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10/4/2011
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ICD-10-CM/PCS Planning
HCCA Physician Practice/Clinic Compliance Conference
October 16, 2011
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� Terry Byrne, RRT FACHE
� Director, Risk Management and Compliance
� Jean Jurek, MS, RHIA, CPC
� Professor, Health Information Tech, Erie Community College
� Joanne McNamara, CPC, CPMA, CMA
� Coding Auditing Specialist, ARIES
� Regina Schaffer, RHIT, CPC
� Senior Auditor, United Health Services Hospital
Presenters
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10/4/2011
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October 1, 2013
3
October 1, 2013
�746 days
�24 months
�8 quarters
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10/4/2011
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Why the Change?
� ICD-9 is over 30 years old
� During those 30 years the advances in medical knowledge
and practice have outstripped the usefulness of the
classification
� The structure is limiting the number of codes that can be
added (running out of room)
� Not enough detail for computerized analysis
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Implementation
� ICD-10-CM (diagnoses) will be used by ALL providers in
ALL health care settings
� ICD-10-PCS (procedures) will be used only for hospital
claims for inpatient hospital procedures
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What isn’t changing
� Current Procedural Terminology (CPT)
� Healthcare Common Procedure Coding System (HCPCS)
� Both will continue to be used for physicians and ambulatory services including physician visits to inpatients
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Major changes from ICD-9 to ICD-10
� Not just the usual annual update
� ICD-10 markedly different from ICD-9
� Requires changes to almost all clinical and administrative systems
� Requires changes to business processes
� Changes to reimbursement and coverage
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Specific Changes
� Diagnosis Codes (ICD-9 to ICD-10-CM)
� Goes from 5 positions - first one alphanumeric, others
numeric
� to 7 positions, all alphanumeric
� From 13,000 existing codes to 68,000 existing codes
� Much greater specificity
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Structure of ICD-10-CM
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Specific Changes to Procedure Code Reporting
(ICD-9-CM Volume III to ICD-10-PCS)
� New Code Set for ICD-10-PCS
� A United States creation not used anywhere else
� Change from 5 to 7 positions
� Each position has a specific meaning
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Structure of ICD-10 PCS
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Issue – No Clear Mapping
� Not always one ICD-9 to many ICD-10s
� Need more specific information to go from ICD-9 to 10
� National Center for Healthcare Statistics (NCHS) has
published “GEMs”, general equivalence tables -Not a clear map!
� How will you determine the are of relevance for your organization?
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Number of Codes
� Diagnoses
� Current ICD-9 Volume I & II 14,315
� New ICD-10-CM 69,099
� Percent increase 382%
� Procedures
� Current ICD-9 Volume III 3,838
� New ICD-10-PCS 71,957
� Percent increase 17,556%!!!!
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The sky is falling
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2011 What to do now
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Planning
� Break it into years, then quarters
� Recognize that the last twelve months must be spent
testing
� Training, training, and more training
� New processes
� Core team
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Next steps
� Training
� Who
� When
� How
� All stakeholders should have some training on the basics by
January of 2012
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Next Steps – Planning Team
� Detail written plan
� Include training of staff
� What if your vendor or business associate’s system is not
ready?
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Testing, Testing, and more
� Testing
� Test from start to finish
� Registration to billing
� Verify every step
� All patient types – inpatient, outpatient, ER
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Training, Training, Training
� Training of front line staff should occur now
� Look for electronic resources to verify understanding and track completion (I’m so busy…)
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October 1, 2013
ICD-10-CM MappingA Coder’s Perspective
HCCA Physician Practice/Clinic Compliance Conference
October 16, 2011
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Presented by
Joanne McNamara, CPC, CPMA, CMA-AAMA
10/4/2011
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Time for a change!
� ICD-10-CM can be Incorporated into all Entity 5010 tested EDI October 1, 2012� Transition*
� ICD-10-CM must be incorporated into diagnostic listing of EDI October 1, 2013
*During transition period, both code sets can be carried accurate mapping is essential by the end of day, September 30, 2012
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There will be no “magic” light switch at 12:00am October 1, 2013
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ABC’s of GEMS?
To go from “A”……… ICD-9-CM
496 = COPD*
401.9 = HTN*
530.81 = GERD*
V25.01 = RxBC
E819.9 = MVA*NOS and/or NEC
To “B”…………….ICD-10-CM
J44.9 = COPD
I10 = HTN
K21.9 = GERD
Z30.019 = RxBC**
V89.2xxA = MVA****Initial Encounter
To “C” → be able to follow the map from B back to A again………….
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You will need a Map!
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General - To consider all code options
Equivalency - with equal descriptor(s) or
best translation(s)
Mapping - and move from the old point
to a new one, and back again
Not all ICD-9 codes have exact
translations in ICD-10, hence the
need for accuracy when making
the transition.
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A detailed map will safely get you to you destination, but also safely A detailed map will safely get you to you destination, but also safely A detailed map will safely get you to you destination, but also safely A detailed map will safely get you to you destination, but also safely
guide you back to your starting point! guide you back to your starting point! guide you back to your starting point! guide you back to your starting point!
ICD-9-CM to ICD-10-CMto ICD-9-CM
WHAAAAT???????
10/4/2011
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Forward and Backward Mapping
Why do we need reciprocal coding?
We are basically teaching EHR data systems (5010 by
1/1/12) to utilize a new language!
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Forward Mapping: Translating your existing ICD-9 code(s) to the more contemporary ICD-10 code(s) Mandates
from DOS 10/01/2013 (Exception: physician services for inpatients, code to discharge date)
BackwardMapping: Translating ICD-10 code(s)
to ICD-9 code(s) during 2012-2013, and grace period (2014)for past receivables and interpretation of historical patient data referenced
https://www.cms.gov/ICD10/01_Overview.asp
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Administrative Simplification to HIPAA Code Sets
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Mapping Starting PointDocumentation
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A Physician’s Focus
� Patient Care (by you and ancillary clinical staff)
� Thorough documentation of encounter as dictated in Guidelines
� Clarity of recording for continuity of care
� Use the coding data base for clinical quality reporting
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Administrative Staff Focus
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� HIT Specialists are for systems maintenance and support
� Compliance coordinator is fully aware and able to train all staff
� Utilize certified coders* or increase training for coding staff
� Perform pre- and post- submission* audit
* See Appendix A for a complete list of Government mandates such as NCCI requiring accurate application of codes as part of all health care compliance plans
Anatomy of an ICD-10-CM Code
_ _ _ _ _ _ _ _ _ . _ _ _ _ _ _ _ _ _ _ _ _
1 2 3 4th 5th 6th 7th
↑ ↑ ↑ ↑ ↑ ↑ ↑
A N N AN AN AN AN
A = Alpha (will always be a letter)
N = Number (will always be a number)
AN = May be a letter or a number
� http://www.cms.gov/NationalCorrectCodInitEd ~ http://www.cms.gov/AboutWebsite/EmailUpdates
� http://www.cms.gov/NationalCorrectCodInitEd ~ http://www.ahima.org/icd10/default.aspx
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S62.102AInitial Encounter for
Fractured Carpal Bone left wrist
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Example – ICD-10-CM code
S62.102A is mapped from 814.00
� Injury Code = S (Injury -Chapter 19)
� (Site) Wrist, Hand, Fingers = 6
� (Traumatic) Fracture wrist/hand = 2
� (Unspecified) Carpal Bone = 1
� NOS (Unspecified) FxWrist = 0
� (Laterality) Left Wrist = 2
� (Enc Status) Initial Encounter, closed fx=A
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What does it replace?
S62.102A = 1st Encounter cl Fx L Wrist
Replace the most specific previous
ICD-9 code:
ICD-9-CM 814.00 = Fracture Wrist NOS
Which is conducive to proper treatment?
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What expanded in S62.102?
The new ICD-10-CM code added the following by requirement of application:
� Known closed fx, not assumed
� Laterality to eliminate confusion
� Encounter status will enhance payment
� Greater specificity to pass Carrier Edits
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BUT…
Let’s focus on the positivepositivepositivepositive,
not the negative negative negative negative !
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Mapping Similarities
Volume One ~ is StatisticalAscending Order in characters
Directional Terms unchanged , i.e., NOS, NEC
Volume Two ~ identical columnar formatMain Terms are Bolded, Subterms are Indented
Neoplasm Table – Lineal Site to Behavior
If you practice precision coding now, the application process hasn’t changed, just a better description
match to PHI
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New “Exclude” Guideline
� ICD-9-CM – Has only one Exclude Box Direction
� ICD-10-CM – Excludes 1: Codes that can never be coded together
� Congenital Anodontia, K00.0
� Acquired Loss of Teeth, K08.109
� ICD-10-CM – Excludes 2: Codes that may be coded together
� Pesbycusis – H91.10
� Bilateral Tinnitus – H93.13
� Ensure coding training identifies this new change to excludes
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Excludes::
Excludes 1:
Excludes 2:
Expanded description ~ SEQUELA
� When mapping documentation
� Follow acute phase of illness
� Following initial injury
� Formerly “Late Effects” Opt for Sequelae!
� Option on 7th Character Encounter Status
� MS system – 7th character can be from three to 16 alpha options: A&B always initial encounter and S always last option for Sequela
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Mapping Types
� Identical match ~ Equivalent code
� Approximate match ~ Linkage is close, redirect any subterms if necessary
� Plausible translation ~ May need combination codes, redirection from guidelines
� There is no plausible translation ~ Multiple main terms, probable combination codes
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� Unlike Hospital/Inpatient coding, Physician coding is very personalized
� Hospital code application is grouped in a centralized location
� The majority of software coding systems are very “Simplified”
� Relying on a default option saves time, but is not Meaningful Use
� Should not market the elimination of human component
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Would it be simpler to replace my
coder with electronic ICD-10, and
will there be Mapping software on the
market?
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Consider:
Reports of early use of EMR “cut and paste” features, duplicated templates and “cloned”patient data, resulted in significanterrors perpetuating discrepancies in continuityof care! (source: NCPS 2003 provider-oriented EMR Gap analysis )
I didn’t mean it, your honor!
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If you do not know If you do not know If you do not know If you do not know
how to code a service, how to code a service, how to code a service, how to code a service,
ask someone you trustask someone you trustask someone you trustask someone you trust
Source: “OIG Fraud and Abuse Training”
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Coding Certification
� These are two HIPAA Compliant Associations in ICD-10-CM Certification
� American Academy of Professional Coders (AAPC)
� Physician Coding Credential (CPC)
� AAPC also certifies in 20 specialty physician coding credentials – see www.aapc.com/certification/specialty-credentials.aspx
� American Health Information Management Association
� Physician Coding Credential – CCS-P
http://www.ahima.org/icd10/default.aspx
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Adherence to the ARRA
� America thinks of coding as a financial necessity. Throughout the world, ICD-10 has users for many things including:
� Research
� Clinical Informatics
� Registry Data Basing
� Mortality & Morbidity Statistics
*ARRA and HIPAA require more than financial consideration*
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ICD-10-PCS
HCCA Physician Practice/Clinic Compliance Conference
October 16, 2011
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Presented by
Jean Jurek, MS, RHIA, CPC
� CMS awarded a contract to 3M Health Information Systems to develop a new procedure coding system
� The new system will replace ICD-9-CM Volume 3 for reporting inpatient procedures
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Background on ICD-10-PCS
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� Standardized terminology
� Includes definitions of the terminology used.
� While the meaning of specific words can vary in common usage, ICD-10-PCS defines a single meaning for each term used in the system
� Multiaxial
� The system has a multi-axial structure. Each character has the same meaning within a section and across sections to the extent possible.
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Benefits of ICD-10-PCS
� Diagnostic information is not included in the code description
� A “not elsewhere classified” option is allowed for new devices and substances
� All substantially different procedures are defined
� Limited NOS Option – A general body part, approach, or root operation can be used when the level of specificity required is not available in the record or cannot otherwise be obtained.
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General ICD-10-PCS Principles &
Guidelines
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� The ICD-10-PCS Draft Coding Guidelines (2012)
� The 3 sections include:
1. Conventions
2. Medical/ Surgical Section
A. Body System
B. Root Operation
C. Body Part
D. Approach
E. Device
3. Obstetrics55
General ICD-10-PCS Principles &
Guidelines
� Body Part:
� Example: “Liver” is used when the specific liver lobe is not identified
� Approach:
� “Open”, “Percutaneous” and “Via Natural or Artificial Opening” are used when a more specific type of approach is not documented and cannot otherwise be determined
� Root Operation:
� “Repair” is used when the procedure documentation does not support a specific root operation and the information cannot otherwise be obtained
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General ICD-10-PCS Principles &
Guidelines
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� Codes are comprised of seven components. Each component is called a character
� All codes are seven characters long
� Individual units for each character are represented by a letter or number
� Each unit is called a value
� 34 possible values for each character
� Digits 0-9
� Letters A-H, J-N, P-Z
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Code Structure
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Code Structure
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1. Medical and Surgical
2. Obstetrics
3. Placement
4. Administration
5. Measurement and Monitoring
6. Extracorporeal Assistance and Performance
7. Extracorporeal Therapies
8. Osteopathic
9. Other Procedures
10. Chiropractic
11. Imaging
12. Nuclear Medicine
13. Radiation Oncology
14. Physical Rehabilitation and Diagnostic Audiology
15. Mental Health
16. Substance Abuse Treatment
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System Structure
• Each table contains four columns and varying number of rows
• Column: Specifies the allowable values for characters 4-7
• Row: Specifies the valid combinations of values
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ICD-10-PCS Tables
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ICD-10-PCS Tables
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ICD-10-CM/PCS Implementation
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Opportunity
External testing of 5010 claims completed by December 2011 for Level 2 compliance
January2013
January2012
Begin external testing of Version 5010 for electronic
claims
All electronic claims must use 5010; 4010 no longer
accepted
Claims for medical diagnosis and inpatient must use ICD-
10
Education and Awareness
Strategic Plan Development
Gap Identification
Vendor Assessment
RemediationPost
Implementation
Organization Change Management, Process Redesign, Change Management
Many clients believe they are behind in preparing for I-10 readiness due to competing priorities and fragmented understanding of the enormity of the ICD-10 impact to
the organization
Clients believe they are in good shape for
meeting 5010 Level 2 compliance
October 20, 2013
January2011
January2014
Source: Centers of Medicare and Medicaid Services, www.cms.gov/icd10, The General Equivalence Mappings
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ICD-10-CM/PCS A Costly Proposition
Patient
SchedulingRegistration
Clinical
DocumentationCoding
Medical
Necessity
Claims
ProcessingPayment
Patient Access Clinical Care Billing and Financial Systems
• Scheduling
• Pre-registration
• Information capture
• Financial assistance
• Registration
• Medicare integration
• Medical necessity
Physicians, NP, PA
• Disease and case management
• Case mix management
• Clinical Documentation
• Care guidelines/protocols
Nursing
• Nursing Documentation
• Health plan contracting
• Denied claims
• Payment policy
• Coordination of benefits
• Physician reimbursement management
Health Information Systems
• Clinical documentation and coding
• EMR/EHR Workflow—CPOE
• e-Rx pharmacy and radiology systems
• Integration RHIO support processes
Performance and Reporting
• Clinical Research and registry reporting
• Performance measurement
• Audit/F&A investigation support
• Quality measures and P4P
• Epidemiology and public health reporting
• Regulatory compliance
Information Technology
• Compatibility and transition • Data Repositories • Software Interfaces
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ICD-10-CM/PCS Key Impact Areas
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Implementation Success
1. Organizing the implementation effort
2. Development of the communication plan
3. Conduct a high-level impact analysis
4. Organize cross functional efforts
5. Develop a budget for ICD-10-CM implementation
6. Information technology – internal system design and development
7. General Equivalency Mappings (GEMs)
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Implementation SuccessContinued…
8. Development of an education and training plan
9. Working with vendors towards successful implementation
10. Planning for implementation
11. Deployment of education and training in phases
12. Analysis of business processes
13. Policy change development
14. Outcomes measurement
15. Deployment of code by vendors and implementation compliance
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Organizing the Implementation Effort
• Review the ICD-10 Final Rule
• Obtain Senior management briefing and organization buy in:
• Complete preliminary analysis
• Prepare briefing materials as appropriate for scope of work
• Identify the senior manager project supporter
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Organizing the Implementation Effortcontinued…
• Obtain support from all providers and senior management
• Talk with providers about ICD-10-CM and its impact on the practice
• Identify all areas that will impact the practice such as the clinical areas, systems, documentation, etc., and share this information with providers
• Establish a regular schedule to report progress to senior management
• Coordinate a briefing with the ICD-10 5010 project team
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Development of the Communication Plan
• Determines the organization’s needs, its stake holders, what information should be collected and when, and who needs the information, when and in what form.
This process also covers the following:1.) Methods used to gather and store information
2.) Limits, if any, on who may give direction and to whom
3.) Reporting relationships
4.) List of contact information for all stakeholders
5.) Schedule for distribution of information
6.) A method to update the communications management plan as the project progresses.
The Communication Plan
• A communication plan is a written document that
describes the following elements:
1. Objective – what needs to be accomplished
2. Goal(s) – what your end result needs to be
3. Flow – with whom communication is established
4. Tools – what methods of communication will you use
5. Timetable – when communications are necessary to meet the final goal
6. Evaluation – how will your results be measured
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Development of the Communication Plancontinued…
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• An in depth look at what systems and processes will be impacted ICD-10-CM. Areas that might be impacted include:• Information Systems• Documentation• Staff education• Clinical• Administrative
• Utilize survey tools to capture information on each business area including:• Infrastructure• Systems (core systems and key business area applications)• Processes (workflows)• Information management uses (data, extracts, reports, etc.)• Linkages to other business area(s) in the organization• Linkages to external entities71
Conduct a High-Level Impact Analysis
• To face ICD-10’s complex challenges, incorporate a wide range of styles, skills, and perspectives.
• Examples of cross-functional team usage in ICD-10 development are:
• Developing of training programs
• Choosing and implementing new technologies for the organization
• Controlling training costs
• Improving the communication process
• Coordinating with the 5010 implementation team
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Organize Cross-Functional Efforts
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Assess full implementation costs by breaking down the costs into four categories:
1. Information systems including software and hardware
� Hardware and software
� Implementation and deployment
� Potential upgrade to an electronic medical record (EMR)
� Upgrade to Version 5010 electronic data interchange (EDI)
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Develop a Budget for ICD-10 Implementation
2. Auditing and monitoring documentation related to ICD-10 implementation
3. Education and training
4. Staffing and overtime costs
� Staff training
� Overtime costs
� Workflow processes
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Develop a Budget for ICD-10 Implementationcontinued…
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• Adopted version 5010 will replace the current x12 Version 4010A standard. This standard must be used by covered entities (health plans, health care clearinghouses, and certain health care providers) when conducting electronic transactions including:
• Claims (professional, institutional, and dental)
• Claims status requests and responses
• Payment to providers
• Eligibility requests and responses
• Enrollment and disenrollment in a health plan
• Coordination of benefits and premium payments
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Information Technology – internal system design and development
• Education will target four strategic education
objectives:
1. Build diagnosis and procedure coding awareness across the organization
2. Maximize educational opportunities
3. Engage the organization’s staff and sustain their interest in ICD-10-CM coding and its significance in the implementation effort
4. Collaborate with others (internally and externally) to continue to enhance knowledge of ICD-10-CM and code change implication to the implementation project
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Development of an education and training plan
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The extensive impact created by this shift in coding architecture requires the creation of a coordinated effort with training and solutions to meet your specific needs.
Training Structure
User Level Training Requirements
Level 1 In-depth
Level 2 Moderate
Level 3 Basic and Awareness
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ICD-10 Knowledge Enhancement
• The education and training plan should include:
1. Assessment of education and training needs
2. Development of program that are effective in meeting those needs
3. Implementation strategies that match programs with those that need them
4. Evaluation of the education programs to ensure stated learning outcomes are achieved
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Development of an education and training plan continued…
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• ICD-10-CM will have a widespread impact for software vendors. Everywhere in the system that ICD-9-CM currently exists will need to be adapted to implement ICD-10-CM. Changes include:
• Field size expansion, which includes the field length format on the screens
• Change to alphanumeric composition
• Use of decimals
• Complete redefinition of code values and their interpretation
• Longer code descriptions
79
Working with vendors towards successful
implementation
• Edit and logic changes for applications that interrogate the content of the codes
• Modifications of table structures that hold codes that will need to be restructured
• Report formats and layouts will need modification
• Expansion of flat files containing diagnosis codes
• Both coding systems ICD-9-CM and ICD-10-CM will need to be supported for a period of time which will add to user expense with more storage required
• Systems interfaces
80
Working with vendors towards successful
implementation continued…
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• Productivity
• System Changes
•Crosswalks and Mapping
•Tracking and Trending
81
Planning for Implementation
• Determine what methods of training will be used – such as internal or external – then determine what venues of education to deploy
• There are four education objectives:1. Build diagnosis and procedure coding awareness across the
organization
2. Maximize educational opportunities
3. Engage the organization’s staff and sustain their interest in ICD-10-CM coding and it’s significance in the implementation effort
4. Promote collaboration with others (internally and externally) to continue to enhance knowledge of ICD-10-CM and code change implication to the implementation project
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Deployment of the education & training phases
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• Process analysis generally involves:
• Define the process boundaries marking the entry points of the process inputs and the exit points of the process outputs.
• Construct a process flow of diagram that illustrates the various process activities and their interrelationships.
• Determine the capacity of each step in the process. Calculate measures of interest.
• Identify the bottleneck, that is, the step having the lowest capacity
• Evaluate further limitations in order to quantify the impact of the bottleneck
• Use the analysis to make operating decisions and to improve the process
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Analysis of the Business Process
• Plan
•Do
• Study
•Act
• Education
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Policy Change Development
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• Measure productivity
• Tips for measuring productivity:
• Measure what you can, and measure what you should
• Plan the evaluation and the programs together
• Consult the standards
• Get the know-how
• Flush-out the details of the baseline
• Full service or self-serve?
• The cycle of refinement
85
Outcomes Measurement
• The first step – moving to 5010
• Testing and deployment of code
• Go-live
• Implementation compliance
• Productivity
• Claim error and denial resolution
• Medical record documentation re-assessment
• Medical policy review
• Monitoring training and productivity outcomes
86
Deployment of code by vendors & implementation
compliance
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After October 1, 2013:
• Analyze reimbursement patterns
• Process claims or denials in ICD-9
• Assess data quality
• Refine revised policies and procedures
• Measure effectiveness
• Continually monitor documentation for specificity
• Develop continuing education program to remain current with regulatory changes
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Follow-up & Support
� Acute and Chronic Cholecystitis with Cholelithiasis
� Open Cholecystectomy
ICD-9-CM Codes ICD-10-CM Codes574.00 K80.12
574.10
ICD-9-CM Codes ICD-10-CM Codes51.22 OFT40ZZ
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ICD-9-CM to ICD-10-CM/PCS
An Example
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� Coronary Artery Disease (CAD) with angina in a patient who chews tobacco
ICD-9-CM Codes ICD-10-CM Codes
414.01 (CAD of native vessel) I25111 – CAD with native coronary artery disease with angina pectoris with
documented spasm
413.9 (Angina) I2583 – Coronary atherosclerosis due to lipid plaque
No code (chewing tobacco) 5A1221Z – Nicotine dependence, chewing tobacco, uncomplicated
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ICD-9-CM to ICD-10-CM/PCS
An Example
Documentation
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Documentation - Neoplasms
91
Documentation - Anemia
92
Alphabetic Index
Tabular List
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Documentation – Diabetic Neuropathy
93
ICD-10-CM
Documentation & AuditingDocumentation & Auditing
Regina Schaffer, RHIT, CPC
2011
10/4/2011
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ICD-10 and Documentation
� Better Information
� Identify diseases/injuries more specifically
� Better convey the severity of the encounter
� More Accurate Data
� Laterality
� Etiology
� Type of encounter
Financial Impact
� Medical Severity-DRG (MS-DRG)� Clinical documentation supporting all diagnosis codes necessary for proper reimbursement
� Incentive Programs� PQRI � Cigna, Fidelis, Medicare Advantage
� Physician/Provider Time� Questions� Reworking of claims
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Unspecified Codes
� Will an unspecified code reflect the severity of the problem the patient presented for?
� Will insurance companies pay for unspecified codes?
� Will insurance companies renegotiate contracts excluding payment of unspecified codes?
Medical Necessity
� What is Medical Necessity?
� Simply put, the services provided to the patient are supported within the documentation as being appropriate as they relate to the reason the patient presented for this visit
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Supporting Medical Necessity
� Medical record is a legal document
� Billing for services rendered is appropriate, however…
IF YOU DIDN’T DOCUMENT IT, YOU DIDN’T DO IT!!
Medical Necessity
See Example 1 and Example 1A
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Medical Necessity
� How does this relate to my practice?
� Is the nature of the presenting problem clearly stated?
� Does the documentation for the visit flow?
� Chief Complaint straight through to Assessment and Plan
� Is the “Plan” for this patient warranted?
Things To Think About
� Did you say everything you needed to say to:
� Support the service billed?
� Maintain continuity of care?
� Did you sign your note either electronically or manually?
� If you are not on an EHR, do you have a signature log on file?
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Auditing
� Why did I get audited?
� Compliance
� Financial Request
� Patient Request
� Who will definitely audit?
� RAC
� CERT
� MAC
� MIC
Who Should Audit
� YOU!
� Internal Audits
� Contracted Internal Audits
� WHY?
� Find problems first
� Corrective Action
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You Should Have a Policy
� Why have a policy?
� Eliminates problems
� Identifies what the expectations are of the provider and the auditor
� What questions should be addressed in the policy?
� If documentation does not give enough information, should the physician be queried?
� Is an addendum necessary or appropriate?
� Keep in Mind: Physician is not required to use the exact terms used in PCS
Evaluation and Management
� History
� Exam
� Medical Decision Making
� Not the same as Medical Necessity
� Does the note flow from Chief Complaint to Assessment and Plan
� Outpatient vs. Inpatient
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Know Your Guidelines
� ICD-10-CM
� ICD-10-PCS
� CMS
� 1995
� 1997
� Other Payers
Basic Auditing Guidelines
� Decide if you are doing a prospective or retrospective audit
� Have a good audit tracking tool
� Give the providers feedback on findings
� Keep records of audit
� Keep records of findings
� Keep records of corrective action
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Basic Elements
� Chief Complaint: Must be on all notes.
� History: Must support level of service.
� HPI
� ROS
� PFSH
� Examination
� Medical Decision Making
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Auditing and ICD-10
� Coding Guidelines will be key
� New coding system
� New rules
� Specificity
� The code set allows for specifics
� Documentation vs. Assumption
� Laterality
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What Dos an Auditor Look For?
� Chief Complaint
� Is the diagnosis code reported supported in the documentation?
� Is medical necessity for services provided supported in the documentation?
� Are co-morbid conditions that impact the visit addressed?
� Was a resident involved in the care of this patient?
� Is the documentation clear and legible? Signatures?
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Will Your Notes Support an ICD-10-CM
Code?
See Example #2
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ICD-10-PCS
See Example #3
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Sources and Links
� Annual updates of each system are posted on the ICD-10 website at
http://www.cms.gov/ICD10
� Maintenance and updates of ICD-9-CM and ICD-10 are discussed at the ICD-9-CM Coordination and Maintenance (C&M) Committee meeting http://www.cms.gov/ICD9ProviderDiagnosticCodes/03_meetings.asp
� General Equivalence Mappings (GEMs) assist in converting data from ICD-9-CM to ICD-10 http://www.cms.gov/ICD10/11b1_2011_ICD10CM_and_GEMs.asp#TopOfPage
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Sources and Links
� Description of MS-DRG Conversion Project http://www.cms.gov/ICD10/17_ICD10_MS_DRG_Conversion_Project.asp
� ICD-10 Timeline and Task Listhttp://www.nchica.org/HIPAAResources/Timeline/ICD-10%20Timeline%2011122010.pdf
� ICD-10-PCS Coding Guidelines
https://www.cms.gov/ICD10/Downloads/PCS_2012_guidelines.pdf
� ICD-10-CM Official Coding Guidelines
http://www.cdc.gov/nchs/data/icd9/10cmguidelines2011_FINAL.pdf
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