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Monitoring Continues in the World of ICD-10

Source

: ICD‐10 M

onito

r

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2016

“With many code assignments currently being paid in accordance with quality 

measures and assignments, using a code with less 

specificity when more detailed information is found in the medical record can hurt your bottom line. It’s also important 

that you work with your physicians on clinical 

documentation improvement.”‐Rhonda Buckholtz

Hypertension in the New World of Ten 1/18/16

Movie: “Concussion”

CTE F07.81Along with many more codes to describe the symptoms, injury and External Cause Codes

‐Laurie JohnsonChronic Traumatic 

Encephalopathy (CTE) and ICD‐10 1/11/16

ICD‐10 Coding Assessments

‐Deborah GriderSurviving in an ICD‐10 

World 1/18/16

*Importance of External Cause Codes*Differences between I‐9 and I‐10

*Coding tips‐Cathie Wilde

Take Advantage of Expanded External Cause Codes in ICD‐10 1/11/16

HCCA 2016 Compliance InstituteSession 101

Cindy CainBetty BibbinsNicole D. Harper Bess Ann Bredemeyer

Monday April 18th, 2016 11:00

ICD-10, 6 Months In:

Impact.Obstacles.Response.Compliance?

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Interactive audience discussion of challenges (or responses) in clinical documentation & revenue cycle compliance experienced with the implementation of ICD-10.

Identify initial challenges and impactful responses that have evolved in compliance since implementation of ICD-10.

Identify evolution of documentation - coding -billing interface dynamics since implementation of ICD-10.

ICD-10, 6 Months In:Impact. Obstacles. Response.Compliance?

Impact

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CMS Announces ICD-10 Claims Metrics for October

According to the CMS’ first reported metrics, CMS has received 4.6 million Medicare fee-for-service claims per day since the commencement of ICD-10 on October 1.

The results? CMS deemed the transition a successful one.

CMS ICD-10 Claims Metrics Detail

Of claims processed throughout October 2015:

10.1% of claims processed have been denied

2% of those denials were due to incomplete or invalid information

0.09% of those denials were due to invalid ICD-10 codes

0.11% of those denials were due to invalid ICD-9 codes

Will we know how well organizations are doing until we get through a least a fiscal year of claims payment activity post ICD-10 implementation?

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Are You Experiencing this?

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Day 1 Day 15-20 Day 20-25 Day 26-30 Day 30-35Claim file to payer Payer processes

claim fileRemit rec’d; pmts & adjs posted

Follow-up done on $1,000.00

$5,000.00 Pmts - $3,000.00 Adjs - $1,280.00Pat – $320.00Not processed –$1,000.00

Day 1 Day 15-20 Day 20-25 Day 26-30 Day 30-35 Day 36 -Claim file to payer Payer processes claim

fileRemit rec’d; pmts & adjs posted

Follow-up done on $1,500.00

$5,000.00 Pmts - $2,500.00Adjs - $800.00Pat – $200.00Not processed –$1,500.00

Post ICD-10 Implementation

Pre ICD-10

Revenue Process

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Client Management

3rd Party Payer Follow Up

Patient Billing &

Collections

Payment Posting

Denials & Appeals

Management

Claim Submission

Patient Identity & Address Verification

Insurance Eligibility

Verification

Medical Necessity & Authorization

Registration & Scheduling

Point of Service Cash Collections

Charge Capture &

Entry

Call Center

Procedure& Diagnosis

Coding

Reporting& Analysis

Payer Contract Management

& Credentialing

Every part of the revenue cycle process has been affected by ICD-10.

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Impact on Claims

• Decreased productivity

• Pay Lag

• Increased Denials

• Accurate NCD’s / LCD’s

• Edits based on back mapping to ICD-9?

6- Month Mark

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Sample of ICD-10 Practice DenialsCoding Denials Comparison

3-Month AVG October November December

Aggregate $ 26,277,594 $ 33,305,601 $ 31,128,122 $ 35,992,725

Denials Increase $ $ 7,028,007 $ 4,850,528 $ 9,715,131

Denials Increase % to Avg 27% 19% 37%

Top Diagnosis Related Coding Denials

October November December

CO50 Deemed Not Medically Necessary

Denials Increase % to Avg 17% 31% 60%

CO11 Diagnosis Inconsistent with Procedure

Denials Increase % to Avg 17% 6% 1%

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Obstacles

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Obstacles

• Hand-Key errors

• Physician Documentation

• LCD/NCD

• Payers

• New Code Updates/ Application of PCS Codes

• System Constraints

6-Month Mark

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Ambulatory Care Providers

For 1 year after implementation of ICD-10…

AMA and CMS agreed to NOT deny claims submitted if non-specific ICD-10 codes are used.

Is this an October 2016 Obstacle…?

Hospital Providers

QIO 2-Midnight Stay Review…QIO Assumes responsibility for 2-Midnight Stay compliance review, October 1, 2016

Inpatient vs. Outpatient Observation Status

Is this an October 2016 Obstacle…?

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Response

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Response

• Monitoring Payer trends and activities

• Coding and documentation reviews

• Ongoing Feedback and Education

• Payment & Denial Follow-Up

What should you be doing?

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The Road to SuccessResponse

• Ongoing collaboration among Coding, Physicians, Case Management, and CDI

• Metrics, Monitoring, Tracking, Reporting

• Enhance CDI Strategy with Physician Champions/ Liaisons

• Review of rules impacted, i.e. Inpatient vs. Observation status, 2 Midnight rule

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ResponsePreventing Denials

Registration

• Denial problems can start before the first ICD-10 code is recorded.

Medicaid

• Can comprise 13 percent of all denials. Start with checking eligibility, medical necessity and pre-authorization.

High Impact Specialties

• Specialties contribute heavily to major amounts of claim denials. Determine your High Impact Specialties.

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Compliance

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• Increasing focus on payment for quality and medical necessity

• Reimbursement impact

• CMS flexibility on an overpayment analysis

• Meaningful use impact

How has the Transition Affected Compliance Departments?

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Key Compliance Indicators

• Communication

• Monitoring and Auditing

• Education

• Policies and Procedures

The Road to Success

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What We’ve Learned

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Compliance

• Better data equals better information

• Ability to track healthcare trends

• Ability to track and monitor quality indicators

• Meaningful use impact

What We’ve Learned

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Aspect Experience Call to Action

Payer ResponsesPayers processes have stabilized and 

on targetContinue to monitor payer turnaround lags

Payments ICD‐10 claims – receiving paymentsScrutinize level of payment for accuracy as 

well as deposit lags

DenialsEvidence of increase in Coding denials 

– continued discoveries

Action plan for deep dive discovery, root cause determination and remediation/recovery

Unspecified Reports of unspecified codes on the 

riseReview unspecified codes with coding team 

to understand cause 

Monitoring Continues in the World of ICD-10What We’ve Learned

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Documentation Really Does Matter

The expectation for sufficient documentation is well rooted in good medical practice, according to § 1156 of the Social Security Act,

“…supported by evidence of medical necessity and quality in such form and fashion and at such time as may reasonably be required by a reviewing quality improvement organization in the exercise of its duties and responsibilities…”

Front Load the Medical Record

QIOs will expect complex medical factors to be documented in the physician assessment and plan of care.

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Tips

• Look for Trends

• Compare Denials - Documentation

• Identify, Report, Track ICD-10 Issues

6 Month Mark

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Questions

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