Countdown to ICD-10. Deborah Grider, CPC, CPC-I, CPC-H, CPC-P, CPMA, CEMC, CPCD, COBGC, CCS-P, CDIP Senior Manager. AMA Author

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1 Countdown to ICD-10 Deborah Grider, CPC, CPC-I, CPC-H, CPC-P, CPMA, CEMC, CPCD, COBGC, CCS-P, CDIP Senior Manager AMA Author ICD-10 Implementation Guide, Make the Transition Manageable Principles of ICD-10-CM ICD-10-CM Workbook Principles of ICD-9-CM Coding with Modifiers Medical Record Auditor Blue and Co., 2012; All Rights Reserved

2 Today s Discussion The Current ICD State ICD-10 - What is it? Why is the ICD-10 implementation so important? What challenges do we face? What should we be doing right now?

3 ICD-10 The Current State April 9, 2012-HHS Published the proposed rule extending the deadline for ICD-10 Compliance to 10/1/2014 Thirty (30 day comment period) Delay will allow small providers and small hospitals to reach compliance The one year delay will cost 10-30% more to implement ICD-10

4 ICD-10 The Current State You should see this as an opportunity to get prepared at a less pressured pace It is not good to assume the transition will be delayed again for two main reasons: First, because many large entities have already invested millions of dollars into their ICD-10 preparation, and training, they would probably fight any additional delay. Second, the IT industry will start to lobby against another delay because of the impact it will have on their companies, workforce, and budgets. They may not have been an organized block to stop this recent delay, but believe me they will be prepared if faced with another one

5 ICD-10 The Current State The code freeze is currently in effect Lifting the code freeze would require extensive reprogramming One health plan estimated lifting the code freeze would cat an additional $1million in additional expense and overall nationally over $2 billion One year delay will give more time to continue on with implementation activities

6 Real Reason for Delay CMS Readiness Survey Will be compliance by 10/1/2013 Will be compliant by December 31, 2013 Does not know wen they will be compliant Do not plan on compliance Providers 74% 14% 11% 1% Payers 72% 17% 13% 8% Vendors 78% 8% 13% 1%

7 Four Options Considered Keep the current date Implement ICD-10-PCS 10/1/2013 with a delay for ICD10-CM implementation potentially October Forego ICD-10 and move to ICD-11 Impossible Why? ICD-11 totally electronic In beta (Stanford) with release potentially scheduled 2015 Will take US 5-7 years to clinically modify CM and PCS Finally release would not occur until 2020 or later Delay ICD-10 one year (October 1, 2014) A delay of more than 1 year would be catastrophic or cause unrecoverable failure

8 Potential Costs for 2014 Implementation Potential Cost by Hospital Size > 100 Beds Beds 400+ Beds $250,000-$ $620,000 $1.85 Million $ $6.16 Million

9 Potential Costs for 2014 Implementation Potential Cost by Medical Practice Size Small Practice Mid-Size Practice Large Practice $8,000 - $15,000 $148,000- $2.9 Million $2 - $9 Million

10 Learning from International Implementations

11 Big Mistake! You should not stop your implementation timeline

12 Change to ICD-10 Most countries use some version of ICD-10 The international version of ICD-10 = 12,500 diagnostic codes United States version of ICD-10 = 69,847 codes (2012) ICD-10-PCS codes are only used in the US

13 Why So Important? Largest change to ever happen to healthcare Will take many hospitals and other health care organizations years to accomplish full implementation May require significant funding May take years to Recover

14 Code Set Comparison: Diagnosis Codes ICD-9-CM Diagnosis Codes 3-5 characters in length Approximately 14,025 codes First digit may be alpha (E or V) or numeric. Digits 2-5 are numeric Limited space for new codes Lacks detail Lacks laterality Difficult to analyze data due to nonspecific codes Codes are non-specific and do not adequately define diagnoses needed for medical research Does not support interoperability because it is not used in other countries ICD-10-CM Diagnosis Codes 3-7 characters in length Approximately 69,348 codes Digit 1 is alpha; digit 2 and 3 are numeric; digit 4-7 are alpha or numeric Very specific Has laterality Specificity improves coding accuracy and depth of data for analysis Detail improves the accuracy of data used in medical research Supports interoperability and the exchange of health care data

15 Why So Many Diagnosis Codes? 34,250 (50%) of all ICD-10-CM codes are related to the musculoskeletal system 17,045 (25%) of all ICD-10-CM codes are related to fractures 10,582 (62%) of fracture codes to distinguish right vs. left ~25,000 (36%) of all ICD-10-CM codes to distinguish right vs. left

16 What is so Different? Expanded Injury coding More combination codes for diagnosis/symptom codes Alphanumeric Laterality Length of characters (7) Expanded External Cause Codes Requirement of use of Status Codes Changes in injury and poisoning reporting Changes in OB coding Diabetes Mellitus expanded to 210 codes so far

17 ICD-10 IMPLEMENTATION STRATEGY

18 Now What!

19 Areas of Impact: Everywhere! Disease Management Quality Measures Registries Clinical Decision Making Financials Case Mgt Health Policy Reimbursement Billing Test Ordering Identifying Fraudulent Practices Research & Studies Registration Scheduling Reporting Payment Systems and Claims Processing Pharmacy Performance Improvement & Measurements Encoding Software

20 Advantage of Moving to ICD-10 More consistent with the rest of the world Considerably more information per code Greater expandability in codes More logical tabular structure Better definition of co-morbidities, complications and disease manifestations Improved support for analysis related to: Risk and severity Predictive modeling Quality and cost efficiency analysis Population epidemiologic research

21 ICD-10 Code Set Reporting Proposed Dates Date of Service Code Set Encounters 09/30/2014 ICD-9-CM 10/1/2014 ICD-10-CM Date of Discharge Code Set Hospital Inpatient 9/30/2014 ICD-9-CM 10/1/2014 ICD-10-CM & ICD-10-PCS

22 The Code Freeze Currently no plans to lift the code freeze On October 1, 2012 and 2013, there will be only limited code updates to both the ICD-9-CM and ICD-10 code sets to capture new technologies and diseases as required by section 503(a) of Pub. L On October 1, 2013 and 2014, there will be only limited code updates to ICD-10 code sets to capture new technologies and diagnoses as required by section 503(a) of Pub. L There will be no updates to ICD-9-CM, as it will no longer be used for reporting On October 1, 2015, regular updates to ICD-10 will begin

23 Key Obstacles Resistance to change Challenge of updating skills Information systems will need to be updated or changed Uses of coded data more complex

24 Health Care Settings Settings ICD-10-CM ICD-10-PCS CPT/HCPCS Hospital X X Inpatient Hospital X X Outpatient Physician X X Laboratory X X Behavioral X X Health Long Term Care X X All Other X X

25 ICD-10 Implementation Plan Year 2011/ / Phase 1 Impact Assessment Phase 2 Preparing for Implementation Phase 3 Go Live Preparation Phase 4 Post Implementation Checklist: /ICD 10 PreparationChecklist.mht

26 Phase 1 Impact Assessment Assess Readiness Develop organizational implementation strategy Develop Communication Plan Inventory Systems and Reports Assess Training Needs Conduct Gap Analysis Identify backup needs to support downtime Develop Budget

27 Phase 2- Preparing for Implementation Review and revise implementation strategy Develop material for communication plan & deliver materials Assess change management processes Provide training based upon assessment Implement documentation improvement plan Align outside resources for backup support Anticipate lower productivity and quality Test systems and processes Assess budget against actual costs Allocate 20% of total expenses

28 Phase 3 & 4 Go-Live & Post Implementation Assess backlog necessary for coding ICD-9 Align resources for ICD-9 coding Begin coding in ICD-10 Review/audit ICD-10 Conduct training as needed Communicate successes

29 PHASE II Training Plan Who will need training?

30 Quality Management Accounting PHASE II Training Plan Senior Mgt Clinicians Utilization Management Software Vendors Coders Data Analysts Clinical Dept. Managers Information Systems Epidemiologists Physicians Data Security Patient Access & Registration Business Office Auditors & Consultants Lab HIM

31 Challenges Ahead

32 Cost to Implement ICD-10 STEP COST Impact Analysis $50,000 - $280,000 GAP and System Analysis $50,000 - $210,000 Documentation Assessment $45,000 - $180,000 Consulting Costs $50,000 - $300,000 Post-Implementation $30,000 -?

33 Documentation For documentations supporting diagnoses or procedures Physicians first must ensure that the services provided are consistent with the symptoms of the patient and that they satisfy generally accepted medical standards Physicians must ensure that their documentation is adequate for coding and quality assurance purposes Part of this effort requires that physicians understand and remain current on the relevant documentation standards.

34 Documentation Physicians should strongly consider attend documentation workshops on an annual basis to establish and to refresh their skills in documentation, and to master changing requirements Change in code sets would necessitate a major change in documentation requirements Significant training and changes in procedures would be necessary to support this change

35 Documentation The increased documentation requirements would increase the amount of time and effort that practices spend on each patient encounter It is difficult to determine the amount of change involved in documentation, but it is a certainty that additional time will be spent documenting care Changes would be based on how health plans revise their requirements to support codes the types of care that a practice deals in the current methods for documentation, and other factors Even a 5% increase in this effort would have an impact on the time of providers.

36 Training Training Time Range from hours depending on need and job function United Kingdom recommends a minumum10 days of basic training (7 hours x 10=70 hours) Keep in mind they have been through this themselves Rand Study estimates cost nationally up to $100 million Final rule-cms under-estimated costs for training

37 Productivity Impact Productivity will be affected Prior to and after implementation Staff when training More documentation will be required to support new coding system It will take more time for the provider to document encounters It will take longer to code claims until learning curve has been realized

38 Productivity Impact Key areas: Queries from coders to clarify documentation in the medical record Increased billing inquiries from payers Increased number of adjustments and pended or suspended claims

39 Challenges Ahead Did 5010 go Smoothly? Documentation may not be sufficient for the level of detail in ICD-10-CM and ICD-10-PCS Systems and Processes must be reviewed, updated and addressed very soon or time will run out Systems may be outdated and need replaced or upgraded GAP Analysis must be performed Project planning key to success

40 Challenges Ahead Medical policy changes GEMS mapping files not 100% accurate Not all payers must comply Workers Compensation (exempt) Auto Insurance (exempt) Will all payers/carriers be ready? Will you? Payers who put a Band-Aid on their old legacy systems will map the claim from ICD-10-CM or PCS back to ICD- 9-CM to pay the claim What problems do you see with this picture?

41 Challenges Ahead What will this COST!!! Hardware upgrades Software upgrades (what software do you use?) Vendor readiness Change in health plan policies Training - everyone will need some form of training Not all staff will need in-depth training Coders and physician s need the in-depth training Consulting fees-pre and post implementation

42 PULL TRIGGER ON GO LIVE PLAN!!!!

43 Post Implementation Challenges What about productivity-time is money Suspended denied claims Payers using old legacy systems and using reimbursement maps What about the old claims prior to October ? Will you need additional coding and/or billing help For how long? Documentation will still be an issue

44 HOW WILL THIS AFFECT YOU?

45 Keys to Success Transform task force into action team Assess Risk Share Information Identify Key Stakeholders Rank needs and development Strategy Budget Schedule Train Implement

46 Take Away Advice Stay positive when educating physicians and don't expect them to become coders Computer assisted coding (CAC) and medical transcription systems can help achieve the documentation needed to create ICD-10 codes There is a fear that payers won't be ready for ICD-10 codes and the issues it creates Hospitals and physicians need to be financially ready for increased accounts receivables and payment delays Schedule to test with payers early 2014

47 QUESTIONS, ANSWERS, DISCUSSION

48 THE COUNTDOWN IS NOW!!!

49 For assistance with ICD-10 Implementation or training contact Deborah Grider at Thank you for Attending