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ICD-10 Trends – Real Talk

Karen Youmans, MPA, RHIA, CCS

President, YES HIM Consulting, Inc.

OBJECTIVES:

– At the end of this session, the attendee will be able to:

• Discuss coder productivity under ICD-10-CM/PCS

• Detail MSDRG shift examples

• Describe some ICD-10-CM/PCS edits and updates needed

• Examine additional coder training hints

• Provide example discussion points for your CFO

Disclaimers

• All responses, advice, and educational materials are designed to provide accurate coding information. Every effort has been made to ensure accuracy. However, each healthcare provider is responsible for correct coding & billing and assumes all risk and liability in connection with the use of the information. YES HIM Consulting, Inc is not liable for any direct, indirect, special, consequential, or other damages or economic loss arising from use of the information provided. There is no representation, warranty, or guarantee that any response, advice, or provided material is error-free.

• AHA Coding Clinic is copyrighted so only highlights, examples, or excerpts are presented here for educational purposes. Most healthcare facilities receive AHA Coding Clinic through your encoder and/or CAC vendors. You are encouraged to research the examples presented in the full version of AHA Coding Clinic.

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Coder Productivity

Productivity

• Predictions – up to 50% productivity loss

• Oct – December 2015 reports of 30-45% productivity reduction for inpatient coding and a 20-40% productivity reduction for outpatient coding

• Jan – March 2016 – reports of inpatient coding productivity drop from ICD-9 average slightly more than 3 charts/hour to 2.15 charts/hour

Productivity

• Dual coding practice and CAC impact

• Analyze workflow –automate queries, coder task queues, categorize physician inquiries, etc.

• Still not at the ICD-9 productivity level

• Some studies predict that a 20% permanent reduction in productivity will remain

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Productivity

• Update with any 2Q statistics or publications

• AHIMA Studying ICD-10 Impact on Coding, Productivity via surveys May 2016

MS-DRG shifts

CMS MS-DRG shift prediction • Results - Using about 10 million FY2013

MedPAR records:

• 0.41% had DRG shift to higher paying DRG

– $13 more per $10,000 (+0.13%)

• 0.66% had DRG shift to lower paying DRG

– $17 more per $10,000 (-0.17%)

• Net: 1.07% with a DRG shift

– $4 less per $10,000 (-0.04%)

• Statistically Zero

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MS-DRG shifts

• Important to differentiate between:

– potential coding errors (e.g. ICD-10-CM sequencing or ICD-10-PCS misinterpretation) and

– encounters correctly coded, but MS-DRG grouper issue.

MS-DRG shift examples

• Review 7th character use for injuries and musculoskeletal conditions in ICD-10-CM (e.g., use of subsequent encounter D code instead of initial encounter A code results in a different DRG).

• Reporting arterial lines for monitoring in ICD-10-PCS can result in a surgical MS-DRG (correctly chosen ICD-10-PCS code affecting the DRG grouper’s logic).

MS-DRG shift examples

• Paracentesis in ICD-10-PCS can be either therapeutic or diagnostic (“diagnostic” character shifts the MS-DRG to surgical).

• OB repair of third degree lacerations (coded to 0DQR0ZZ per Coding Clinic) changes the MS-DRG from 775 (vaginal delivery) to 989 (non-extensive OR procedure unrelated to PDx)

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MS-DRG shift examples

• Sequencing differs between ICD-9 and ICD-10 in the following key areas:

• • anemia due to neoplasm; • anemia due to a chronic kidney disease; • admission for rehabilitation; and • changes to instructional notes in the ICD-10 tabular (e.g. gangrenous pressure ulcer).

MS-DRG shift examples • Some of the changes related to MCCs and CCs

include the following:

• • major depressive disorder: CC deletion • malignant HTN (hypertension): CC deletion • second-degree heart block (Mobitz II): CC deletion • Schatzki's ring – default is acquired instead of congenital: MCC deletion • acute respiratory distress (default code): CC deletion.

MS-DRG shift examples • Some of the changes related to ICD-10-PCS

Procedure coding include the following: • In ICD-9, a knee or hip revision was captured with one

procedure code which grouped to MS-DRG 468 (revision knee or hip replacement). In ICD-10-PCS, two PCS codes are required to ensure the correct MS-DRG of 468: 0SPD0JZ, Removal of Synthetic Substitute from Left Knee Joint, Open Approach, and 0SRU0JZ, Replacement of Left Knee Joint, Femoral Surface with Synthetic Substitute, Open Approach. If the coder assigns only 0SRU0JZ, then the MS-DRG assigned is 470 (major joint replacement) which does not adequately describe the procedure performed.

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MS-DRG shift examples • Some of the changes related to ICD-10-PCS

Procedure coding include the following:

• Patient with pneumonia (J18.9) undergoes a bronchoscopy with aspiration (drainage) of the left lower lobe bronchus (0B9B8ZZ). The aspiration of the bronchus in the current MS-DRG grouper takes this to a surgical MS-DRG of 165, Major Chest Procedures without CC/MCC, a significant increase in reimbursement compared with the ICD-9 MS-DRG of 195, Simple Pneumonia and Pleurisy w/o CC/MCC.

CFO discussions

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CMS recommended KPIs • Days to final bill

• Claims denial rate

• Coder productivity

• Payer edits

• Medical necessity pass rate

• Discharged, not final billed

• DRG volumes (by group) under ICD-9 versus ICD-10

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Denials • RelayHealth reported a denial rate of 1.6 percent

for claims processed between Oct. 1, 2015 and Feb. 15, 2016.

• Compiled more than 262 million claims processed between the implementation of ICD-10 and February of this year. More than 2,400 hospitals and 630,000 providers used RelayHealth Financial revenue cycle management solutions during that time.

• Of the $810 billion in claims processed, the total denial rate represents $12.9 billion in denied claims since Oct. 1.

Denials • Below are the top 10 highest denial rates

RelayHealth experienced by payer: • Mississippi Medicaid — 59.7 percent

• Washington Medicaid — 10.5 percent

• Florida Health Options HMO — 8.2 percent

• Great Lakes Health Plan — 7.8 percent

• Gateway Health Plant - Medicaid PA — 7.5 percent

• Florida Blue Cross — 7 percent

• Michigan Medicaid — 6.5 percent

• HorizonNJ Health — 6.4 percent

• Blue Care Network — 6.1 percent

• South Carolina Medicaid — 5.8 percent

Denials • Some facilities are stating that their claim

denials have increased from 4% - 7% (Traditionally has been around 1.6 - 2%)

• Organizations may not be monitoring denials as closely - or claims are being fixed and not informing/educating anyone

• Not all payers have implemented all I-10 edits yet – are there more edits coming?

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Excludes 1

Example denials

A. Newborn born outside hospital B. Admit dx related to PDX C. Sequence Principal Proc

OB: O80

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OB: O80 and O09

To be discussed at an

upcoming Coordination

and Maintenance mtg

OB: back to ICD-9

OB: O80 and O09 or O30

Also get same edit with:

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OB: O09 or O30

OR PDX

Additional coder education

Example additional education

A. ICD-10 question queues B. Review AHA Coding Clinics for ICD-10 C. Quarterly quality audits and follow-

up education D. YES 10-10-Tuesday topics

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Brush Biopsy:

A brush is used as a catheter with bristles to gather the sample needed for the biopsy.

Brush Biopsies = Excision per AHA & now in 1QCC

FROM AHA:

• Not truly an excision

because it doesn’t cut.

• It sounds closer to

“extraction”, even if there

isn’t a whole lot of force.

FROM AHA: “Excision” has been chosen for brush biopsies of the lung or bronchus because “extraction” is not a body part value for the respiratory system (except for the pleura).

“Excision” is being

advised because

there is no other

option available.

Brush Biopsies = Excision per AHA & now in 1QCC

When coding the placement of an infusion device

such as a peripherally inserted central catheter

(PICC line), the code assignment for the body

part is based on the end placement of the

catheter tip.

PICC line (also in CC)

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AHA Coding Handbook:

Simple venous catheters are sterile catheter systems that provide repeated access to the vascular system for procedures such as blood withdrawal and medication for fluid administration. The catheter is inserted into a peripheral vein, such as the cephalic vein, by puncturing the skin and then taping the catheter in place. For example code:

05HB03Z Insertion of infusion device into right basilic vein, open approach

is assigned for insertion of a simple catheter system into the basilic vein in the right arm.

Midline Peripheral Catheters

Selection of the body part value for insertion of vascular access devices as well as simple venous catheters is based on the site in which the catheter resides after the insertion procedure is completed, meaning the end placement of the device rather than the point of entry.

Midline Peripheral Catheters

Placement of a midline

catheter (i.e., catheter tip

terminates in the axillary

vein) from a peripheral

approach.

Copyright © 2014 by Medlearn Publishing, a division of Panacea

Healthcare Solutions, Inc. All rights reserved.

National Institutes of Health:

• Midline catheters are inserted into the antecubital (or other upper arm) vein. They are typically 20 cm long and their tips do not reach the central veins of the thorax.

• Is similar to a PICC, but is shorter in length (about 25 cm) and is inserted into a large vein in the upper arm, termination not beyond the axillary vein distal to the shoulder.

http://www.piccresource.com/faq.php

Midline Peripheral Catheters

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What’s Next • Prepare for ICD-10 code changes 10-1-16 3,651 new procedure codes (ICD-10- PCS) and 487 code revisions and 1,928 new diagnosis codes (ICD-10-CM) • Some changes in guidelines and definitions • Continued QA and Productivity monitoring • Establish and monitor KPIs • Educate finance, providers, and coders • More edits from payers? Unspecified codes?

References

http://www.ahacentraloffice.org/codes/march252015webinar.shtml https://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD10NextStepsToolkit20160226.pdf http://www.fortherecordmag.com/archives/0116p10.shtml http://www.icd10monitor.com/enews/special-bulletin/item/1620-medicare-proposes-changes-to-the-icd-10-code-list http://www.healthcareitnews.com/ http://www.beckershospitalreview.com/finance/relayhealth-financial-1-6-of-claims-denied-post-icd-10.html

Thank you