ICD-10 Transition

Community Physician Impacts and Risks

ICD-10 Overview

• ICD-9 has been in use in the United States since 1979

• ICD-10 was approved by the World Health Organization (WHO) in 1990 (99 countries use it for morbidity; 138 countries use it for mortality)

• U.S. is the only industrialized country not using ICD-10

• U.S. Government Mandated all HIPAA covered entities are required to transition to ICD-10

• ICD-10 transition date is October 1, 2014

• Documentation and coding for ICD-10 is more specific: severity of disease, laterality, level of care, and treatment

ICD-9 vs. ICD-10

ICD-9-CM •3-5 characters •First character is

numeric or alpha (E or V) •Characters 2-5 are numeric

•Always at least 3 characters

•Use of decimal after 3 characters

ICD-10-CM •3-7 characters •1st character is alpha (all

letters except U are used) •2nd character is numeric

•Characters 3-7 are alpha or numeric

•Use of decimal after 3 characters

•Alpha characters are not case-sensitive (e.g., Right ankle sprain, initial encounter: S93.401A, S93.401a, s93.401A, s93.401a)

Changes to the codes

Code Matching from ICD-9 to ICD-10

CPT not changing only the DX codes

Cost for mid-size practice could be around $300,000 for costs associated to ICD-10 changes (Training, system upgrades)

Increase in denials resulting in a decrease in cash flow

Practices could have a significant productivity impact for 3-6 months (Increase in documentation time, larger code sets)

Reduced productivity due to training and increased documentation requirements

Impacts to Physician Practices

Vendor readiness Payer readiness Training Productivity loss Cost

5 Areas of Focus

Reach out to software vendors for all software systems used in your practice and begin to capture their timelines for ICD-10 compliant versions as well as their test plans

If your office has an internal lab or radiology department the software will also need to be updated

Vendor Readiness

Survey conducted in July 2012 stated 39% of payers will not be ready to accept ICD-10 codes

Rule: claims with dates of service before 10/1/14 need to be coded in ICD-9. Claims with dates of service after 10/1/14 need to be coded in ICD-10 regardless of the date the claim is billed or rebilled

Workers Compensation is exempt from ICD-10. Some may move to ICD-10 but they are not required If a carrier chooses not to switch to ICD-10 you will

need to submit claims with ICD-9 codes

Payer Readiness

Reach out to each payer for readiness and track those who will not be ready for ICD-10 acceptance after 10/1/14 Submit ICD-9 codes until they are ready See if you can build rules in your system to

accommodate this challenge (back mapping from ICD-10 back to ICD-9)

If systems can’t manage back mapping rules by payer there will need to be a manual process put in place to manage

Payer Readiness continued

Estimated Training Hours for: Billers: 2 to 4 hours of training Clinical Staff 5 to 10 hours of training Documenters: 5 to 10 hours of training Coders: 16 to 20 hours of training

Source: HIMSS-Training for ICD-10 : A Complete Plan Beyond Coders, 2012

Training

Projected there will be an initial 70% loss in productivity*

Loss related to: Extended time for clinicians to document

specificity See less patients Decrease in revenue

Increase in coder’s time coding and preforming physician inquiries for documentation gaps

Billers working denials: Denials expected to increase 300% *

*Medical Group Management Association (MGMA), William Blair & Company 2011 report

Productivity Loss

Direct and Indirect CostsTypical Small

PracticeTypical Medium

PracticeTypical Large

Practice

Education $2,405 $4,745 $46,280

Process Analysis $6,900 $12,000 $48,000

Changes to Superbills $2,985 $9,950 $99,500

IT Costs $7,500 $15,000 $100,000

Increase Documentation Costs* $44,000 $178,500 $1,758,500

Cash Flow Disruption $19,500 $65,000 $650,000

Total $83,290 $285,195 $2,702,280

*Resulting from productivity loss due to increased documentation requirements

Small: 3 providers, 2 admin staffMedium: 10 providers, 1 coder, 6 admin staffLarge: 100 providers, 10 coders, 54 admin staff

Source: The Impact of Implementing ICD-10,” Nachimson Advisors, LLC, October 8, 2008

Areas Impacted

Application upgrades & new implementations

Inbound & outbound interfacesApplications & databases not supported by

ITICD-10 awareness training

System design, test, train & supportForms changes

Process redesignCoding education and training Policy and procedure changes

Contract management & monitoringDocumentation assessment & training

Workflow training & supportProtocol changes

Report redesign & testing

HIMCodingCase

ManagementCompliance

Revenue CycleSchedulingRegistration

BillingClaims

Follow-upContracting

ReportingAdministration

QualityReportingFinance

All Departments Using Reporting w/ICD Codes

ITAll Applications, Interfaces and

Data bases with ICD Information

Clinical Care Delivery

Medical StaffAll Patient Care

Department

Other Departments

Any Department that uses ICD Information

Risks and Tasks Business Operations

Denials – 300% increase Pre-authorizations in ICD-10 received

prior to ICD-9 for services after 10/1/14

Clinical Operations Super bill changes Increased time charting to meet ICD-

10 documentation requirements Identify unspecified codes currently

used

HIM Dual Coding (Coding in ICD-9 and ICD-

10 for rebills) Education and recertification in ICD-10

IT System updates Interface rebuilds Payer testing

Reporting Rebuild reports for ICD-10 coding If using reports for yearly

trending 2014 will reports will need mapping for reporting consistency

Training Determine the level of training

each staff member will need Time away for training will

reduce productivity

Payers Payer testing Delay Claim payment Payer/Vendor readiness

assessments Re-contracting

Requisitions for Services: Labs, Radiology, etc.

Beginning the summer of 2014 some departments at Rockingham Memorial Hospital will be requesting requisitions/orders to have the ICD-10 compliant descriptions on the orders. This gives the provider and hospital time to practice this new interaction so we can better and accurately service the patient come October 2014

Would like signs and symptoms with any rule out dx on the order.

be as specific as possible example: right side, left side, benign or malignant hypertension….avoid unspecified

Still unable to use “rule out”, “questionable”, “suspected”, “consistent with”, on the order.

Please be patient when we call you back for additional information during the transition. This is new to everyone…..there will be a learning curve.

Changes with practice and hospital interactions

Not officially released by WHO – Expected to be released in 2014

Development and testing of a clinical modification to ICD– 11 to make it usable in the United States will take an estimated additional 5 to 6 years. Earliest projected date to begin rulemaking for implementation of ICD–11 would be the year 2020

The alpha-numeric structural format of ICD–11 is based on that of ICD–10, making a transition directly from ICD– 9 to ICD–11 more complex and potentially more costly.

Waiting until we could adopt ICD–11 in place of the adopted standards address the more pressing problem of running out of space in ICD–9–CM Volume 3 to accommodate new procedure codes.

Why not move directly to ICD-11?

Most practices use practice specific codes in ICD-9 today so the impact may not be as large since you are not going to utilize all 68,000 codes

CPT codes are not changing

Provides a detailed patient care record for other physicians to assure continuum of care

Quality Measurement – Will provide detail to accommodate new technologies/procedures

More accurate trending and cost analysis

Fewer gray areas – better justification for medical necessity

Good News

ICD-9 to ICD-10 conversion tools http://www.icd10data.com/ICD10CM/Code

s http://www.aapc.com/icd-10/codes/

Training Groups Visit the VHP Portal for a list of groups offering

Physician Practice ICD-10 training

Resources

There’s a code for that!

E012.0 - Knitting accident

There’s a code for that!

W59.21XD - Bitten by Turtle Twice

There’s a code for that!

V9733xD – Sucked into jet engine, subsequent encounter

Z621 - Parental overprotection

Z62891 - Sibling rivalry

Z631 - Problems in relationship with in-laws

There’s a code for that!

QUESTIONS??????