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ICD-10 FINAL

COMPLIANCE PUSH AND

COUNTDOWN

HCCA

Southwest Region Conference

November 2013

SPEAKER

�Gloryanne Bryant, RHIA, RHIT, CCS, CDIP, CCDS

� 30+ year HIM Professional and Leader

� CHIA Immediate Past-President� National Director Coding Quality, Education,

Systems and Support

� National Revenue Cycle,

� Kaiser Foundation Hospitals and Health Plan - Oakland, CA

The opinions and comments expressed during this presentation are those of the speaker and not of Kaiser Permanente or that of CHIA.

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DISCLAIMER

� This material is designed and provided to communicate information about clinical documentation, coding, and compliance in an educational format and manner.

� The author is not providing or offering legal advice but, rather, practical and useful information and tools to achieve compliant results in the area of clinical documentation, data quality, and coding.

� Every reasonable effort has been taken to ensure that the educational information provided is accurate and useful.

� Applying best practice solutions and achieving results will vary in each hospital/facility and clinical situation.

GOALS & OBJECTIVES

� Where are the potential gaps as we Countdown

� Documentation and Reimbursement

� People, Process and Technology Readiness

� Coding Productivity Plans

� Check list for HIM, CDI and others

� Review your final educational needs and plans

� Going Live and Questions to Ask

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ICD-9 VS ICD-10

� While the coding process is the same, there are

distinct differences...

ICD-9:

3-5 characters

First character is numeric or alpha

Characters 2-5 are numeric

ICD-10:

3-7 characters

First character is alpha

Characters 2-7 are alpha or numeric

ICD-10 CODES ARE

THE FOUNDATION FOR

REIMBURSEMENT AND MUCH

OF YOUR PRACTICE ANALYTICS.

ELECTRONIC DATA INTERCHANGE

(EDI) IS THE TRANSPORT TOOL

FOR YOUR CLAIMS AND MEETING

COMPLIANCE.

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COUNTDOWN

Provider readiness seems to vary depending

on the size of the organization. Larger

hospitals and physician practices are mostly

faring well, but smaller ones may be

struggling to stay on track, says Sue

Bowman, MJ, RHIA, CCS, FAHIMA,

AHIMA’s senior director of coding policy and

compliance.

COUNTDOWN . . .

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WHAT ARE YOUR ICD-10

IMPLEMENTATION GOALS?

� Eliminating protection of coder productivity

� Avoiding any unfavorable financial impacts

through the analysis of current coding and

documentation patterns

� Minimizing disruptions in patient throughput in

the outpatient setting

� Ensuring that physician documentation is ICD-

10 compliant

� Implementing information systems to support

the work and compliant claims

� Education and training of staff

• MAKE SURE THERE ARE SUFFICIENTPROJECT MANAGEMENT SKILLS

ON YOUR TRANSITION TEAM. YOU

NEED SOMEONE SEASONED IN

FACILITATING CROSS-FUNCTIONAL

COOPERATION, ACCURATELY

ESTIMATING TIME AND RESOURCE

REQUIREMENTS, AND MANAGING

HUNDREDS OF TO-DO ITEMS.

COMPLIANCE READINESS CHECKS

SHOULD BE IN PLACE.

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READINESS AND IMPACT AREAS?

�Education & Training

�Systems

�Contracts and Coverage

�Documentation and Coding

�Cash Flow (DNFB)

�Billing and Collections

�Compliance and Risk

WHO IS MY DEDICATED ICD-10 CONTACT

PERSON?

�Find a point person you can speak to

directly, and make sure he or she is high

enough in the organization to give you

meaningful answers in a timely manner.

�A leader and leadership.

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• ICD-10 INTENSIVE TRAINING FORCODERS SHOULD OCCUR EIGHT TO

TO SIX MONTHS PRIOR TO

IMPLEMENTATION. THEN “PRACTICE”.

• REMEMBER THAT

IMPLEMENTATION SHOULD

OCCUR AHEAD OF GO-LIVE FOR

THE PURPOSE OF TESTING AND

RESOLVING PROBLEMS.

EDUCATE YOUR STAFF

�Education and training

�Your staff will need to be as close to

“experts” as they can get on ICD-10

when it comes October 1, 2014.

�Arrange for education and training

for all staff that will use the new

codes.

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EDUCATION AND TRAINING

� Education and Training – Education and training will be a large expenditure. Everyone in the medical practice will require both. In general:

� Providers will need approximately eight to 16 hours of training.

� Depending on current use of the code set

� Nurses will need an introduction to ICD-10-CM with six to 10 hours of training.

� Depending on current use of the code set

� Coders will need 40-60 hours of training, depending on specialty.

� Ancillary staff will need six to 10 hours of training

CODING READINESS & IMPACT

� Coding quality – how accurate are you today?

� MS-DRGs – shifts to be expected?

� Reimbursement

� Compliance

� Dx accuracy: IP and OP

� Medical Necessity

� Compliance

� Run some data reports and analyze

� Software update

� Encoder

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HIM CODING READINESS

� Inventory Physician Queries

� Review and Revise

� Create New Physician Queries

� Compliant

� Inventory P&Ps that contain ICD-9 codes and

descriptions

� Review and Revise

� Create New Policies

CDI READINESS

� Awareness, Education and Training

� Physician Queries

� Tracking tool and systems

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ELIMINATING IMPACT TO CODER

PRODUCTIVITY

� Turn to technology to help address this goal. implementing a computer-assisted coding tool within your organization. “We want to get this tool in place well before the switch to ICD-10 so we can get past the learning curve before the code sets change.”

� To further enhance productivity, CHE also partnered with a local community college to provide online training to coders systemwide in anatomy and physiology. “Because the level of detail is much greater in ICD-10, we wanted to supplement coder knowledge and be sure all received the same level of training,” comments Fry.

� Evaluate coder backfill strategy and coder retention plan.

WHEN WILL YOUR ICD-10 COMPLIANT SYSTEM

BE READY?

�Vendors

�Beta testing

�Updates

�Checks and balances

�Providers, payers, clearinghouse, etc.

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ARE THERE ANY ADDITIONAL COSTS INVOLVED

FOR IT UPGRADES OR ONGOING MAINTENANCE?

�Check with Vendors

�Engagement with IT

�Interfaces

�Planning

�Budgeting

• CMS IS PROVIDING GENERALEQUIVALENCY MAPPINGS (GEMS)

TO HELP IN THE DEVELOPMENT

OF CODE MAPPING TOOLS THAT

COMPARE ICD-9 TO ICD-10

CODES. CMS IS ALSO HOSTING

FREE TELECONFERENCES TO

HELP PROVIDERS PREPARE FOR

THE TRANSITION TO ICD-10.

YOU CAN FIND BOTH OF THESE

RESOURCES BY VISITING

WWW.CMS.GOV/ICD10.

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WHAT IS THE BASIS OF YOUR CROSSWALK OR

MAPPING STRATEGY?

� GEMs … limited utility as a crosswalking

platform

� Challenges of translating ICD-9 into ICD-10

� “A practice management vendor told me earlier

this year that they were ready for ICD-10 in the

US because they downloaded ICD-10 from the

World Health Organization (WHO) website

rather than using ICD-10 CM and ICD-10 PCS,”

recalls Sue Bowman, MJ, RHIA, CCS of AHIMA.

WILL YOUR PRODUCT SUPPORT DUAL CODING?

�Dual processing

�Dual coding

�Plan to include dual coding in your

implementation plan

�Benefits of dual coding

�Systems ready for dual coding?

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MORE CODES MEAN BETTER ANALYSIS

� Richer set of data for practice analysis.

� Use your electronic medical record

solution, ICD-10 should enable improved

outcomes analysis that will help enhance

your quality of care.

� The new ICD-10 codes combined with

patient financial data will better prepare

your practice to demonstrate physician

quality reporting systems (PQRS) and

address other pay-for performance

programs.

CDI READINESS

�Go through ICD-10 education session

�Work very closely with HIM

�Conduct an internal ICD-10 analysis data

� Areas of documentation improvement

�Slowly start to query for key areas of

documentation for ICD-10

�Use technology to help ie EHR

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DOCUMENTATION

� Gap analysis/audit

� The completeness of documentation/coding has

never been as important as it is now!

� Increased queries to clinicians:

�Watch for query fatigue

� Increased time in digging for diagnoses:

�Cut and paste in progress notes

� Need more documentation to support the third

party audits:

�Blue Cross audits

�RAC Audits

DOCUMENTATION

� ICD-10 Documentation Gap Analysis:

� Evaluating the adequacy of documentation in

preparation for ICD-10 coding. Audit sample size

commensurate with hospital bedsize.

� Review / ICD-10 coding of targeted sample of

inpatient records – includes assessment of DRG

impact within the record sample

� Review / ICD-10 coding of targeted sample of

outpatient records – includes assessment of

impact to coverage policies within the record

sample

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PHYSICIANS

� Awareness

� Engagement

� Need to develop service specific education such

as:

� Cardiology

� Orthopedics

� GI surgery

� Work with physician advisors to assist in

education efforts

� Share information and data

� Enhance lines of communication

PLAN FOR ICD-10 REJECTION

� Establish close communications with billing

companies and billing departments

� Watch for:

� Lower than expected reimbursements on medical

claims.

� Cash flow slow down

� More rejection and denials by healthcare payers.

� Longer payment cycles for medical claims.

� Fewer returned phone calls from healthcare payers.

� Coders and Billers quit

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I-10 BRINGS ABOUT COMPUTER ASSISTED

CODING

� When a CAC system is utilized, it systematically

works to extract information from the medical

record and assigns ICD-9 and/or ICD-10 codes to

the medical record for review and overall Plan

submission for payment.

� CAC systems use what is called “Natural

Language Processing,” or (NLP), in order to

review and extract from plain-text

documentation, which the CAC then makes a

determination on whether the documentation

requires an ICD code for assignment.

POA COMPLIANCE

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DRG REIMBURSEMENT SHIFTS

PROFICIENCY AND VALIDATION

� Do you have this in place?

� How is compliance obtaining confidence in all the

workflows and areas for ICD-10 readiness?

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PRE GO-LIVE

� Lower your coding backlog

� Catch up

� Overtime and/or contract coding

� Secure your contract coding support

� Lower your billing backlog

� Test and check systems

� Check list review

� Establish a “command center”

GO-LIVE

� Business office and billing

� Case Management/UR

� CDI (Clinical Documentation Improvement)

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GO-LIVE 10/1/2013

� Command Center

� 800 Calls daily for 1-2 weeks

� 30 mins to one hour

� Include all functional work areas

� Depending on the size of the organization

� Track and trend issues and problems through the

command center

� Continue for 1-2 weeks depending on the issues

WHAT HAPPENS IF THINGS GO WRONG?

� You need contingency planning.

� Backup plans

� Ask …….what if…?

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DEVELOP CONTINGENCY PLANS

�For each area of readiness and

implementation

�Compliance should ask for these

contingency plans

�Compliance can help drive preparedness

� One thing is certain—ICD-10 will impact

nearly everyone in the health care field

including: providers, nurses, coders,

billers, IT personnel, claims adjudicators,

managers, HR personnel, researchers, data

managers, auditors, compliance officers,

fraud and abuse and investigators.

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IMPACT AND READINESS EVERYWHERE

REVENUE CYCLE: MS-DRG SHIFTS

�There will be “some” changes in MS-

DRGs due to coding guideline

changes.

� Anemia vs malignancy

�Some changes in MS-DRG

assignment will occurred due to code

specificity.

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� MS-DRG 812, Red Blood Cell Disorders without MCC

� Sequencing Anemia as the principal diagnosis under ICD-9 groups these cases to MS-DRG 812.

� However, the ICD-10-CM guideline states to sequence the appropriate code for the malignancy as the principal or first-listed diagnosis followed by code D63.0, Anemia in Neoplastic Disease. Sequencing the malignancy first under ICD-10 usually will group these cases to a higher-weighted MS-DRG related to cancer.

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� MS-DRG 391, Esophagitis, Gastroenteritis & Miscellaneous Digestive Disorders with MCC

� Under ICD-9, Esophageal Hemorrhage has its own unique code, 530.82 and groups to MS-DRG 368 (with the addition of an MCC). Also, ICD-9 code 530.89, Other Disorders of Esophagus, groups to MS-DRG 391 (with the addition of an MCC). Code 530.89, which is not an MCC, is the closest match to the ICD-10 code, K22.8, Other Diseases of Esophagus which includes esophageal hemorrhage in its definition and is the cause of about 90% of the weight change. A record without an MCC will shift to a lower-weighted MS-DRG.

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�MS-DRG 885, Psychoses

� ICD-9 cases that have code 296.20, Major Depression, Single Episode, Unspecified sequenced as the principal diagnosis groups to MS-DRG 885, Psychoses. Under ICD-10, this same diagnosis is assigned to F32.9, which includes Depression NOS. This will group the case to a lower-weighted MS-DRG 881, Depressive Neuroses.

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Source: Long, Peri L. "The DRG Shift: A New Twist for ICD-10

Preparation." Journal of AHIMA 83, no.6 (June 2012): 76-78.

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POST GO-LIVE

� Coding quality assessment

� Audit

� Action Plans

� Ongoing Education and Training

� Denial Mgmt.

� Systems

� Contracts, etc.

� Remediation?

� Compliance requirements and validation?

POST GO-LIVE

� In phase four (post-implementation), providers

should shift their focus to monitoring coding

accuracy and productivity as well as ICD-10’s

impact on reimbursement and denials/rejections.

� Compliance leaders can help!

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NON-COMPLIANCE WITH HIPAA 5010 AND

ICD-10

� • Reimbursement - The most significant negative impact will occur with reimbursement. If claims are not properly formatted to the new requirements, claims may be significantly delayed, or your organization may not be paid.

� • Fines - No official word has been handed down regarding exactly what fines the federal government may levy against healthcare organizations that fail to comply with HIPAA 5010 or ICD-10, but there are industry discussions taking place on this subject.

� • Long-Term Benefits - The failure to comply leaves your organization at risk for not achieving the full benefit of ICD-10, including better patient care and the ability to exchange data between entities. When healthcare organizations world-wide are using the same code set, experts suggest a rise in global healthcare quality.

USE A CHECK LIST

� Inventory and update Policies and Procedures

� Coding

� Billing

� Compliance

� Inventory and update Physician Queries

� Review and Update job descriptions

� Compliance should help drive this readiness

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NEXT STEPS . . .

� Go to the CMS website

� Other resources

� Contract coding services: check for available staff

� Look at technology solutions

� Systems readiness

� Documentation and Coding readiness

SUMMARY

� Counting down to 10/1/2014

� ICD-10 readiness and plan

� Inclusion of all work areas/streams

� Proactive rather than reactive

� Have a good plan

� Include contingency

� Go-Live and Post Go-Live

� Other – solutions and technology

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WHAT IS YOUR ANSWER TO THIS

QUESTION . . .?

QUESTIONS ?

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REFERENCES/RESOURCES

� EHR Intelligence – July 2013

� CMS.gov

� AHIMA.org

� www.ahima.org/downloads/pdfs/resources/checkli

st.pdf.

� Eramo, Lisa A. "The Final Countdown: Industry

Moves Closer to ICD-10-CM/PCS Implementation

Deadline." Journal of AHIMA 84, no.6 (June

2013): 24-30

� AAPC.com

OTHER RESOURCES: WEBSITES

� Visit the following websites for advice and

updates:

� http://www.himss.org/ASP/topics_FocusDynamic.

asp?faid=220

� https://www.cms.gov/ICD10/

� http://www.ahima.org/icd10/

� http://icd10watch.com/

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THANK YOU