ICD-10 Panel Presentation: Operational Successes & Challenges

of 22

Page 0August 20, 2015

Incomplete Work ProductPrepared for Tennessee MGMA

Tennessee MGMA

August 20, 2015

ICD-10 Transition Update:Final Countdown



What is the current regulatory status ofICD10?

Overview of testing to-date: successesand challenges

Future use of ICD-10 for outcome-basedand populationhealthfocused data

What to expect regarding claim denialsbased on insufficient specificity

Final Countdown: What now?

What to do AFTER Oct. 1, 2015

Learning Objectives

of 22



Countdown

DAYS HOURS MINUTES SECONDS

41 12 54 03



When Is It Official?

January 1,2010

Payers andproviders shouldbegin internaltesting of Version5010 standardsfor electronicclaims

December31, 2010

Internal testing ofVersion 5010must becomplete toachieve Level IVersion 5010compliance

Providers shouldform ICD-10sponsorshipteam

January 1,2011

Payers andproviders shouldbegin externaltesting of Version5010 forelectronic claims

CMS beginsacceptingVersion 5010claims

Version 4010claims continueto be accepted

December31, 2011

External testingof Version 5010for electronicclaims must becomplete toachieve Level IIVersion 5010compliance

January 1,2012

All electronicclaims must useVersion 5010

Version 4010claims are nolonger accepted

October 1,2015

Claims forservicesprovided on orafter this datemust use ICD-10 codes formedicaldiagnosis andinpatientprocedures

CPT codes willcontinue to beused foroutpatientservices

Per the Department of Health and Human Services, thecompliance date for implementation of ICD-10-CM and

ICD-10-PCS is October 1, 2015.

of 22



ICD-10 Organizational Impact

Physician Documentation Physician Integration Physician Performance

Staffing Effectiveness Revenue Impact Assessment Process Flow & Improvement

Decision Support Impact

Documentation Analysis ICD-10 Education & Training Coding Production Impact

PhysicianOffice

Post AcuteServices

Scheduling, ED & Access Areas DNFB, Coding, CDI Case Management

Billing, Reimbursement

HealthInformation

Management

ICD-10

RevenueProcess

PhysicianOperational

Planning

InformationTechnology

IT Systems Capability, Communication Functionality

Vendor Preparedness



What is the Current RegulatoryStatus of ICD 10?

of 22



CMS ICD-10 Mitigation Provisions CMS clarified, through a recent Q&A release, its announcement from July 6, 2015,

of mitigation provisions to help ease the potential impact associated with the ICD-10 implementation

CMS will not deny Part B claims under medical review if the ICD-10 codereported is within the appropriate family until Oct. 1, 2016..

COPD (Chronic Pulmonary Obstructive Disease)

J44.0 COPD with acute lower respiratory infection/bronchitis

J44.1 COPD with acute exacerbation/decompensated

J44.9 COPD, unspecified

The family for COPD is J44.

Source: https://www.cms.gov/Medicare/Coding/ICD10/Clarifying-Questions-and-Answers-Related-to-the-July-6-2015-CMS-AMA-Joint-Announcement.pdf



CMS ICD-10Mitigation Provisions (cont.)

CMS ICD-10 mitigation provisions key information:

A valid ICD-10 is still required on all claims starting Oct.1, 2015.

The medical review policy will be adopted by the MACs, RACs, ZPICS, andSupplemental Medical Review Contractors

Quality reporting: PQRS, VBM, MU

Mitigation Provisions do not change the coding specificity required bythe NCDs and LCDs policies

Medicare Part B Contractors are offering an advance payment conditionalpartial payment, which requires repayment if they are unable to processclaims within established time limits due to problems

Commercial payers have no obligation to adopt CMS provisions

of 22



H.R. 2247ICD-TEN Act

Introduced to the House on May 12, 2015

Bill that would mandate an 18-monthtransition period for testing submittal of ICD-10 claims

As of July 23, 2015, this bill has not beenapproved



H.R. 3018The Code-FLEX Act of 2015

Introduced to the House of Representatives on July 10, 2015

Objective of bill is to provide a safe harbor period for thetransition from the ICD-9 to the ICD-10 standard for healthcare claims

If approved, claims will be processed/payable by public andprivate payers if submitted with ICD-9 or ICD-10 codes

Many are against this because a dual coding system is not asimple solution and may confuse claims processing. It wouldrequire complex and costly changes to all systems toaccommodate this bill

To date, this bill has not been approved

of 22



Current Regulatory Status

Expect additional attempts in the upcomingmonths to halt the implementation of ICD-10

If your organization is not ready: braceyourself, its going to be a bumpy road



Overview of Testing To-Date:Successes and Challenges

of 22



Industry Readiness Survey

The Workgroup for Electronic Data Interchange (WEDI) is the leadingauthority on the use of Health IT to improve the exchange of healthcareinformation

WEDI conducts frequent surveys to measure industry readinesspertaining to the ICD-10 transition

Most recent survey results are from February 2015

WEDI completed another survey this summer that was open until July 10,2015, and is currently compiling results

Updates to this recent survey: http://www.wedi.org/news/press-releases/2015/06/11/WEDI-Opens-ICD-10-Readiness-Survey-for-June



Industry Readiness Survey Results,February 2015

Many organizations did not take full advantage ofthe additional time afforded by the one-year delay

The delay had a negative impact on somereadiness activities

Some tasks have slipped into 2015, particularlythose related to testing

Compliance date uncertainty was listed as theprimary obstacle to implementation

of 22



Industry Readiness Survey Results,February 2015 (cont.)

Key findings from February 2015 survey include:

Health plan testing: Slight improvement from the prior survey, whichshows that more than 50 percent of health plans have begun externaltesting and of these, a few have completed testing. This is a slightimprovement from the prior survey

Health plan impact assessment : About four-fifths of health planscompleted their impact assessment, up from about in August 2014

Provider testing: Only 25 percent of provider respondents hadbegun external testing and only a few others had completed this step



Payer Testing

Many payers offer ICD-10 testing andreference/tools:

BCBS TN: http://www.bcbst.com/providers/icd-10.page

CMS: https://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-Simplification/Affordable-Care-Act/End-to-End-Testing.html

of 22



Payer Testing Tips

Check with your clearinghouse for payer alertsregarding ICD-10 testing and track them. This willgive you an idea on the financial impact that youcan expect based on your payer mix

Review what happened to your organization withthe HIPAA 5010 transition, as this will be a goodbaseline. As with the 5010 transition, there will bedelays in reimbursement with ICD-10



Medicare CoverageDetermination Changes

of 22



National CoverageDeterminations (NCDs)

CMS is responsible for converting approximately 330NCDs

Not all are appropriate for translation

Edits based on HCPCS

Older obsolete technology or considered outdated

CMS has determined which NCD should be translatedfrom ICD-9 to ICD-10, and is in the process of completingsystem changes for those NCDs

http://www.cms.gov/outreach-and-education/medicare-learningnetworkmln/mlnmattersarticles/downloads/MM7818.pdf



Local CoverageDeterminations (LCDs)

According to CMS, LCDs are made by theindividual Medicare Auditing Contractor (MAC i.e. CAHABA)

Contractors have published all ICD-10 LCDsand ICD-10 associated articles on theMedicare Coverage Database (MCD) underFuture LCDs

of 22



Local CoverageDetermination (LCD) Example

LCD Title: Drugs and Biologicals:Palonosetron HCL Injection (Aloxi)

ICD-10 LCD ID: L34259

Original ICD-9 LCD ID: L30033



LCD Example for Aloxi

of 22



Future Use of ICD-10 for Outcome-Based and PopulationHealth

Focused Date



ClinicalDocumentation

Accurate diagnosis Improved quality of care

Quality Pay-for-performance Public Reporting

Financial Utilization management Cost containment

ICD-10 Transitional Impact

of 22



Provider Impact

Value-based compensation

Increased documentation time up to 15%

May affect patient volume

Quality Measures/P4P need to be determinedbased on ICD-10 codes

Difficult to measure impact of change Due tochange of code set or due to changes in underlyingpractice?

24



ICD-10 Impact with Quality Measures

Expansion means improved data whenassessing patient severity, the quality of carereceived, and patient outcomes

ICD-10 will impact quality measures that will befelt for many years following implementation

Make sure to review definition changes for allconditions with changes, i.e., pressure ulcers,fractures and myocardial infarctions

of 22



Definition Impact

Myocardial Infarction

ICD-9-CM: coded as acute if it has a duration ofeight weeks or less

ICD-10-CM: coded as acute if it has duration offour weeks or less



Potential Impact of Implementationand Mitigation Steps

of 22



ICD-10 Potential Financial ImpactDecrease in Cash Flow / Loss of Revenue

Industry experts from CMS and AHIMA estimate thefollowing:

Denial rates will increase by 100% to 200%

Accounts receivable days will be extended by 20%to 40%

Healthcare organizations will be hindered withpayment declines for more than 2 years after theimplementation Date of October 1, 2015

Claims-error rates will increase from 6% to 10 %(The average current rate is close to 3%)



How to Mitigate the PotentialFinancial Impact

Determine your organizations payer mix

Consider how your major payers reacted to the5010 transition as a base line on what to expectwith the ICD-10 transition

CMS recently announced mitigation provisions willnot reduce the potential financial impact from CMSpayers for the first 12 months; however, theprovisions do decrease audit risk

of 22



Expected Denial Reasons

Minich-Pourshadi, Karen. ICD-10 Puts Revenue at Risk. HealthLeaders Media Intelligence (July 2011), p. 22.



Claim Denial Process Improvement

Focus on improving your current denialsmanagement process

The cost to work a denial is estimated at $25-$40 per claim

Ignoring denials is throwing away money

of 22



Top 3 Steps to Improved DenialManagement

Analyze Current ClaimsProcess

How are your claimdenials identified?(manually when postingpayments, systemprograms, reports viaelectronic remit messagecodes, etc.)

How are your denialstracked? (manually viaspreadsheet, denialsmanagement software,etc.)

Prevent Denials

Identify current topdenials

Stay on top of currentreimbursement news orcompliance issues anddetermine if it applies toyour practice

Initiate proactiveprocesses to prevent topdenials or complianceconcerns (education,system edits, etc.)

Track denials over aperiod of time to ensurethat you are seeing areduction

Aggressive ClaimResolution

Assign appropriate staffto work denials

Aggressive resolutiontechniques (strongappeals, clearunderstanding of denial,effective compliantresolution to denials,etc.)

Track employeeperformance andcompare to peers toestablish benchmarks



Final Countdown: What Now?

of 22



Priority List

Have coders dual code a % of claims per day, and increase the % each week until Oct 1, 2015

Ensure your foundational IS structure is ready for the transition

Determine if additional staff is needed, or some areas be outsourced to prepare for the reduction inproduction

Prepare for an increase in denials and work on improving your current denials management process

Continue to identify specific documentation gaps to determine focused educational needs

Calculate potential impact on financial results based on payer testing results and payers previous experience with5010 transition. Also have cash reserve established to prepare for interruptions in cash flow.



What To Do AFTEROctober 1, 2015

of 22



Plan for coding in ICD-9 and ICD-10 for a brief period to address services renderedbefore October 1, but discharged after October 1 (split claims)

Monitor physician documentation to ensure ICD-10 compliance

Monitor impact on claim-processing activity, claim denials, and rejections

Audit coder productivity and accuracy

Monitor patient satisfaction

Post-transition Review

Whats working?

What needs fixing?

Schedule 30-day post-conversion claims assessment

ICD-10 Go Live, The Day After



The Future?

WHO is currently working on ICD-11

They will build upon ICD-10

The first draft was made availableonline in July 2011 for review

The final draft is expected to besubmitted to WHO's World HealthAssembly for official endorsementby 2017

of 22



Key Resources

ICD-10 Proposed and Final Rules http://edocket.access.gpo.gov/2008/pdf/E8-19298.pdf

http://edocket.access.gpo.gov/2009/pdf/E9-743.pdf

CMS Website on ICD-10 https://www.cms.gov/ICD10/

CDC Website on Classification of Diseases http://www.cdc.gov/nchs/icd.htm

CMS ICD-10-CM Quick Reference Guide https://www.cms.gov/ICD10/11b14_2012_ICD10CM_and_GEMs.a

sp#TopOfPage



Key Resources (cont.) CMS Mitigation Provisions

https://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD-10-guidance.pdf

Status of H.R. Bills

https://www.congress.gov/bill/114th-congress/house-bill/2247

WEDI Feb 2015 Survey Result

http://www.wedi.org/docs/resources/full-comment-letter-and-survey-results.pdf?sfvrsn=0

of 22



Key Resources (cont.) ICD-10 Future LCD and Articles- Cahaba

http://www.cahabagba.com/part-b/medical-review/local-coverage-determinations-lcds-and-articles/



MLN Connects National ProviderCall: Countdown to ICD-10

Thursday, August 27; 2:30-4pm ET

To Register: Visit MLN Connects Event Registration. Spacemay be limited, register early.

Agenda

National implementation update, CMS Acting Administrator AndySlavitt

Coding guidance, AHA and AHIMA

How to get answers to coding questions

Claims that span the implementation date

Results from acknowledgement and end-to-end testing weeks

Provider resources

of 22



Questions?



Contact Information

Jennifer Kastner, CPC, CPMA, CEMCAHIMA Approved ICD-10-CM Instructor

(404) 266-9876

[email protected]