Presentation Goals - Health Care Compliance Association · ... S52.521A Torus fracture of lower end of ... Download area makes all licensed

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3/7/2014

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Presented by

W6162XA: Struck By A Duck!

What Compliance Officers need to

know about ICD-10 Implementation

D. Scott Jones, CHC

WWW.HPIX-INS.COMWWW.HPIX-INS.COM

Presentation Goals

● History of the International Classification of Disease system

● The Compliance Officers Role in ICD-10

● Easy education resources for physicians and staff members

from WHO, CMS

● Tips for timely, effective training and implementation:

Teaching doctors and staff about ICD

● Avoiding billing errors and improper payments

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ICD-9 History

● World Health Organization (WHO) developed ICD-9

for worldwide use

● U.S. developed clinical modification (ICD-9-CM)

� Implemented in 1979

� Expanded number of diagnosis codes

� Developed procedure coding system

3http://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/2013-08-22-ICD10-NPC.pdf


ICD-9-CM Problems

● 35 years old → technology has changed

● Many categories are full

● Not descriptive enough for modern day purposes

● Lacks accuracy for payment for services rendered

● Improve quality monitoring by facilitating evaluation of medical

processes and outcomes

● Not flexible enough to quickly incorporate emerging technologies

● Not exact enough to precisely identify diagnoses and procedures

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ICD-10

● 1990 – Endorsed by World Health Assembly (diagnosis

only)

● 1994 – Release of full ICD-10 by WHO

● 2002 (October) – Published in 42 languages

● Implementation

� 138 countries for mortality

� 99 countries for morbidity

● January 1, 1999 – U.S. implemented for mortality

� Death certificates

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ICD-10: It’s Here.

● "There are no more delays and the system will go live

on Oct 1. Let's face it guys, we've already delayed it

several times and it's time to move on. It's a standard in

the rest of the world."

� Marilyn Tavenner

� Administrator, CMS

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ICD-10● 45 CFR 162.1002 HIPAA Administrative Simplification

● SPECIFICITY

● Implementation Deadline: October 1, 2014

● ICD-9 = 14,567 diagnosis codes; ICD-10 = 69,832 codes

● ICD-9 CM = 3,878 procedure codes; ICD-10 PCS = 71,920

● ICD-9 Five digits; ICD-10 Seven digits; alpha numeric

� Allows disease etiology, anatomic site, severity coding

● Specific and lateral (right vs. left diagnoses)

● Not an update; fundamentally different

● Ability exists to add new codes in future releases7


ICD-10 Example: S52.521A

● S52 Fracture of Forearm

● S52.5 Fracture lower end of radius

● S52.52 Torus fracture of lower end of radius

● S52.521 Torus fracture of lower end of right radius

● S52.521A Torus fracture of lower end of right radius,

initial encounter for closed fracture

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ICD-10 Web Resources● General ICD-10 Information

� http://www.cms.hhs.gov/ICD10

● ICD-10-PCS Coding System and Training Manual

� http://www.cms.hhs.gov/ICD9ProviderDiagnosticCodes/08_ICD10.wsp

● ID-10-CM Coding System

� http://www.cms.hhs.gov/ICD10/02k_2010_ICD_10_CM.asp#

● AMA information releases and examples

� http://www.ama-assn.org/ama1/pub/upload/mm/399/icd10-differences-fact-sheet.pdf

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ICD-10 On Line Training

● CMS training: Provider Resources Internet Page at

CMS.Gov

www.cms.gov/Medicare/Coding/ICD10/ProviderRes

ources.html

� Physician training

� Vendor information

� FAQS

� Medical Practice Tips

� Checklists and Implementation Guides 10

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The World Health Organization (WHO)

● ICD-10 Instruction Manual

� http://www.who.int/classifications/icd/ICD10Volume2_en_2010.pdf?ua=1

● Available in 42 languages

● On-Line Training Tool

� http://apps.who.int/classifications/apps/icd/icd10training/ICD-10%20training/Start/index.html

● Download area makes all licensed materials available

� http://www.who.int/classifications/icd/en/

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ICD-10: WHO Overview for non-coders

● Introduction to classification

● Structure of the classification and how to code – Summary only

● Chapters I to XXII – Overview only

● Certification – Summary only

● Rules and guidelines for mortality coding – Summary only

● Rules and guidelines for morbidity coding – Summary only

● Statistical presentation – Summary only

● Quality – Summary only

● Confidentiality & ethics – Summary only

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ICD-10: WHO for medical personnel

● Introduction to classification

● Structure of the classification and how to code

● Chapters I to XXII – Review of the chapter, Exercises,

Summary

● Certification

● Rules and guidelines for mortality coding

● Rules and guidelines for morbidity coding

● Statistical presentation

● Quality

● Confidentiality & ethics13


Basics of E&M coding

● History

● Physical examination

● Medical decision making

● Time

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Categories of E&M codes

● Outpatient

● Inpatient

● Consultation

● Emergency department

● Nursing home

● Rest home

● Home visits

● Other

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Our Favorites

● Hurt at the opera Y92253

● Stabbed while crocheting

Y93D1

● Walked into a lamppost

W2202XA

� Lamppost, subsequent

encounter W2202XD

● Submersion due to falling or

jumping from crushed water

skis V9037XA

● Struck by a duck W6162XA

● Bitten by a duck W6161XA

● Struck by a turtle W5922XA

● Spacecraft crash injuring

occupant V9541 (not billable)

● Spacecraft fire injuring

occupant, initial encounter

V9544XA

▪ Prolonged stay in weightless

environment X52XXXD

*16

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ICD-10 Implementation

● Awareness

� Communication

� Training Plan

● Assessment

� Review implementation

� Remediation strategy

� Identify outliers

● Remediation

� Update policy and

process

� Re-training

● Testing

� End to end testing

● Transition

� Evaluate outcomes

� Implement remediation17


Interdisciplinarity in Compliance● PPACA INTERDISCIPLINARITY

� Electronic Medical and Health Records

� Proper Coding

� Self Disclosure of Overbilling

� Quality of Care Reporting

� Risk Management

� Medical Error Reduction

� Medical Error Disclosure

� Patient–Staff–Physician Communications and Portals

� Quality of Care Violations/Medical Malpractice

� Physician/Medical Practice Management

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INTERSECTION:

Compliance, Quality, Fraud, & Malpractice

● OIG Work Plan 2014

● PPACA & Quality

● Government Accountability Office (GAO)

� “…beneficiaries…who receive healthcare from providers who adhere to

PPACA…may receive higher quality of care…Conversely, those who receive

care from providers who fail to do so may receive lower quality of care.”

19www.gao.gov/assests/590/589657.pdf


INTERSECTION:

Compliance, Quality, Fraud, & Malpractice

● General Accounting Office (GAO)

� “…it is possible that, if these (PPACA) standards and

guidelines become accepted medical practice, they could

impact the standard of care against which provider

conduct is assessed in medical malpractice litigation.”

20www.gao.gov/assests/590/589657.pdf

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Teaching Physicians

“No college junior studies organic chemistry and

takes the MCAT planning to devote 4 years to

medical school and 3 plus years to residency and

fellowship just to cheat Medicare and Medicaid.”

Julie K. Taitsman, M.D., J.D.

CMO for the OIG, Department of HHS

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About Doctors in General

● Main Goal: Deliver quality care in effective safe manner

● Competitive, OCD, delayed gratification & clinical

● Tend to be detailed overachievers and/or survivors

● Compliance?…may not “get” it

● Think in terms of medical malpractice avoidance

● No prior training about fraud, abuse, & medical malpractice

● Inherently may not trust administrators22

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Approaching Physician Education

● ICD Coding is not a new concept

● One size does not fits all programs

● Each organization has unique needs

● One teaching method alone is not enough

● A “check off” approach to physician education does not

work

● You catch more flies with honey that you do with

vinegar…PARTNER WITH YOUR DOCS!

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Things to Consider• Size of practice / orgainzation to be educated

• Physical location of practices

• Method(s) & venue of physician education

• Education is perpetual; not a one shot deal!

• Relevant & necessary topics

▪ Provide education relevant to your physician

▪ OIG Work Plan

▪ Areas of risk that have internally or externally surfaced

• Allowable time - Time is money to physicians

• Budget

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Teaching Principles: A Doctor’s

Perspective

● Positive attitude – Compliment & encourage

● Explain topic background & reference

● Engage physicians to share experiences

● Avoid confrontation with physicians

● Helpful & supportive approach

● Teamwork philosophy

● Avoid intimidation

● Request feedback, review it, act on it!

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Teaching Principles: An Administrator and

Compliance Officer’s Perspective

● Physicians are taught to assess, diagnose, implement correct

treatment action, and be responsible for outcomes

● Little tolerance for ambiguity

● As scientists, respect facts and data that can be supported by

research

● Understand but often dislike Peer Review

● Dislike being outliers

● Dislike being embarrassed before peers

● Generally want to do the right thing…What is it?26

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OIG EHR VULNERABILITY REPORT

● January 2014: OEI

● Objective:

� Describe how CMS & its contractors implemented program

integrity practices in light of EHR adoption

● Concerned that EHRs may make it easier to commit fraud

● 2 Major areas where EHRs c/b used to commit fraud:

� Copy/Pasting

� Over documentation

27http://oig.hhs.gov/oei/reports/oei-01-11-00571.pdf


EHR Liability Issues● Cloning/Cut & Paste

● Did/did not perform

� Dropdowns, templates, defaults, macros

● Pre-populated templates

● Voice recognition issues

http://oig.hhs.gov/oei/reports/oei-01-11-00571.pdf 28

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EHR Liability Issues

● Failure to check all areas of program for results

� Scanned data v. direct drop

● Improper scanning by support staff

● Failure to check “paper chart” or “scanned chart”

● Changing the note

● Locking the note

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EHR Liability Issues

● Chart inconsistencies

� History

� Exam

● Failure to read office visit notes created

● Automatic acceptance of coding engine

recommendation

● Automatic acceptance of modifier recommendation

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Surgical Mystery

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Voice Recognition Error

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To Tattoo or Not to Tattoo

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To Tattoo or Not to Tattoo

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D. Scott Jones, CHC ● Senior VP Claims, Risk Management &

Corporate Compliance – HPIX

● Leads a team managing over 700 malpractice claims

● Compliance, Risk and Claims for 3600 providers

● Former medical practice & hospital administrator

● Board Certified Healthcare Compliance Officer (CHC)

● Author, 12 nationally published books and over 50 articles on quality,

practice management, and regulatory compliance

● Frequent speaker to state, regional and national organizations

● Over 1000 risk assessment service visits to healthcare organizations

nationwide

● [email protected] (904) 294.563335

WWW.HPIX-INS.COM

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Presented by

HCCA Regional Washington, DC

Thank You

Documents

Presentation Goals - Health Care Compliance Association · ... S52.521A Torus fracture of lower end of ... Download area makes all licensed