are assessed from both clinical and environmental perspectives
Notify Quality & Patient Safety of patient occurrences
Notify Security of visitor or property occurrences
Risk Management will be notified and will participate in evaluation of occurrence
Risk Management will report occurrences to insurance carrier in cases of potential liability
Risk Management will manage claim as indicated
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Documenting an Occurrence in the Medical Record
Date (MM/DD/YY) and time (military)
State facts, be clear and concise
Your own observations
If event described to writer, use quotes or “according to …”
Do not place blame in the record
DO NOT REFER TO OCCURRENCE REPORT IN THE MEDICAL RECORD
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EMTALA Regulations
EMTALA is the Emergency Medical Treatment and Active Labor Act (aka COBRA)
EMTALA provides a guideline for safely and appropriately transferring patients in accordance with Federal regulations.
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EMTALA Regulations
The law provides for a medical screening exam (MSE) to all individuals seeking emergency services on hospital property.
Hospital property includes the driveway, parking lot, lobby, waiting rooms and areas within 250 yards of the facility.
If an emergency medical condition is found, it will be stabilized within the hospital’s ability to do so, prior to the
patient’s transfer or discharge.
If a patient does not have an emergency medical condition, EMTALA does not apply.
*** IMPORTANT: NEVER SUGGEST THAT
A PATIENT GO ELSEWHERE FOR TREATMENT
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Identity Theft
Fair and Accurate Credit Transactions Act of 2003
or“RED Flag Rules”
Hospitals that maintain covered accounts must develop and implement written
policies and procedures to identify, detect, prevent, and mitigate identity theft.
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Identity Theft "Red Flags"Alerts, notifications, warnings
Presentation of suspicious information
Suspicious activity
Notice from patient, law enforcement, etc.
** Patient Access, Health Information, Finance, I.T. departments primarily involved.
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Identity Theft
You can help reduce opportunities
for Identity Theft by keeping
PHI confidential and out of public view.
If you believe someone is presenting
suspicious documents or acting in a
suspicious manner, notify your supervisor
who will notify Risk Management.
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Risk Management DepartmentNancy Sheehan, 821-4462
Interim Director, Risk Management
Joanne Ricotta, RN, BSN 821-4463Risk Management Coordinator
Terri Tobola 821-4467Risk Management Technical Assistant
Penny Arnold 821-4468Legal Services Administrative Assistant
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Social Media Policy
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Social Media Policy Review
What is Social Media?Social Media is defined as user generated content that is shared over the internet via technologies that promote engagement, sharing and collaboration.
What does Social Media Include: It includes, but is not limited to:Social networking sites such as Facebook, LinkedIn, Flickr and Twitter Personal websitesNews forums Chat rooms
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Social Media Policy Review
Catholic Health recognizes social media as an avenue for self-expression. Associates must remember that they are personally responsible for the content they contribute and should use social media responsibly. The following Catholic Health policies apply to all associates on line conduct:
Human resources policies, Equal employment opportunity policiesSexual harassment/non-harassment policies Patient confidentiality/HIPAA policies
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The Uninsured Expected Payment and Healthcare Assistance Policy
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Policy
The policy is divided into three distinctsections that grant different rights to patientsbased on the following Catholic Healthministries:
Acute CareContinuing CareHome Healthcare
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Acute Care
All uninsured patients of Catholic Health receivingtreatment at one of the Catholic Health’s acute carefacilities who are residents of New York State, a contiguousState or the state of Ohio, excluding the following services:
- Non-Medically Necessary Elective Services (e.g. cosmetic surgery),
- Long term level of care services (Sub-Acute or Skilled Nursing),
- Physician services other than Catholic Health primary care physician services, and
- Medical equipment and supplies
Who does this policy apply to?
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Continuing Care
All residents of Catholic Health receiving treatment at one of the Catholic Health’s Long Term Care facilities (Hospital and Non Hospital Based) that are subject to insurance co-payments or deductibles and Adult Home residents may be eligible for charity care.
Who does this policy apply to?
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Home Healthcare
All patients that receive services within the Catholic Health Home Care division (Certified Agencies, Licensed Agencies, and Infusion Pharmacy) may be eligible for Charity Care.
Who does this policy apply to?
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Acute Care Section - Policy and ProceduresAll patients registered as uninsured (i.e., those without insurance, also often referred to as self pay) will automatically be enrolled in the Healthcare Assistance Program.
An optional application form will be offered at time of registration, but failure to complete the application will not exclude enrollment.
As such, uninsured patients presenting for care at a Catholic Healthcare acute care facility need do nothing to apply for healthcare assistance.
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Acute Care Section - Policy and Procedureso Balances after insurance payment due from the
patient or patient guarantor are referred to as After Insurance Balances.
o These balances include, but are not limited to, co-pays, deductibles and co-insurance.
o For insured patients without the financial ability to pay After Insurance Balances, After Insurance Balance Allowances are available based on a sliding scale.
o A different set of procedures must be followed in
order to be the eligible for this allowance.
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Violence in the Workplace
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What is Workplace Violence?
NIOSH (National Institute for Occupational Safety
and Health) defines workplace violence as violent
acts (including physical assaults and threats of
assaults) directed toward persons at work or on
duty.
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Types of Violent ActsThreats: Expressions of intent to cause harm, including verbal threats, threatening body language, and written threats.
Physical Assaults: Attacks ranging from slapping and beating to rape, homicide, and use of weapons such as firearms, bombs, or knives.
Muggings:Aggravated assaults, usually conducted by surprise and with intent to rob.
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Who is Violent?
Workplace violence in hospitals usually results
from patients and occasionally from family
members who feel frustrated, vulnerable,
and out of control.
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When Does Violence Occur?
Violence takes place
During times of high activity such as meal time or visiting hours or patient transportation
When service is denied
When a patient is involuntarily admitted
When limits are set regarding eating, drinking, tobacco use or alcohol use
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Hospital personnel having direct contact with
patients and families are at increase risk.
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Case ReportsAn elderly patient verbally abused a nurse and pulled her hair when she prevented him from leaving the hospital to go home in the middle of the night.
An agitated psychotic patient attacked a nurse, broke her arm, and scratched and bruised her.
A disturbed family member whose father had died in surgery walked into the E.D. and fired a handgun, killing a nurse and an EMT and wounding a physician.
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Where May Violence Occur?Anywhere in the hospital, but it is most frequent in the following areas:
Emergency Departments
Any Critical Care area
Waiting Rooms
Geriatric Units
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Effects of Violence
Violence can have a negative effect on an organization as reflected by:
Low morale
Increased job stress
Increased worker turnover
Reduced trust of management or co-workers
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Risk Factors
Contact with violent people or those with history of violence
Contact with those under the influence of drugs and/or alcohol
Contact with people having psychotic diagnoses
Contact while transporting patients
Contact with people perceiving a long wait for service
Working alone
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Safety Tips
Watch for signals of impending violence:
Verbally expressed anger and frustration
Body Language such as threatening gestures
Signs of drug or alcohol use
Presence of weapons
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Be Alert
Assess current demeanor when you enter a room or begin to relate to a patient or visitor
Be vigilant throughout the encounter
Don’t isolate yourself with a potentially violent person
Keep an open path for exiting
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Diffusing Anger
Present a calm, caring attitude
Don’t match the threats
Avoid giving commands
Acknowledge a person’s feelings
Avoid behavior that may be interpreted as aggressive
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If Potential for Violence Occurs
Remove yourself from the situation
Call Security or 911 for HELP if needed
Report any potential or actual violent incidents to your department manager
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Summary
No universal strategy exists to prevent violence
All hospital workers should be alert and cautious when interacting with patients and visitors
Staff need to be aware of polices and procedures relating to violence prevention
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The Bariatric Patient : Understanding, Awareness, and Sensitivity
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Consequences of ObesityPsychological and Social Well-Being
Negative Self-ImageDiscriminationDifficulty maintaining personal hygieneDepressionTurnstiles, cars, and seating may be too smallDiminished sexual activity
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Social Discrimination
Studies show society has a low respect for morbidly obeseThese people may have limited number of friendsThe people may experience social rejectionThese people may have poor quality relationships
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Weight Bias in Healthcare
What assumptions do I make based only on weight regarding a person’s character, intelligence, professional success, health status, or lifestyle behaviors?Could my assumptions impact my ability to care for these patients?Do I only look at their weight problem, and not other health related issues?
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Challenge the Bias
Lead by example: influence peers and others to demonstrate patient sensitivity, become a good role model.Don’t tolerate behind-the-back whispers, jokes, even in private.If no one questions obesity bias, what will ever stop it?
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Strategies for Healthcare Professionals
Consider that patients may have had negative experiences with other healthcare professionals regarding their weight; approach patients with sensitivity.Recognize that many patients have tried to lose weight repeatedly.Acknowledge the difficulty of lifestyle changes.
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Our Role
We need to care for both physical and emotional needs.Support and encouragement are so important.Compassion and empathy must be conveyed.Communication and listening skills are essential.Smile, look at the person, do not ignore a patient because of their obesity.
Catholic Health SystemsEmployee Breastfeeding Support
Overview
Catholic Health WomenCare l WomenCareWNY.org 55
Support of Breastfeeding is a Priority
Reduced Risk for Infants with Exclusive Breastfeeding 1, 2
• Obesity• Ear Infections• Respiratory Infections• Asthma• Gastrointestinal Infections• Atopic Dermatitis• Type 1 & Type 2 Diabetes• Leukemia• Sudden Infant Death Syndrome• Necrotizing Enterocolitis
Catholic Health WomenCare l WomenCareWNY.org 56
Public Health Case
• Breastfeeding is the standard for infant feeding and protects infants and children from many significant infectious and chronic diseases.
• $13 billion of direct pediatric health-care costs and more than 900 lives would be saved annually if 90% of women were able to breastfeed exclusively for six months as recommended.2
• Women who breastfeed have a reduced risk of breast and ovarian cancer, type 2 diabetes, postpartum depression, and cardiovascular disease.3-5
Catholic Health WomenCare l WomenCareWNY.org 57
Work Remains a Barrier to Breastfeeding6-10
• Full-time employment decreases breastfeeding duration by an average of more than eight weeks.
• Mothers are most likely to wean their infants within the first month after returning to work.
• Only 10% of full-time working women exclusively breastfeed for six months.
• Catholic Health is a leader in supporting breastfeeding moms in the workplace.
Catholic Health WomenCare l WomenCareWNY.org 58
If a mother chooses to breastfeed, she needs to pump breast milk during the workday in order to maintain her milk supply.
Missing even one needed pumping session can lead to decreased milk production and other undesirable consequences.
Catholic Health WomenCare l WomenCareWNY.org 59
Women Need Worksite Lactation Support11
• Breaks for lactation are similar to other work breaks for attending to physical needs:
• Time to eat/drink, restroom breaks, accommodation for health needs (e.g., diabetes)
• When mother and child are separated for more than a few hours, the woman must express milk.
• Missing even one needed pumping session can have undesirable consequences: – Discomfort – Leaking – Inflammation – Infection – Decreased Milk Production– Breastfeeding Cessation
Catholic Health WomenCare l WomenCareWNY.org 60
How to Support Breastfeeding Employees
• In general, women need 30 minutes (15 to 20 minutes for milk expression, plus time to get to and from a private space and to wash hands and equipment) approximately every 2 to 3 hours to express breast milk or to breastfeed.
• Needs may vary from woman to woman and over the course of the breastfeeding period.
Catholic Health WomenCare l WomenCareWNY.org 61
Business Case11
• Lactation programs are cost-effective, showing a $3 return for every $1 invested.
• By supporting lactation at work, employers can reduce turnover, lower recruitment and training costs, cut rates of absenteeism, boost morale and productivity, and reduce health-care costs.
• Lactation accommodation is not one-size-fits-all. Flexible programs can be designed to meet the needs of both the employer and employee.
Catholic Health WomenCare l WomenCareWNY.org 62
Breastfeeding = Increased Productivity11
• Breastfeeding reduces illness of the baby = fewer absences of parent employees = immediate return on investment.
• Breastfeeding support in the workplace helps families meet their breastfeeding and childrearing goals = higher job satisfaction, increased loyalty, increased ability to focus on job responsibilities, higher return to work postpartum, and lower turnover = immediate return on investment.
• Breastfeeding prevents chronic disease in women who breastfeed and contributes to a healthier future workforce through reduction of obesity and chronic disease = long-term payoff that keeps on giving.
Catholic Health WomenCare l WomenCareWNY.org 63
Fair Labor Standards ActSection 7 of the Fair Labor Standards Act was amended effective March 2010:
Employers are required to provide “reasonable break time for an employee to express breast milk for her nursing child for 1year after the child’s birth each time such employee has need to express the milk.”
Employers are also required to provide “a place, other than a bathroom, that is shielded from view and free from intrusion from coworkers and the public, that may be used by an employee to express breast milk.”
Legal Basis
Catholic Health WomenCare l WomenCareWNY.org 64
Common Concerns of Breastfeeding Mothers 11
• Modesty• Time and social constraints• Lack of support• Making enough milk for their babies• Talk with your manager – if you want to
breastfeed your baby – you are encouraged to at Catholic Health. We are here for you!
Catholic Health WomenCare l WomenCareWNY.org 65
Resources
What resources are available for managers?• Catholic Health Policy on Lactation (Compliance 360)• Identify location within your department for your associate –
talk with your manager about a room for your use• Direct associates with specific breastfeeding/personal
questions regarding lactation that they can call 862-1939
What resources are available for employees?• Baby Café at Sisters• Mercy and Sisters Hospital Lactation Department• Educational materials, professional support.
Catholic Health WomenCare l WomenCareWNY.org 66
References (1-6)
1. Ip S, Chung M, Raman G, Chew P, Magula N, DeVine D, Trikalinos T, Lau J. (Tufts-New England Medical Center Evidence-based Practice Center). Breastfeeding and maternal and infant health outcomes in developed countries. Evidence Report/Technology Assessment No. 153. Rockville, MD: Agency for Healthcare Research and Quality; 2007 Apr. AHRQ Publication No. 07-E007. Contract Nu. 290-02-0022. 415 pp. Available from: http://www.ahrq.gov/Clinic/tp/brfouttp.htm
2. American Academy of Pediatrics Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 2012;129(3):e827-41.
3. Bartick M, Reinhold A. The burden of suboptimal breastfeeding in the in the United States: A pediatric cost analysis. Pediatrics. 2010;125(5): e1048-56.
4. Schwarz EB, Ray RM, Stuebe AM, Allison MA, Ness RB, Freiberg MS, Cauley JA. Duration of lactation and risk factors for maternal cardiovascular disease. Obstet Gynecol. 2009;113(5):974-82.
5. Gunderson EP, Jacobs DR, Chiang V, et al. Duration of lactation and incidence of the metabolic syndrome in women of reproductive age according to gestational diabetes mellitus status: A 20-year prospective study in CARDIA—The Coronary Artery Risk Development in Young Adults Study. Diabetes. 2010;59(2):495-504.
6. Fein B, Roe B. The effect of work status on initiation and duration of breast-feeding. American Journal Public Health. 1998:88(7): 1042-46.
Catholic Health WomenCare l WomenCareWNY.org 67
References (7-12)
7. Cardenas R, Major D. Combining employment and breastfeeding: Utilizing a work-family conflict framework to understand obstacles and solutions. J Bus Psychol. 2005; 20(1): 31-51.
8. Galtry J. Lactation and the labor market: Breastfeeding, labor market changes, and public policy in the United States. Health Care Women Int. 1997;18(5): 467-80.
9. Texas Department of State Health Services. WIC Infant Feeding Practices Survey, 2009. 10. United States Breastfeeding Committee. Workplace Accommodations to Support and
Protect Breastfeeding. Washington, DC: United States Breastfeeding Committee; 2010. Available from: http://www.usbreastfeeding.org/Portals/0/Publications/Workplace-Background-2010-USBC.pdf
11. Department of Health and Human Services (U.S.). The Business Case for Breastfeeding. Steps for Creating a Breastfeeding Friendly Worksite: Bottom Line Benefits [Kit]. US Department of Health and Human Services, Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau. 2008. HRSA Inventory Code: MCH00254. Available from: http://www.womenshealth.gov/breastfeeding/programs/business-case/index.cfm
12. US Department of Labor. Break Time for Nursing Mothers. [Online]. 2010. Available from: http://www.dol.gov/whd/nursingmothers
Harassment and Diversity in the Workplace
What is Harassment?
Verbal or physical conduct that denigrates or shows “hostility” or aversion toward a person.
Harassment can be based on race, color, national origin, citizenship, religion, gender, marital status, sexual orientation, age, disability, or any other characteristic protected by law.
What is Harassment?
Harassing conduct includes:
Abusive words, phrases, slurs, put-down jokes, or negative stereotypes.
Harassing behavior can be hidden behind humor, insinuations, and/or subtle remarks or acts.
The Costs of Harassment?
The cost of harassment is high and includes: Legal costs and out-of-court settlements Decreased productivity Lowered morale Increased employee turnover The chance of workplace violence Loss of credibility in the community
Title VII of the Civil Rights Act of 1964 prohibits discrimination
The Civil Rights Act prohibits discrimination based on the following traits: Race Color Religion Sex National Origin
What Prohibits Further Types of Discrimination or Harassment?
Age Discrimination Act of 1975
Americans with Disabilities Act of 1990
In 1998, a Supreme Court ruled that employers can still be held liable in a harassment suit even if they did not know it was happening in their own workplace.
Hostile & Pervasive
Harassment and/or discrimination must be both hostile and pervasive:
Hostile statements make another person uncomfortable.
Hostile” might not mean angry or violent.
Hostile comments/behaviors that are pervasive and ongoing.
Preventing Harassment
Think before you speak!
Think twice before you “send” emails.
Be careful with humor.
Ask yourself: How would I feel?
What to do if you are Harassed?
Tell the offender their behavior is unwelcome and needs to stop!
If it is too awkward to talk to the offender, speak to your HR manager.
What to do if you think you Harassed Someone?
Apologize to the person you may have offended.
Be careful not to repeat the behavior!
Harassment Summary
Every associate is responsible for their professional on-stage behavior.
The costs of harassment are high: think before you speak!
Respect for Diversity
Cultural competence is a set of attitudes, behaviors and skills that enable staff to work effectively in cross-cultural situations. It reflects the ability to gain and use knowledge of health-related beliefs, attitudes, practices and communication.
Respect for Diversity
It should be understood that there is no one way to treat any racial and ethnic group. As health care providers, we must provide evidence-based care that is appropriately tailored to meet the needs of our patients, their families and the community.
Respect for Diversity
Cultural competence begins with an honest desire not to allow biases to keep us from providing care and treating each patient with respect.
Respect for Diversity
Cultural Diversity covers many obvious and less-obvious manifestations to include: Religion, Ethnicity (race), National Origin, Gender, Age, Education, Mobility – including handicaps
Respect for Diversity
To respect diversity, staff need to understand the following terminology: Culture
– is the sum-total of the way-of-living that includes values, beliefs, standards, language, thinking patterns, behavioral norms and communication styles.
– Culture guides decisions and actions.
Respect for Diversity
Culture affects health belief systems in the following ways:– Define and categorize health and illness– Offers explanatory models for illness– Based upon theories of the relationships between
cause and the nature of illness and treatments– Defines the specific “scope” of practice for healers
Respect for Diversity
Culturally diverse populations have varying belief preferences, nutritional preferences, communication preferences and varying beliefs on patient-care and dealing with death.
To assist you with the care of culturally diverse populations, the Catholic Health Culture Tool will be provided to you at General Orientation
Respect for Diversity
Acquiring cultural competence starts with awareness, groups with knowledge, is handled with specific skills, and is refined through cross-cultural encounters. In caring for culturally diverse populations:
– Listen to the patient’s perception of the problem– Explain your understanding of the problem– Discuss differences and similarities– Recommend a treatment-plan and negotiate the plan
Harassment & Diversity
If you would like additional information on Harrassment and Diversity in the Workplace, the video link below can be viewed on Internet Explorer:
http://www.youtube.com/watch?v=V1PY8kgO1PA
Content ICD-10 Overview:
What is driving the change and why? Who is impacted?
ICD-10 Transition Introduction & Basics
Difference between ICD-9 and ICD-10 Diagnosis Codes and Procedure Codes What is the change in documentation
and systems we need to accommodate? Impacts to the System CHS and External Resources for
Education Competency Questions
What Is Driving the Change?
The World Health Organization (WHO) publishes the International Classifications of Diseases (ICD) code set, which defines diseases, signs, symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or disease.
As part of the Health Insurance Portability and Accountability Act of 1996, all “covered entities” will be required to adopt ICD 10 codes for use in all HIPAA transactions with dates of service on or after October 2013*
* Implementation has been delayed to October 1, 2015
ICD-9, the current methodology is over 30 years old, contains outdated terminology, and is inconsistent with current medical practice. In addition, the codes lack specificity and detailed support
Why Change to ICD-10? ICD-10 is used internationally, converting will enable
global diagnosis comparison.
ICD-9 is 30 years old and does not contain enough detail for meaningful analysis and disease reporting.
ICD-10 is expected to result in better medical necessity justification, fewer claim errors and reduced opportunity for fraud.
Specific reporting of diagnosis codes is key to many health insurance coverage policies and are used in pay-for-performance initiatives.
Better quality data collection for research, improved measures for severity, risk and outcomes, and disease tracking affecting public health.
Practice management and electronic health records will be improved with more effective use of diagnosis and procedure codes.
Who Is Impacted By ICD – 10?
• All Covered Entities:• Physicians• Hospitals• Home Health Care• Long Term Care• Rehab, Lab, Imaging
• Teams Impacted:• Physicians• Health Information Management – Coding• Patient Financial Services• Clinical Documentation Improvement• Care Management/Utilization Review• Quality • Financial Reporting
ICD-10 Overview ICD International Classification of Diseases is used
on virtually 100% of patients and visits within CH – all ministries
ICD CODES are used to describe and catalog the patients’ conditions (Diagnosis) and the Acute Inpatient Procedures
ICD directly influences 90% plus of all of CH Revenue Streams
The WORDS and Clinical VALUES (a tumor size measurement) present in the clinical record are used to assign the CODES
Physicians must document with the correct specificity in order to code ICD-10
ICD-10 is federally mandated change from ICD-9, due Oct 2015
ICD-10 directly impacts all Software Applications that process/contain ICD-9 codes and their interfaces – all will need to be upgraded
ICD-10 is a major Financial risk and carries significant clinical impact
Introduction to ICD-10-CM/PCS
The implementation date for ICD-10-CM is October 1, 2015.
Physicians are responsible for ensuring that their documentation supports the services provided to the patient in order for appropriate code assignment to be completed.
Due to ICD-10 code specificity, documentation is more crucial than ever.
Coders are responsible for translating the documentation into the ICD-10 codes per the coding guidelines to populate claims for billing; however, this cannot be done appropriately without the correct specificity documented.
If documentation is not present to support the codes needed for billing, we will be at significant financial risk.
Basic Facts about the Change from ICD-9 to ICD-
10 ICD-10-CM is Diagnosis coding used by all
providers in every healthcare setting
ICD-10-PCS will be used for inpatient hospital procedures. It will not be used on physician claims of any kind.
CPT and HCPCS codes used for outpatient procedure coding are not affected
Use of ICD-10-CM and ICD-10-PCS will start with visits or discharges that occur on or after October 1, 2015.
All IT software that houses, uses or generates ICD-9 codes will need to be updated to an ICD-10 compatible version by the go-live date.
Practice tools such as charge capture forms, problem lists or superbills will need to be converted to ICD-10 codes.
Diagnosis Codes: Comparison of ICD-9 to ICD-
10-CMICD-10-CM (NEW) ICD-9 (OLD)
3 – 7 Characters in Length 3 – 5 Characters in Length
Approximately 68,000 codes
Approximately 13,000 codes
Digit 1 is alpha; digits 2 and 3 are numeric; digits 4-7 are alpha or numeric
First digit may be alpha (E or V) or numeric; digits 2-5 are numeric
Flexible for adding new codes
Limited space for adding new codes
Very specific Lacks detail
Has laterality (codes identify right vs. left)
Lacks laterality
Example:K21.0 – Gastro-esophageal reflux disease with esophagitis
Example: 540.9 – Acute appendicitis
Comparison of ICD-10-CM to ICD-9 Specificity
ICD-10-CM ICD-9Multiple codes differentiating
unique types of mechanical complications and grafts and
devices
One code for a mechanical
complication of a vascular device, implant
or graft
T82.41XA – Breakdown (mechanical) of vascular dialysis catheter, initial encounter
T82.511A – Breakdown (mechanical) of vascular created arteriovenous shunt, initial encounter
T82.513A – Breakdown (mechanical) of balloon (counterpulsation) device, initial encounter
T82.515A – Breakdown (mechanical) of umbrella device, initial encounter
996.1 – Mechanical complication of other vascular device, implant, and graft
Procedure Codes: Comparison of ICD-9 to ICD-
10-PCSICD-10-PCS (NEW) ICD-9 (OLD)
7 alpha-numeric characters in length
3 – 4 Numbers in length
Approximately 87,000 codes Approximately 3,000 codes
Reflects current usage of medical terminology and devices
Based on outdated technology
Flexible for adding new codes Limited space for adding new codes
Very specific Lacks detail
Has laterality Lacks laterality
Detailed descriptions for body parts Generic terms for body parts
Provides detailed descriptions of methodology and approach for procedures
Lacks descriptions of methodology and approach for procedures
Precisely defines procedures with detail regarding body part, approach, any devices used, and qualifying information
Lacks precision to adequately define procedures
ICD-10-PCS Character Meanings
Character 1 2 3 4 5 6 7
Definition
Name of
Section
Body System
Root Operat
ion
Body Part
Approach Device Qualifi
er
Right Knee Joint Replacement = 0SRD0JZ0 Medical and Surgical
Section
S Lower Joints
R Replacement
D Knee Joint, Right
0 Open
J Synthetic Substitute
Z No Qualifier
*When documenting procedures, these documentation elements must be specified in order for coding to occur
Clinician Impacts Documentation practices must change to specify as
required by codes Encounter forms, charge capture forms, scripts for
tests such as lab work and super bills must be modified to use ICD-10 codes
The number of documentation queries to physicians to provide more detailed diagnosis information may increase
Potential delays in reimbursement if coding cannot be completed due to lack of documentation or denials due to incorrect coding on claims.
Patient Financial Services and Patient
Registration/SchedulingImpacts Potential risk for increase of denials due to
coding/claim issues related to ICD-10 Scripts for tests such as lab work must use ICD-10
codes, if the code on the script is not an ICD-10 code follow up will need to be done to get the correct code for processes such as medical necessity checking, etc.
Any registration tip sheets that used ICD-9 codes will need to be updated and/or new tools will need to be used to look up ICD-10 codes
The individuals should become familiar with ICD-10-CM and ICD-10-PCS codes in order to better understand when issues arise and/or identify issues with registrations, claim creation, or payer remittances.
Scheduling systems must accommodate ICD-10 codes.
Reporting Impacts Code structure is changing, so all reports using ICD-
9 codes will need to be updated with applicable ICD-10 codes.
Codes are changing from being numeric to alpha-numeric
No one-to-one match exists between ICD-9-CM and ICD-10, so manual intervention will be required to map information and develop comparable reports
ICD-10-CM and ICD-10-PCS may use more or fewer codes to identify procedures or conditions.
Reporting in both ICD-9-CM and ICD-10-CM/PCS may be necessary for a period of time during the transition
Increased specificity of ICD-10 codes will require more documentation and change the definitions of what is reported
Coding/Clinical Documentation Impacts Coders and Clinical Documentation
specialists must have in depth education in order to learn the new coding system and how to code in ICD-10 format
Coders must learn documentation and coding guidelines in order to identify when physician queries are needed to complete coding
CHS Intranet Education & Training ICD-10 https://my.chsbuffalo.org/edu/icd-10
CHS Education and Training Resources:
Catholic Health Intranet
CHS Resources:Elsevier Online Training
Elsevier/MC Strategies Performance Manager – ICD-10 eLearning Page www.webinservice.com/CatholicCoreLearning All CHS employees and CMP physicians/office managers have access to ICD-10
education modules via Elsevier. Default username and password prompts are on the Elsevier homepage linked above.
CMS Resources:Implementation Guide &
Timeline CMS ICD-10 Implementation Guide for Small and Medium Practices http://www.cms.gov/Medicare/Coding/ICD1
0/Downloads/ICD10SmallMediumPracticeHandbook.pdf
CMS ICD-10 Small Providers Timeline http://www.cms.gov/Medicare/Coding/ICD1
0/Downloads/ICD10SmallProvidersTimeline.pdf
CMS ICD-10 Myths and Facts http://cms.gov/Medicare/Coding/ICD10/Do
wnloads/ICD-10MythsandFacts.pdf
AMA Resources AMA ICD-10 Resource
Page: http://www.ama-assn.org
/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/hipaahealth-insurance-portability-accountability-act/transaction-code-set-standards/icd10-code-set.page
See AMA Educational Resources Fact Sheets #4 & #5 for Implementation
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Corporate Compliance
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Corporate Compliance
The following content will be covered live in General Orientation Please review this information so that you are familiar with the terminology before attending classThis material can also be used as a reference after class
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Corporate Compliance
Leonardo Sette‐Camara, Esq.
Corporate Compliance & Privacy Officer
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Objectives of Compliance Education
To prevent, find and correct violations of CHS standards, governmental laws, regulations and rules
To promote honest, ethical behavior in the day-to-day operations
To understand the ethical, professional, and legal obligations associates have and our role in meeting those obligations
Integrity
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Principles of Compliance
As healthcare professionals and providers,
we are dedicated to caring for and
improving the health and well being
of the people we serve in the community
Compliance means “doing the right thing”
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Catholic HealthAttain compliance by:
Embracing our Mission and Values
Adherence to Policies and Procedures
Found in Compliance 360
Maintaining high standards of business
and ethical conduct
Delivering high quality patient care
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Important Keys to CH Compliance
Standards of Conduct & Ethical ConductDeal openly and honestly with otherMaintain high standards of conduct in accordance to the CH Mission, directives of the Catholic Church, and applicable federal, state and local laws and regulations
Documentation and BillingMust be accurate and complete
Conflict of InterestWe have a responsibility to act on the best interests of Catholic Health. We need to avoid situations that lead to actual or perceived conflicts of interest
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CH Standards of Conduct
Associate Compliance Guidebook
Provides information on the Standards of Conduct. Available on CH website.
An observation of failure to follow Standards of Conduct, Policies or Procedures, or observation of an error requires reporting.
Associates can face disciplinary action and even termination for failure to report such events.
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CH Standards of Conduct
Promotes ethical behavior in the workplace every day
All associates are expected to follow standards for:
Legal and Regulatory Compliance
Business Ethics
Conflict of Interest
Appropriate Use of Resources
Confidentiality
Professional Conduct
Responsibility
And to follow the Code of Ethics
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Creating a Culture of Service
Enhance the Patient Experience
Have a questioning attitude
Pay attention to details
Follow the rules
Be accountable for your actions
Providing high quality services
and upholding patient rights
supports the Compliance Program.
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Compliance policies and procedures are available onCompliance 360
(or in an on-site reference manual)and apply to all CH associates.
Additional compliance policies are applicable to:HospitalClinical LaboratoryPhysician PracticesNursing FacilitiesHome Health Agency & Infusion Pharmacy CH- LIFE
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It is fraudulent to either document services that werenot performed or to submit claims for services withoutappropriately documenting those services.
Missing clinical notes or test results, (dates, signatures, orders, care or service rendered)incomplete or illegible documents, orimproper billing and coding
can be interpreted as fraud or abuse and lead to a false claim with the government resulting in penalties.
Reimbursement can only be sought for services or itemsthat have been provided and appropriately documented.
If it’s not documented, it’s not done.
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It is a crime to knowingly make a false record, file, or submit a false claim
with the government for payment.
A false claim can include billing for service that: was not provided or documented
was not ordered by a physician
was of substandard quality
improperly coded or billed
Allows for Qui Tam Relator – notification to government with protection (Whistleblower provision)It is also unlawful to improperly retain overpayments.
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Government Sanctions
Individuals or entities can be excluded from participation in Medicare and Medicaid programs.
CHS must not submit any claims to Medicare and/or Medicaid in which a sanctioned individual or entity provided care or services.
If an associate/provider is sanctioned,he/she must provide notification
immediately to the Compliance Officer.
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If working on behalf of CH, do your actions or activities result in
• personal gain or advantage, • potential adverse effect for CH or • the potential to interfere with professional
judgment, objectivity or ethical responsibilities?
Potential conflicts of interest relationships includefinancial relationship for yourself or your immediate family member or secondary employment as
ConsultantSpeakers’ BureauAdvisory PanelAdministrative positions with Pharm or DMEThird Party PayorOther entities doing business with CH
All potential Conflicts of Interest must be reported.
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Gifts and other Free Items
Associates may NOT accept any cash gifts or cash equivalent gifts (gift cards) from any person or business conducting or seeking to conduct business with Catholic Health
Prior to receiving work-related
• Gifts• Social or entertainment events• Free meals
Associates must consult with their supervisor.
See CH Policy for further information.
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Patient Communication Assistance
Language Assistance Ensures that limited English proficient or hearing impaired persons are able to
understand and communicate with CH associates & physicians.
Language Assistance isprovided FREE of charge to the patienta MANDATORY service by lawand needs to be DOCUMENTED
Language Assistance information can be found in the Communication Assistance Policy
Blind or Visually Impaired PatientThe hospital must “offer” pre-admission information or a patient discharge plan in enlarged print to the visually impaired patient. If a blind patient requests an audio of the above documents, follow policy or check with your manager.
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HIPAA Patient Privacy/Confidentiality
HEALTH
INSURANCE
PORTABILITY
ACCOUTABILITY
ACT
and new regulations of
HITECH and the Omnibus Rule
Privacy and Security Policies are found in Compliance 360
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What is Protected by HIPAA?
Individually identifiable health information
also known as
Protected Health Information (PHI)
Transmitted or maintained in any form or medium
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Protected Health Information
NamesFull face photosMedical Record NumberHealth Plan NumberAccount NumbersCertificate/License NumbersVehicle IdentifiersE-mail and web addresses
Biometric IdentifiersGeographic subdivisions smaller than a stateAll elements of dates related to birth date, admission, discharge, or date of death, ages over 89Telephone and fax numbersSocial Security Number
Any other unique identifying data
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When Can Protected Health Information (PHI) Be Shared?
for
Treatment, Payment or Health Care Operations
or unless an authorization has been signed
or an exception is met.
Access, Acquire, Use, or Disclose theminimum necessary
related to your job function and that of the other person’s job function
Access, use, or disclosure other than above is UNAUTHORIZED!
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HIPAA Safeguards
Be aware of surroundingsBe conscious of who is in the immediate area when discussing sensitive patient information or at your computer terminal (lower your voice)
Secure area when not attendedLog off of computer screens containing PHI before leaving the areaClose medical records/chart when not in useDo not allow other associates to utilize your passwordReport theft or loss of computer devices immediately
Correctly Dispose of PHI Use of shred bin
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Additional HIPAA SafeguardsTelephones
Be careful with phone call pertaining to patient information
Fax Machines and ScannersPick up faxed or printed PHI immediatelyUse fax cover sheet, verify # and receiptScan PHI only to CH e-mail accounts
E-MailEncrypt e-mail sent outside CHCareful forwarding and replying
MailDouble check name/address and material prior to sending
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Computer Security Policies
Computer accounts and passwords are confidential and are not to be shared with othersDo NOT download any programs or software without permission from the IT departmentNever leave Mobile Computing Devices (ie. Laptops, etc) unsecured and report thefts immediatelyDo NOT open suspicious e-mail attachmentsDo NOT respond to SpamDo NOT post patient PHI to Social Media sitesDo NOT text PHI via unsecured means
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Curiosity can be a normal human trait …however accessing health information or disclosing PHI on family members, friends, co-workers, persons of public interest or any others that is not related to your work responsibilities is … VIOLATION of HIPAA
Computer use is monitored.
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Associates viewing their own Medical Record.
It is a violation of CH policy for an associate to look up their own medical record
Associates may file a written request with Health Information Management for
their medical record information OR
Associates are encouraged to utilize the Patient Portal for direct secured access
to their medical information.
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Compliance ConcernsFraud and Abuse
Fraud Defined: An intentional deception or misrepresentation that could result in some unauthorized benefit to a person or Catholic Health
Abuse Defined: Practices that are inconsistent with sound fiscal, business, or medical practices, and result in unnecessary cost, or in reimbursement of services that are not medically necessary or that fail to meet professionally recognized standards for health care
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Compliance ConcernsInaccurate, incomplete, or missing Documentation
Improper billing and coding
Offering or receiving kickbacks, bribes, or rebates
A service has not been rendered by the identified provider, to the identified person, or on the identified date
Failure to comply with government rules and regulations affecting healthcare
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Additional Compliance ConcernsLack of integrityEthical incidentsTheft or misuse of servicesImproper political activityBreech of corporate confidentialityImproper use of proprietary informationEnvironmental health and safety issuesDishonest communication (spoken or documents)Improper business arrangementsFailure to follow Record Retention policyReceipt of incentives for patient referrals
The Associate Guidebook or your supervisor can provide additional info.
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3 Steps to Reporting Compliance Concerns
Immediate supervisor or appropriate department
Higher level manager
Compliance OfficerLeonardo Sette-Camara, Esq.
821-4469
Also available 24/7Compliance Line 1-888-200-5380
Confidential. Anonymous (if desired)
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Human Resources ConcernsBehavior issues
Human Resource policy violations
Union contract matters
Any of above should be reported to Human Resources
HR Policies on Compliance 360 include:
Corrective Action
Fair Treatment Review
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Catholic Health Non-Retaliation PolicyProtects associates from adverse action when they do the right thing and report a genuine concern
Reckless or intentional false accusations by CH associates are prohibited
Reporting the possible violation does not protect the constituent from the consequences of their own violation or misconduct
Associates have a duty to report HIPAA/Compliance concerns
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CH Associate's ResponsibilityUpholding CH Mission and Values
Adhering to Code of Conduct, Policies and Procedures and the Law
Completing education and employment requirements
Constant monitoring for concerns
Duty to report concerns and support non-retaliation
During an investigationBe truthful
Preserve documentation or records relevant to ongoing investigations
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Possible Consequences for Non-Compliance
For CH associates
Fines and Prison sentences
Corrective action
Includes possible termination of employment
for violations or failure to report concerns
For Catholic Health System
Exclusion from government funded insurance programs (Medicare/Medicaid)
Fines
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Do You Walk the Talk?
Putting words into action …
“We judge ourselves based on our intentions …
others judge us based on our actions.”
Adhere to the CH code of conduct, policies and procedures, and other standards.
Uphold Catholic Health Values.
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Things to RememberDuty to report Compliance/HIPAA concerns as soon as aware of situation
Do the right thing …
Apply ethical decision making
If uncertain …
Always Seek Knowledge (A.S.K.)
Use Associate Booklet on CH website as a reference
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CH Compliance Contacts
Corporate Compliance and HIPAA Privacy Officer Leonardo Sette-Camara, Esq. 821-4469
CH HIPAA Hotline 862-1790
Compliance Hotline 1-888-200-5380 (available 24/7)
All reports are confidential.
