Billing and Coding Now and Into The Future!

Presenter: Eduardo Porras CPC,CPMA AHIMA Approved ICD-10 CM/PCS Ambassador

The Constant is Change!

The Constant is Change!

❖ICD-10-CM ❖Meaningful Use ❖HIPAA Security Risk Analysis ❖Administrative Simplification

ICD-10: Managing Through the Transition

Why is ICD-9 Being Replaced?❖ICD-9-CM is out of date and running out of space for

new codes. !❖Lacks specificity and detail ❖No longer reflects current medical practice !

❖ICD-10 is the international standard to report and monitor diseases and mortality, making it important for the U.S. to adopt ICD-10 based classifications for reporting and surveillance.

❖ICD codes are the core elements of HIT systems, conversion to ICD-10 is necessary to fully realize benefits of HIT adoption.

Major Differences Between ICD-9-CM and ICD-10-CM

ICD – 9-CM ICD – 10-CM13,600 codes 69,000 codes

Code book contains 17 chapters Code book contains 21 chaptersConsists of 3 to 5 characters Consists of 3 to 7 characters

1st 1st

Only utilizes letters E and V Utilizes all letters (except U)Second, third, fourth, and fifth characters are always numeric

Second character is always numeric

Third, fourth, fifth, sixth, and seventh

characters can be alpha or Shorter code descriptions because

of lack of specificity and abbreviated code titles

Longer code descriptions because of greater clinical detail

and specificity and full code titles

Comparison of ICD-9-CM and ICD-10-CM

• A - Category of code • B - Etiology, anatomical

site, and/or severity • C - Extension ▫ 7th character for obstetrics,

injuries, and external causes of injury

• A - Category of code • B - Etiology, anatomical

site, and manifestation

ICD-9-CM Code ICD-10-CM code

A B

A B C

Comparison of ICD-9-CM and ICD-10-CM

ICD-9-CM Codes ICD-10-CM Codes

Pressure ulcer codes 9 codes

707.00 – 707.09

Pressure ulcer codes 125 codes

L89.0-L89.94 Codes: 707.0 Pressure ulcer 707.00 - unspecified site 707.01 - elbow 707.02 - upper back 707.03 - lower back 707.04 - hip 707.05 - buttock 707.06 - ankle 707.07 - heel 707.09 - other site

Code Examples: L89.131 – Pressure ulcer of right lower back, stage I L89.132 – Pressure ulcer of right lower back, stage II L89.133 – Pressure ulcer of right lower back, stage III L89.134 – Pressure ulcer of right lower back, stage IV L89.139 – Pressure ulcer of right lower back, unspecified stage L89.141 – Pressure ulcer of left lower back, stage I L89.142 – Pressure ulcer of left lower back, stage II L89.143 – Pressure ulcer of left lower back, stage III L89.144 – Pressure ulcer of left lower back, stage IV L89.149 – Pressure ulcer of left lower back, unspecified stage L89.151 – Pressure ulcer of sacral region, stage I L89.152 – Pressure ulcer of sacral region, stage II …

ICD 10 Key Strategies

❖Coder Transition ❖Training ❖Dual coding environment

❖Physician Transition ❖Prospective deficiency analysis—note by note ❖Physician-specific, data-driven education

Coder Training❖ Key issues include training courses, but equally ramping up to

productivity standards and confidence ❖ Future needs to meet:

❖ Coders will need to train in real environments with real notes/encounters and see where skill gaps exist

❖ Multiple passes –at first getting comfortable with coding, then testing productivity. See where the gaps exist and retrain specifically.

❖ Computer-assisted rules-based coding will greatly assist the transition ❖ Dual coding environment –specific notes, rules engine suggested codes, coders

code, after-the-fact analyses of generic versus specific codes ❖ The Practice will want to be sure they understand revenue risk from non-specific

coding prior to October.

Physician TrainingThe Problem ❖ Physicians have learned how

to document at the detailed level over the last 20 years

❖ More detailed information required to get to the most specific codes

❖ Organizations have meaningful revenue risk with ICD-10 if documentation is not up to the new standard

❖ No physicians want to worry about this now, but every physician will need to adapt

Needed approach ❖Note-by-note and ICD-by-ICD analysis of the specific changes each physician needs to make ❖Data-driven training with physicians – their documentation, their deficiencies, needed changes ❖ “Small footprint” discussions over time—topic-by-topic rather than all-at-once. Aggregated plan between now and October ❖Follow-up data analysis to determine effect of training and to structure additional interactions

Needed Documentation Deficiency Analysis❖Step 1: Data Processing ❖Take historical notes and code for ICD10 !

❖Compare—at the note level—specific language in note with documentation needed for specific ICD10 code !

❖Determine gaps overall and by doctor !

❖Group training activity into themes or specific areas so that effective and granular training can be performed

Needed Documentation Deficiency Analysis

❖Step 2: Data Analysis and Aggregation ❖Determine patterns by physician, modality !

❖Isolate highest impact deficiencies ❖Frequency ❖Value

❖Based on identified deficiencies, collate examples of deficient documentation

Needed Documentation Deficiency Analysis

❖Step 3: Reporting and training ❖Overall patterns ❖Physician-specific reporting

❖ Work with physicians one on one or in relevant focus groups to train !

❖ Analyze and repeat as necessary to ensure the new concepts stick !

❖ Utilize existing coding management and teams to conduct the training (they are the ones who do it normally anyway)—but you have to free up their time to do so

Be Prepared for the ICD-10 Migration

Be Prepared for the ICD-10 Migration

❖Are you in good hands?? ❖MGMA Research Finds !❖More than 52 percent of doctors indicated they had not

heard from their practice management system vendor regarding when software changes would be available to the practice. !

❖Almost 50 percent had not heard from their EHR vendor.

Revenue Cycle: Overview

Revenue Cycle: Overview

"19

REG

ULAT

IONS

PROCESS

CULTURE

TOOLS

PEOPLE

BILLING

CDMP

SCHEDULING

REGISTRATION

INSURANCE VERIFICATION

FINANCIAL COUNSELING

CASE MGMT/QUR

CDM/CHARGECAPTUREMEDICAL

RECORDS

CUSTOMER SERVICE

THIRD PARTY FOLLOW- UP

SELF PAY COLLECTIONS

PROGRAMADMINISTRATION

CASH POSTING

POST PAYMENT REVIEW

TECHNOLOGY

CUSTOM

ER

EXPECTATIONS

PAYO

RS

POINT OF SERVICE COLLECTIONS

DENIALS MANAGEMENT

FINANCIAL CLEARANCE

Getting Paid for the Services That are Provided. The first time!

Getting Paid for the Services That are Provided. The first time!

❖Step One: Automate ❖ Automating Coding and Claims ❖ Automating the Clearinghouse ❖ Automating Eligibility ❖ Automating Denial Management ❖ Automating Self-Pay Collections ❖Step Two: Analyze ❖ Business Intelligence Tools ❖ Benchmarking ❖Step Three: Detect and Fix ❖Step Four: Refine and Repeat

Importance of Collecting Accurate Information

Importance of Collecting Accurate Information!

❖ It starts with the collection of comprehensive and accurate financial data. !

❖ Garbage in, garbage out! Collecting accurate demographic and billing information should not be limited to new patients !

❖ Another headache for practices is monitoring patients with aged balances who keep coming in for additional services !

❖ Untimely submission of insurance claims and poorly designed patient statements will thwart collection efforts !

❖ Failure to analyze collection performance can be a major headache

Leverage Technology to Ease the Pain!

Leverage Technology to Ease the Pain!

!❖Technology is your

friend! Use it wisely. ❖A lonely writer who

develops an unlikely relationship with his newly purchased operating system that's designed to meet his every need.

Thank you!

Presenter: Eduardo Porras CPC,CPMA

AHIMA Approved ICD-10 CM/PCS Ambassador

If you would like more information on this topic or other ways to increase your reimbursements, contact us directly.

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