Shellie Sulzberger, LPN, CPC, ICDCT-CM. Coding & Compliance Initiatives, Inc.
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1 Shellie Sulzberger, LPN, CPC, ICDCT-CM Coding & Compliance Initiatives, Inc.
2 My connection to coding and documentation My connection to clinical processes My connection to ICD-10 My connection to YOU Coding & Compliance Initiatives, Inc. 2
3 Reasonable efforts have been made to provide the most accurate and current information. However codes, guidelines, and policies are subject to change and interpretation. No guarantee is given that this presentation is free of errors, omissions, misuse, or misinterpretation and this presentation should not be considered a legal or authoritative opinion. This presentation does not replace coding manuals or other authoritative resources. Coding & Compliance Initiatives, Inc. 3
4 Discuss how documentation and ICD-10 will impact your business Have a better understanding for the role of the provider, coding staff and manager Discuss what you need to do to prepare Coding & Compliance Initiatives, Inc. 4
5 How familiar is your organization with ICD- 10? Does your coding staff understand the terminology and disease processes? Do your providers understand their role? Coding & Compliance Initiatives, Inc. 5
6 Define Needs o Project team, timelines, budget, risk assessment, gap analysis reviews, education, etc. Analyze Operational Impact Areas Facilitate Education Providers and staff Implement prior to go live Monitor Coding & Compliance Initiatives, Inc. 6
7 Establish a team/committee to drive the process Focus on key positions (coding, billing, clinical, ancillary) Review ICD-10 requirements and resources Consider your specific scope of practice (specialties) Coding & Compliance Initiatives, Inc. 7
8 Develop an ICD-10 implementation plan with timelines Training for whom and by when IT capability assessment by when Initial gap analysis chart review by when Workflow considerations by when Budget considerations by when Coding & Compliance Initiatives, Inc. 8
9 Will any new costs need to be incurred for you to implement ICD-10? Training curriculum Hardware, software, interfaces Overtime Also consider potential costs related to cash flow disruption during implementation (training time, IT upgrades, etc.) Coding & Compliance Initiatives, Inc. 9
10 Your committee should discuss potential coding challenges and process challenges based upon their respective areas of expertise List the potential challenges, then rank them in order of importance Develop strategies to reduce the potential negative impact Coding & Compliance Initiatives, Inc. 10
11 Work flow document where, how and who uses ICD-9 codes in all workflows and identify where changes will be needed for ICD-10 Technology ensure your systems (EMR, Practice Management, Clearinghouse, etc.) can accommodate ICD-9 and ICD-10 Support you will need support and commitment get your staff and providers on board they need to be prepared and work as a TEAM Coding & Compliance Initiatives, Inc. 11
12 Gap Analysis perform a documentation review for the top 5 diagnoses coded for each provider Consider 5 10 charts per provider Make sure the notes accurately reflect what was done so the staff can code to the highest level of specificity. Coding & Compliance Initiatives, Inc. 12
13 Effective education and training will be key to a successful transition Consider educational frequency so you can establish a timeline Determine the level of training for each department the level of training will not be the same for each area Coding & Compliance Initiatives, Inc. 13
14 Implement Contact Vendors Engage Providers Convert ICD-9 to ICD-10 Codes Coding & Compliance Initiatives, Inc. 14
15 Coding & Compliance Initiatives, Inc. 15
16 Operational Productivity coders, billers, providers Coding Training and education for the coding staff Technology updates (i.e. EMR, coding software, scrubbers) Encounter ticket/superbill Audits Coding (i.e. gap analysis, CPT, credible documentation) Internal External Recovery Audit Contractors (RAC Fraud and abuse (i.e. whistleblower) Coding & Compliance Initiatives, Inc. 16
17 Contracting Reviewed and renegotiated Carve outs Compliance Training staff Physician Education Risk Assessment HIPAA Advisory Board Education Other Compliance Issues Coding & Compliance Initiatives, Inc. 17
18 Reimbursement Denials (i.e. lacks medical necessity, wrong code, sequencing issues, modifiers) Pay for performance Billing Training and education for the billing staff Technology updates (i.e. new codes, billing edits) Benefits and coverage determinations Coding & Compliance Initiatives, Inc. 18
19 Everywhere ICD-9 currently intersects with your practice there can be impacts with ICD-10 Productivity (provider, coder, data entry, etc.) Charge ticket/superbill Referrals Orders for lab, x-ray, therapy, etc. Insurance verification and pre-authorization Coding & Compliance Initiatives, Inc. 19
20 Providers may see fewer patients initially Coder productivity may decrease Specificity may be lacking to code accurately Billing productivity may decrease Increased denied claims and re-billing Coding & Compliance Initiatives, Inc. 20
21 New coverage policies, edits, fee schedules Review managed care contracts You may receive updates or amendments from your payors Vulnerability could include the payer lowering payments linked to more specific codes You may need to contact your payor rep s proactively and inquire about potential changes in your contracts Coding & Compliance Initiatives, Inc. 21
22 Providers may see fewer patients initially Coder productivity may decrease Specificity may be lacking to code accurately Billing productivity may decrease Increased denied claims and re-billing Coding & Compliance Initiatives, Inc. 22
23 New coverage policies, edits, fee schedules Review managed care contracts You may receive updates or amendments from your payors Vulnerability could include the payer lowering payments linked to more specific codes You may need to contact your payor rep s proactively and inquire about potential changes in your contracts Coding & Compliance Initiatives, Inc. 23
24 Assess your current systems Several systems will be impacted Practice Management Software Charge Entry Modules Scrubbers and Interfaces EMR (problem list, assessment/impression, CPOE) Coding Software Quality reporting software Clinical Protocols Coding & Compliance Initiatives, Inc. 24
25 Coding & Compliance Initiatives, Inc. 25
26 Scheduling staff Front desk Clinical (MA s, nursing, lab techs, etc.) Providers (Physicians and NPP s) Referral coordinators Precertification and authorization staff Coding and billing staff Coding & Compliance Initiatives, Inc. 26
27 Focus training efforts on those codes that are used most frequently in your practice A well trained staff is the best way to ensure a smooth transition A boot camp is not always the best way Break your training in small manageable training sessions so the staff do not feel overwhelmed This is particularly true with providers Coding & Compliance Initiatives, Inc. 27
28 Develop a training calendar determine the type and level of training for each area This should be considered during the planning phase to improve training effectiveness Coding & Compliance Initiatives, Inc. 28
29 Accurately describe the work performed to support the severity of the patient s condition Describe the nature of the patient conditions Describe the services done to maintain and/or improve those conditions Document the plan of care what did you tell the patient Coding & Compliance Initiatives, Inc. 29
30 Assure that coding correlates with the documentation Query the provider when necessary Educate the provider when documentation is not as specific as coding allows Think outside the box Be a resource Be honest and confident Coding & Compliance Initiatives, Inc. 30
31 Verify the claims are coded accurately and supported by the documented facts Ensure the coding staff have ongoing education and training Query your providers on how the coding staff is doing Engage providers in the process Coding & Compliance Initiatives, Inc. 31
32 Make a list of the areas that may directly or indirectly impact coding or the use of codes. Make a list of the areas that may impact your ability to successfully implement ICD-10 Who needs to know about ICD-10 and Clinical Documentation? Coding & Compliance Initiatives, Inc. 32
33 Analyze your business and clinical areas impacted by ICD-10 Develop a project plan Priority Timing Who is responsible for execution? How will you measure progress? Test Coding & Compliance Initiatives, Inc. 33
34 Do you have a current baseline rate for claims denials and rejections? Is it consistent for all provider or does it vary? Track if the rate changes across the transition and if so, where? Do you appeal denials? Track denials is there an increase? Is there more medical necessity denials, etc? Coding & Compliance Initiatives, Inc. 34
35 Are there changes in the ratio of what you were paid before as it relates to what you billed? What is your current claim lag? Billed to paid Is it related to specific payors or across the board? Coding & Compliance Initiatives, Inc. 35
36 Coding & Compliance Initiatives, Inc. 36
37 Assess coding knowledge A timeline should have been established Has the education and training been effective? Closely monitor coding accuracy during the implementation period Periodic documentation review (gap analysis) Coding & Compliance Initiatives, Inc. 37
38 Test that your office staff can work with the redesigned office flows and new processes Gauge the efficiency and effectiveness of your new work flows Test integration with the vendor Health Plans Billing Service Clearinghouse Coding & Compliance Initiatives, Inc. 38
39 Develop a communication plan that outlines the steps for go live Who will be the point of contact How will you disseminate information Coding & Compliance Initiatives, Inc. 39
40 Develop a contingency plan for continuing operations if problems occur with go live implementation Work with the bank Inform staff they may need to work extra Think about indirect costs Payment delays Productivity losses Overtime and temporary staff Incorrect reimbursement Contracts renegotiate with payors Coding & Compliance Initiatives, Inc. 40
41 Are you receiving denials? Which payors? Reason (i.e. lack of medical necessity, inaccurate ICD code)? Focus on patterns Is the reimbursement correct? Is the payment timely? Is the coding correct? Coding & Compliance Initiatives, Inc. 41
42 Define Needs o Project team, timelines, budget, risk assessment, gap analysis reviews, education, etc. Analyze Operational Impact Areas Facilitate Education Providers and staff Implement prior to go live Monitor Coding & Compliance Initiatives, Inc. 42
43 Haven t started hoping it will get delayed Established a team/committee Developed a project plan Conducted a practice impact assessment Performed a gap analysis Started training staff and providers Payor and vendor discussions underway Coding & Compliance Initiatives, Inc. 43
44 CCI assists our clients improve their documentation quality, coding and billing accuracy, and compliance with health care regulations TSP Healthcare assists our clients with strategic planning, LEAN / process improvement, compliance effectiveness, and compensation / benefit analysis Coding & Compliance Initiatives, Inc. 44
45 Shellie Sulzberger, LPN, CPC, ICDCT-CM Coding & Compliance Initiatives, Inc. 45
Shellie Sulzberger, LPN, CPC, ICDCT-CM Coding & Compliance Initiatives, Inc.
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