4/23/2014

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ICD-10

Are we Ready?

Presented by: Lynn HandySenior Director Professional Coding &

Education

Altegra Health

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HCCA 2014 PUERTO RICORegional Area Compliance Conference

ICD-10 Delay Polling Question

�We have an ICD-10 implementation plan and we are sticking to it

�We have an ICD-10 implementation plan but we will delay portions

of it due to the delay

�We have an ICD-10 implementation plan but were behind in

executing so the delay will help us catch up

�We did not have an ICD-10 implementation plan, but we will get

started now. The delay was very helpful

�We did not have an ICD-10 implementation plan, don’ t believe it will

ever happen

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Agenda

�ICD-10 Training

�Why?

�Who?

�What?

�Where?

�When?

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Why?

�Providers will continue to be reimbursed by their CPT/HCPCS codes

�But the ICD-9-CM/ICD-10-CM will provide the medical necessity for reimbursement

� If the diagnosis code is invalid, the provider will most likely not

get paid.

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Why?

�Because we have too!!

�Because we don’t want to see a drop in reimbursement

�Because we don’t want to see an increase in denials

�Because compliance says we need better documentation to support the new ICD-10-CM diagnosis codes

�Because the Hospital needs better documentation to support the ICD-10-PCS codes they must report

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ICD-10-CM at a glance

Procedure CodesUsed to describe WHAT services/ supplies provided

HCPCS(For other than

hospital inpatients)

HCPCS Level 1CPT Codes (AMA)

Category 1Items commonly

accepted in clinical practice

Category IIUsed to track performance

measures

Category IIINew / emerging

technologies

HCPCS Level 2(CMS, BCBSA,

AHIP)

ICD-10-PCS(For hospital inpatients)

ICD-10-CMUsed to describe WHYservices are rendered

Volume 1: Tabular listing of medical

conditions, causes and/or status

Volume 2: Alphabetic index

(Used first in locating condition in Volume 1)

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Code Comparison: Diagnosis Codes (“CM”)

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ICD-10-CM Major Modifications

�Expanded codes for specificity (e.g., diabetes, reasons for encounters, other factors influencing health)

�Added code extensions for injuries and external causes of injuries

�Expansions for laterality

�Combination codes for diagnosis and symptoms

�Full code titles

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Benefits to ICD-10

�Fewer queries and/or requests for additional clarification

�Fewer denials based on medical necessity

�Financial impact for VBP, ACO and other quality driven incentives

� Improved clinical outcomes

� Patient‐related risk factors

� Treatment effectiveness

� Quality of care rendered (metrics)

� Death, Complications, Readmissions, Length of Stay

� Predictors

� Resource Intensity, Severity of Illness, Risk of Mortality, Risk of Complications,

Risk of Readmission

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Challenges of ICD-10

� Insurance plan coverage limitations may be affected� Authorization requirements

�New policies and procedures for impacted part of the revenue cycle� New coding system will mean new coverage policies, new medical

review edits, new reimbursement schedules

�Challenges may occur with vendor contracts

�Budgets affected

�Cash Flow October 1, 2015?� Expect increased rejects, denials, and pends as both plans and

providers get used to new codes

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Unspecified Codes

�Imprecise documentation can be captured in both ICD-9-CM and ICD-10-CM codes

�Work toward better documentation to�Avoid misinterpretation by third parties (auditors, payers,

attorneys, etc.)

� Justify medical necessity

�Provide a more accurate clinical picture of quality of care provided

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Why?

�Physicians do not need to know precisely how the system works, but the importance of operative report documentation is vital! Coders will need to translate the clinical information from the physician’s operative report into the new ICD-10-PCS system. In most cases, the process will be transparent to physicians. However, incomplete documentation will result in queries, thus delaying the billing process

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Code Comparison: Inpatient Procedure Codes (“PCS”)

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What is Missing From Operative Reports?

�Harvesting Saphenous Vein� ICD-10-PCS provides detailed descriptions for body parts. � For example, saphenous veins are commonly used conduits for

surgical revascularization of coronary arteries. During coronary artery bypass grafting, a healthy saphenous vein is grafted around the blocked portion of a coronary artery.

� In ICD-10-PCS, there is a choice to be made between Greater Saphenous and Lesser Saphenous. Without this piece of documentation, a coder cannot select the correct code. Even if it is obvious to the surgeon, documentation should state the exact vein that was excised or resected.

�Colon� Under ICD-9-CM, a biopsy of the colon is assigned a code based

on technique (open or closed).

� In ICD-10-PCS, all procedures of the colon, whether resection, biopsy or otherwise, are assigned a code based on the exact site. For example, was the biopsy of the ascending, descending, sigmoid or transverse colon?

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Who? Impacted Areas

� Patient intake

� Eligibility determination

� Authorization

� Certification

� Scheduling

� Care management/disease management (including clinical documentation)

� Coding and supporting clinical documentation requirements

� Billing and reimbursement (including diagnosis-related group (DRG), capitation rates, case rates and per diems)

� Contracts and fees

� Payment reconciliation (including denial management)

� Regulatory and compliance reporting

� Quality assessment and management

� Case mix and population risk assessment

� Audit response

Hospitals and medical groups must understand, anticipate, and address the impact of the ICD-

10 transition on revenue cycles and clinical, compliance, reporting and operational systems.

This includes but is not limited to the following functional areas:

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Who?

�Let’s focus on the provider’s

�Physicians

�NPP (NP, PA, etc)

�Physician education is one of the biggest concerns in Hospitals, Medical Groups and Healthcare Systems.

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CDI and Physician Education

�Below is a poll by ICD-10 Monitor in January 2013

Response Ratio

Creating a CDIP 11%

Re-evaluating your CDIP 9%

Staffing your CDIP 6%

Educating your CDIP staff 12%

Educating Physicians 63%

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Provider Education Polling Question

�We have started ICD-10 provider training and will continue

�We have started ICD-10 provider training but will stop due to

the delay (will restart later)

�We have planned ICD-10 provider training but will delay now

�We have planned ICD-10 provider training and will start as

planned

�We have no ICD-10 provider training planned yet

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What?

�CDI programs have been in place for a long time

�Documentation improvement is just as important as it has always been.

�Teach the providers what they need to know within their specialty

�Show them examples of their own notes and what needs to improve

�Specific training

�Targeted training

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What? Documentation Improvement

�Identify medical record documentation improvement opportunities – ICD-10-CM does not require an increase in quantity of

documentation, however, high quality documentation will increase benefits of the new coding system which is increasingly being demanded by other initiatives

�Analyze ICD-9-CM frequency data and focus educational efforts on most frequently-coded conditions�Perform an “Education Gap Analysis”

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Inpatient Documentation Improvement Plans

� It is important to plan and coordinate a strategy for ICD-10 PCS implementation. For healthcare facilities, tackling your 10-20 most frequently performed surgical inpatient procedures first and holding a weekly coding roundtable discussion to communicate findings should be part of the plan.

�The outcomes of these activities can be used to help establish a communication plan with physicians as well as to evaluate the need for coding training sessions. Such a communication plan can include monthly articles in newsletters as well as inviting surgeons to the coding roundtables..

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Training Tips

�Start small and train often

�Do not overwhelm the physicians

�Have an agenda and stick to it

�Customize the training sessions for the specialty

�Review how the codes in their specialty have been improved

upon, are more granular and consist of greater specificity. Explain

how the new codes will support their patients’ stories accurately

and completely

�Let them know what they are already doing correctly

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At a glance ICD-9 CM v. ICD-10 CM

�Detailed documentation will be required to support greater specificity

ICD-9-CM ICD-10-CM

493.92 Asthma, Acute

Exacerbation

J45.21 Mild, intermittent, w/acute

exacerbation

J45.41 Moderate, persistent, w/acute

exacerbation

J45.51 Severe, persistent, w/acute

exacerbation

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Training Example

� Orthopedic Physicians

�Be prepared with key training items

� ICD-10-CM Ortho coding will be based on the following key

documentation items:

� Location

� Laterality

� Type of Fracture

� Type of visit

ICD-9 ICD-10

822.0: Patella Fracture, closed S82.025A: Nondisplaced Longitudinal

fracture of left patella, initial encounter

for closed fracture

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Renal Failure

�Acute:

�With cortical necrosis, medullary necrosis, tubular necrosis

�Acute kidney injury (non-traumatic)

�Chronic:

�Stage?

�Due to hypertension? Due to diabetes?

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Hemiplegia

� This is a 69-year-old patient who presented with slurred speech. Went from Mesa

Christian Healthcare Center, also have altered mental status. The patient was being

treated for a femur fracture, status post fall. The patient was admitted and was seen

by neurology, had MRI, PT, OT. The patient slowly improved. Doing better. She is

back to her normal baseline. The patient will continue her PT, OT. Okay by

neurology to be transferred.

� FINAL DIAGNOSES:

1. Cerebrovascular accident

2. Multiple sclerosis

3. Spastic hemiplegia

(ICD-10-CM- Indicate affected side and dominant side)

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Physician Champions

�There is always a physician or two with your organization that

loves a challenge

�Recruit them for your education team. Leverage their skills in

creating the training curriculum and assisting with delivering the

training

�They are always willing to let you know what will work and what

will not and why

�They can assist you with breaking down barriers with physicians

who do not accept change

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ICD-10 Humor

�The specificity of ICD-10-CM can sometimes be Hilarious!!!!

�Funny ICD-10 Articles

�Healthcare IT News, by Michelle McNickle and Kelly Mehler

@HITNews Tweet, 2/6/2012

�Wall Street Journal, “Walked into a Lamppost? Hurt While

Crocheting? Help Is on the Way” by Anna Wilde Mathews,

9/13/2011

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Health plans may never again wonder where a

patient got hurt!

�Locations

�Opera houses

�Art galleries

�Squash courts

�9 locations in and around mobile homes

�Swimming pool of prison

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Injuries during a specified activity

�While sewing

� Ironing

�Playing a brass instrument

�Crocheting

�Doing handcrafts

�Knitting

�Accidental striking against or bumped into by another person, initial encounter

�Pedestrian on foot injured in collision with roller-skater, subsequent encounter

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Specific Injuries

�Burn due to water-skis on fire

�72 codes about injuries tied to birds

�312 animal codes in all (we currently have 9)

�Struck by lightning, subsequent encounter

�Dependence on other enabling machines and devices

�Spacecraft crash injuring occupant, initial encounter

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Rural Humor

�Pecked by chicken, initial encounter

�Bitten by pig, initial encounter

�Bitten by other hoof stock, initial encounter

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Add Technology

�Cell phone and Tablet APPS

�AHA Press

�Find A Code (Free)

�AHIMA

�Android Search: 164 APPS

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Where?

�Grand Rounds

�Department meetings (already scheduled)

�Specialty department training

�1:1 provider feedback

�Webinars: Live or recorded

�On-line modules

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When?

�Pre-Training preparation should be going on now!!!

�Charge Tickets/Superbills

�EMR Database

�EMR Pick List (Favorites)

�Crosswalks from ICD-9 to ICD-10

�Documentation review

� What is missing?

� Is anything missing?

� Education Gap Analysis

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Templates, Forms and the EHR

�Start now to modify your existing forms and templates to allow for the increased specificity of ICD-10

�Laterality

�Specificity

�Location

�Timing

�Forms can be modified to capture key elements required for ICD-10 code capture

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Compliance and CDI Partnership

�Routine involvement in partnering committees

�Track Query trends and response time

�Coder/CDI feedback on EHR template builds

�Enhanced Documentation does not have to be restricted to ICD-10 implementation!!

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When?

�Continue training or Start now

�Introduce ICD-10 (Overview, why is it better)

�Provide Specialty Specific Training

�Have an agenda and outline

�Keep the training sessions to 30 minutes

�Build on the content and reinforce previous sessions

�Train to the physicians strengths and weaknesses

�Don’t waste the physicians time

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Resources

� http://www.infosysblogs.com/healthcare/2010/01/icd_10_uncertainty_around_prov.html

� www.InfoSysBlogs.com

� www.cms.hhs.gov

� Ingenix Draft ICD-10-CM/PCS Manuals

� http://www.healthcarefinancenews.com/news/experts-predict-top-10-payer-trends-2010

� http://news.avancehealth.com/2009/01/icd-10-no-time-to-relax.html• http://www.cms.hhs.gov/ICD10/09_ICD10_MS_DRG_Conversion_Pr

oject.asp• www.cms.hhs.gov/MLNMattersArticles• AAPC, AHIMA, AHA, AAFP, MGMA, AMA, CMS, OIG, WHO

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Thank you!

Lynn HandySenior Director of Professional Coding Services

and Educationlynn.handy@altegrahealth.com

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