2015 HIM Educational Summit ICD-10-CM Discussion Panel

Transcription

1 2015 HIM Educational Summit ICD-10-CM Discussion Panel

2 PRESENTED BY Karen Scott, MEd, RHIA, CCS-P, CPC, FAHIMA AHIMA Approved ICD-10-CM/PCS Trainer Brian Boyce, BSHS, CPC, CPC-I, CRC AHIMA Approved ICD-10-CM Trainer AAPC Approved ICD-10-CM Trainer

3 WELCOME We are open to questions so please take time to annotate any questions This is Vegas: Don t be afraid to ask your question Agenda: Updates Areas of concern in ROI/audit needs Post implementation issues

4 ICD-10-CM UPDATES July 6, 2015 AMA backs use of ICD-10 to begin on Oct 1, 2105 Direct relation with CMS guidance to not penalize providers during the first year if diagnosis codes are not specific enough, provided the codes come from the proper code family CMS will also establish an ICD-10 Ombudsman to answer questions from healthcare providers CMS also provided a website: to help small practices with the switch to ICD-10-CM

5 NEW RULES ICD-10-CM time frame for Acute MI is < 4 weeks ICD-9-CM time frame for Acute MI was < 8 weeks ICD-10-CM time frame for abortion vs. fetal death is 20 weeks ICD-9-CM time frame for abortion vs. fetal death was 22 weeks ICD-10-CM division of pregnancy codes is based on trimester ICD-9-CM division is by antepartum, delivered during this episode of care or postpartum ICD-10-CM has given disease and conditions of the Eyes and Ears their own chapters ICD-9-CM had these in the nervous system section ICD-10-CM has 2 different types of Excludes notes ICD-9-CM had only one type of Excludes note

6 Specificity DOCUMENTATION CHALLENGES Laterality Manifestations and Complications Episode of Care Depth, Location, Stages, etc. EMR Cut and Paste PMH Vs. Chronic Ongoing Conditions Medical Decision Making

7 With vs. Without NEW RULES Without is the default if not documented Combination Codes There are MANY! Stages (Glaucoma) Manifestations (Diabetes) 2 or more DX (CAD + Angina) 7 th Character Episode of Care (Active, Follow Up, Sequela) Fetus (OB) Stages (Glaucoma)

8 ICD-10-CM UTILIZATION Measure Quality of Care delivery Benchmark Performance Improvements Expansion of Targeted Community Health, Disease Management and Medical Management Programs Prevent Fraud, Waste, & Abuse

9 FORGING FORWARD: EDUCATION Continued education and re-education Make education fun Appropriate for adult learners Blend educational efforts Cognitive Affective Behavioral Lectures Values clarification Role Play Brainstorming Group Process Simulation Discussions Consensus-Seeking Activities Teach Backs

10 FORGING FORWARD: DOCUMENTATION Use ICD-10 to set a new standard for clinical documentation Allow providers to focus on clinical documentation over coding itself when possible Incorporate ICD-10 compatible terms into electronic systems Consider cheat sheets or apps to assist with clinical documentation and code selection

11 High Risk Codes RISKS Justification of medical necessity now and in the future Coding Accuracy & Coding Productivity Future Financial Impacts (Year ) Lack of training, understanding or over-burdened coding and billing teams are at risk!

12 SELF ASSESSMENT Review top coded diagnoses by specialty, practice, office, etc. Review specialty codes for cause and effect or manifestation relationships etc. that may impact combination codes and train, then retrain Review current clinical documentation for each provider and make friendly helpful recommendations Create your own crosswalk for your most frequently coded items and share all information Cross training and knowledge sharing is key!

13 3 SMALL STEPS FOR PROVIDERS 1. Begin to document Right vs. Left whenever possible 2. Begin to document all manifestations and/or complications due to other diagnoses with cause and effect relationships 3. Become clear on Past medical History diagnoses as opposed to Ongoing, Chronic Conditions

14 To mitigate revenue loss and manage accounts receivable (A/R), hospital finance leaders are making ICD-10 denials management a top priority. Leaders are recognizing that the transition to ICD-10-CM/PCS is not simply a coding or health information management (HIM) challenge; it is a significant threat to the organization s revenue and cash flow, requiring top-most attention. HFMA

15 ISSUES TO ADDRESS Reporting requirements may increase Older technology/systems may need to be upgraded/replaced New value-based purchasing initiatives Budgets for investment in electronic health record (EHR) applications

16 ADDITIONAL ISSUES Clinical documentation must be improved to support higher level of specificity within ICD-10 Retirement/incentives to retain experienced coders Productivity may decrease-coding backlogs, learning curve training on the new technology and ICD-10 code set Provider/payer processing errors cause claim denials/reduced cash flow

17 HEALTHCARE PAYMENT REFORM Move from reimbursement driven by volume to valuedriven Current healthcare costs rise if # people w/ a condition increases, if cost of treating that condition increases (# of episodes of care) or both RISK ADJUSTMENT MODELS Proposed Model: Episode of Care Payment Proposed Model: Condition-Specific Capitation Payment 1

18 RELATIONSHIPS TO HEALTHCARE MODELS Bundled Payments Condition-Specific Capitation Model Episode of Care Model Accountable Care Organizations Managed Care Risk Adjustment Models 1

19 CONDITION-SPECIFIC CAPITATION Pt has DM. Insurance company pays PCP a monthly comprehensive payment for managing DM and potential complications. PCP has team of MDs, NPs, labs, Ophthal, etc. to help w/ care PCP develops plan of care that patient agrees to w/ actions that each will take to manage his condition. A NP will be used to perform many regular checks & call MD if needed Costs of blood tests, special visits, etc. paid by the PCP from the monthly care payment 1

20 EPISODE OF CARE Patient falls, breaks hip, has hip prosthesis implanted as IP. Each hospital has defined price to charge insurance company for the surgery and all postop care. Price includes hospital care, surgeon s fees, prosthesis, care by anesthesiologists, intensivists, etc., any posthospital rehab and HH needed. The hospital divides up the payment among all providers involved Hospital & MD will treat any HA infection at no additional charge Patient receives small rebate for her share of costs if she achieves the rehab goals set w/ her MD postdischarge. 2

21 BASELINE MEASUREMENTS Where are we now: Baseline and target measures of coding efficiency and productivity Current Queries? High volume/high value clinical areas DNFB Current and potential impact

22 PROVIDERS IN YOUR NETWORK Possible outdated practice management systems Many physician offices do not employ certified coders Which could increase risk of coding errors Especially problem with common working file Obtaining codes vs. diagnosis statement

23 IMPLEMENTATION STRATEGIES Set strategies to minimize productivity decrease One of first steps is to review payers contracts: DRG? Payment formulas, pay based on code numbers? Are they going to include ICD-10 in contract? Need to have payer agreement negotiation discussions ocompliance errors and claims denials

24 STRATEGIES TO CONSIDER Backup plans Streamline the workflow Gap analysis Examples of findings

25 POTENTIAL DENIAL INCREASES Denial rates may rise Days in A/R may grow by 20 to 40%

26 INCREASE IN CLAIMS ERRORS CMS predicts that claims error rates may be more than two times higher with ICD-10, reaching a high of 6 to 10% in comparison with the average 3% error rate with ICD-9

27 INCREASE IN BACKLOGS Projected to increase by at least 20% What will that do to your cash flow?

28 ROI INCREASE More chart review due to greater chances of misinterpretation Medical necessity LCD/NCD will be based on specific codes Increased potential for PHI issues Security and privacy risks

29 Cash flow decrease PROCESSING ISSUES A typical turnaround time for claims processing of 45 to 55 days could end up being extended another 10 to 20 days

30 POTENTIAL CLAIMS DENIAL INCREASE Due to poor understanding of new code sets and coding requirements Transition planning is key May need to run dual systems to facilitate adequate reimbursement and cash flow

31 DOCUMENTATION TO SUPPORT DENIALS Denials will be more about specifics Capturing the details Responses needed from those with chart knowledge Medical necessity Specificity in codes

32 TRACE AND FIX IN DENIAL RESOLUTION Assess communication between the business office/him department Regarding current denials Where they are in the process of management, How effectively they manage when codes have been changed or documentation is amended Look for bottlenecks, poorly managed hand-offs, or workflow issues

33 TRACK AND TREND DENIALS Select and Develop tracking metrics to help the organization better identify post-icd-10 denial Identify existing denials trends by payer, procedure, and diagnostic code Categorize the reasons for denial Identify payment barriers

34 ASSESSMENT OF VENDOR READINESS Determine vendor readiness and timelines for upgrading software to new coding systems and determine if upgrades are covered by any existing contracts New encoder? or updates? Cost for updates? Vendors and IT departments going dark

35 BUSINESS ASSOCIATE READINESS Including payers, providers, system vendors, and electronic data interchange trading partners Follow up periodically on the readiness status of business associates for updates on ICD-10 transition progress Use vendor questionnaire when working with vendors Identify any changes to the readiness timeline communicated during assessment phase

36 PARTNERS & VENDORS Significant technology changes IT vendors, trading partners, external reporting entities and third-party payers All systems accepting or reporting diagnostic and procedure codes require modification and the ability to run dual nomenclature solutions Significant testing, cross-walk analysis, report development and data aggregation across time periods

37 OUTSOURCED COMPANIES Coding - inpatient versus outpatient What is their plan for readiness for ICD-10? Ensure they have received the necessary education Ask for documentation to confirm that training has occurred and has been provided by a qualified trainer

38 TRAINING & STAFFING IMPACT Analyze the impact on claims If clinical documentation is incomplete, coding will be inaccurate and claims will be impacted Early education Disconnect between physician language and coder language Establish CDI/documentation review program Pre-discharge Review of documentation Query program Streamline documentation workflow Automated tools Query software Electronic Documentation CAC

39 PRODUCTIVITY Productivity impacts to ANY area using codes during initial implementation Not just coding staff! Case management Clinical documentation Health information management Claims processing (electronic billing system) Collections Decision support

40 REDUCE DECREASED PRODUCTIVITY Take inventory of coding professionals knowledge base Part of assessment-honesty about desire to learn new materials Need for ICD-9 coding for awhile Encourage those who plan to retire to stay on as ICD-9 expert Eliminate coding backlogs prior to ICD-10 implementation Use outsourced personnel for coding to assist with workload during the initial implementation period

41 REDUCE DECREASED PRODUCTIVTY Prioritize medical records to be coded Additional training prior to implementation to improve confidence levels and minimize slow downs Additional efforts to improve the clarity of medical record documentation (CDI program)

42 PRODUCTIVITY & ACCURACY STRATEGIES Identify what steps can be taken to diminish the effects of decreased productivity Review and determine the effect or impact of decreased coding accuracy, and develop a quality improvement plan as needed

43 ADDITIONAL STAFFING During training and periods of decreased productivity Assess impact of reduced code assignment productivity on the organization s accounts receivable status What is the anticipated impact on code assignment through-put? How long is coding professional productivity expected to be reduced?

44 IMPLEMENTATION CHECKS Amount and level of preparation Extent of coding staff education and credentials Individual code assignment experience Knowledge of anatomy and disease processes Extent of training Quality of medical record documentation Organizational size and complexity

45 QUESTIONS

46 CONTACT INFO Karen Scott, MEd, RHIA, CCS-P, CPC, FAHIMA Owner, Karen Scott Seminars AHIMA Approved ICD-10-CM/PCS Trainer Brian Boyce, BSHS, CPC, CPC-I, CRC CEO, ionhealthcare