ICD-10-CM An overview of changes relevant to behavioral health

Transcription

1 www. TheNationalCouncil. org ICD-10-CM An overview of changes relevant to behavioral health Presented by: Donna Pickett - CDC/OPHS/NCHS Joe Nichols - MD Date: January 24, 2014

2 Agenda www. TheNationalCouncil. org Overview ICD-10, the basic facts How is ICD-10-CM different? Clinical documentation - What s needed to support proper coding in ICD-10-CM? What s changed for behavioral health What are the business impacts? What do I need to do to prepare? 2

3 Source: Health Data Consulting ICD-10-CM Overview 3

4 ICD10 Quick Facts ICD-10 international version Adopted by WHO in 1990 Most countries other than the US currently use ICD-10 ICD-10 (International version) ~ 12,500 diagnostic codes Source: Health Data Consulting ICD-10 used for mortality reporting in the US ICD-10-CM (US version) ~ 69,000 diagnostic codes Final rule published 2012 Compliance date Oct 1, 2014 Source: Health Data Consulting 4

5 ICD-9 Diagnosis Codes vs. ICD-10-CM (Diagnosis Codes) ICD-9-CM Diagnosis Codes 3 to 5 digits Alpha E and V on 1 st character No place holder characters Terminology Index and Tabular Structure Coding Guidelines Approximately 14,000 codes Severity parameters limited Does not include laterality Combination codes limited ICD-10-CM Diagnosis Codes 7 digits Alpha or numeric for any character Include place holder characters ( x ) Similar Similar Some what similar Approximately 69,000 codes Extensive severity parameters Common definition of laterality Combination codes common Source: Health Data Consulting 5

6 ICD9 Comparison to ICD10-CM Diagnosis Codes Clinical Example A patient is evaluated for a [drug induced] [sleeping disorder] that is related to [dependance] on a [sedative drug]. ICD9 Code Description Drug induced sleep disorders ICD10 Code F13282 Description Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced sleep disorder Source: Health Data Consulting 6

7 ICD9 Comparison to ICD10-CM Diagnosis Codes Clinical Example A patient is evaluated for a [drug induced] [sleeping disorder] that is related to [dependance] on a [sedative drug]. ICD9 Code Description Drug induced sleep disorders ICD10 Code F13282 Description Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced sleep disorder Source: Health Data Consulting 7

8 There are too many Codes There are lots of words in the dictionary, but that doesn t seem to trouble authors 34,250 (50%) of all ICD-10CM codes are related to the musculoskeletal system 17,045 (25%) of all ICD-10CM codes are related to fractures ~25,000(36%) of all ICD-10-CM codes to distinguish right vs. left Only a very small percentage of the codes will be used most providers Source: Health Data Consulting 8

9 Current Distribution of ICD-9 diagnosis codes 3 Years of Data - All claims - All lines of business - 1million Lives 80.0% Total Charges by Code 3years - $10 Bill 70.0% 60.0% 50.0% 40.0% Charge % 30.0% 20.0% 10.0% 0.0% 5% next 5% Source: Health Data Consulting 9

10 Varying Code Volume By Clinical Area Clinical Area ICD-9 Codes ICD-10 Codes Fractures Poisoning and toxic effects Pregnancy related conditions Brain Injury Diabetes Anxiety Disorders Autism Spectrum Disorders 6 4 Mood related disorders Schizophrenia Hypertensive Disease End stage renal disease 11 5 Source: Health Data Consulting 10

11 Documentation It could be better Incomplete clinical documentation is bad for Payers, Providers and Patients. Billing accuracy Quality measures Population management Risk management Healthcare analytics Patient Care Bad Mojo is not a diagnosis 11

12 Good Clinical Documentation is Not a New Requirement The number and type of new concepts required for ICD-10 are not foreign to clinicians The focus of documentation is good patient care Patients deserve to have accurate and complete documentation of their conditions If other industries understand the value of accurate and complete documentation of data about encounters; shouldn t we? Source: Health Data Consulting 12

13 Documentation Why is it important? Supports proper payment reduced denials Assures accurate measures of quality and efficiency Assures accountability and transparency Captures the level of risk and severity Provides better business intelligence Supports clinical research Enhances communication with hospital and other providers It s just good care! Source: Health Data Consulting 13

14 Coding The Patient Interface Where it all begins History Physical Exam Internal Record Review External Record Review Studies Assessment/Diagnosis 14

15 Getting to the Code A Necessary Step Back-office Coding The Super Bill Back to the Doctor? 15

16 The Super Bill Not That Super Really [Note] For all codes related to fractures of the radius: ICD-9 codes = 32 ICD-10 codes =

17 New concepts supported by ICD-10 Drug use vs dependence vs abuse Bipolar II Recurrent depressive disorder Mood disorder related to physiologic condition Adjustment insomnia Adjustment reaction with withdrawal Asperger's syndrome Rett's syndrome Distinguishes between current episode and most recent episode for bipolar disorders Source: Health Data Consulting 17

18 Removed concepts from ICD-9 Substance dependence o o continuous episodic Amphetamine o o Dependence Abuse Bipolar I Passive-aggressive personality Pervasive Disorders o o current or active state residual state Source: Health Data Consulting 18

19 Removed concepts from ICD-9 Schizophrenia o o o o o o o Latent Simple type Subchronic Chronic Subchronic with acute exacerbation Chronic with acute exacerbation In remission Source: Health Data Consulting 19

20 Source: Health Data Consulting ICD-10-CM Key coding changes relevant to behavioral health 20

21 Changes in detail and content Code Examples Substance related sleep disorders: ICD-9 Code Description Drug induced sleep disorders More Codes ICD-10 Code F11182 F11982 F11282 F14182 F14282 F14982 F13182 Description Opioid abuse with opioid-induced sleep disorder Opioid use, unspecified with opioid-induced sleep disorder Opioid dependence with opioid-induced sleep disorder Cocaine abuse with cocaine-induced sleep disorder Cocaine dependence with cocaine-induced sleep disorder Cocaine use, unspecified with cocaine-induced sleep disorder Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced sleep disorder Multiple other substances Source: Health Data Consulting 21

22 ICD-9 Code Changes in detail and content Code Examples Substance related abuse: Description (Non-dependent) Opioid abuse, unspecified More Codes ICD-10 Code F1110 F11120 F11121 F11122 F1114 F11150 F11151 F11181 F11182 F11188 F1119 Description Opioid abuse, uncomplicated Opioid abuse with intoxication, uncomplicated Opioid abuse with intoxication delirium Opioid abuse with intoxication with perceptual disturbance Opioid abuse with opioid-induced mood disorder Opioid abuse with opioid-induced psychotic disorder with delusions Opioid abuse with opioid-induced psychotic disorder with hallucinations Opioid abuse with opioid-induced sexual dysfunction Opioid abuse with opioid-induced sleep disorder Opioid abuse with other opioid-induced disorder Opioid abuse with unspecified opioid-induced disorder Source: Health Data Consulting 22

23 Changes in detail and content Code Examples Schizophrenia: Less Codes ICD-9 Code Description Paranoid type schizophrenia, unspecified Paranoid type schizophrenia, subchronic Paranoid type schizophrenia, chronic Paranoid type schizophrenia, subchronic with acute exacerbation Paranoid type schizophrenia, chronic with acute exacerbation Paranoid type schizophrenia, in remission ICD-10 Code F200 Description Paranoid schizophrenia Source: Health Data Consulting 23

24 Changes in detail and content Code Examples Schizoaffective disorder: ICD-9 Code Description Schizoaffective disorder, unspecified More Codes ICD-10 Code F250 F251 F258 F259 Description Schizoaffective disorder, bipolar type Schizoaffective disorder, depressive type Other schizoaffective disorders Schizoaffective disorder, unspecified Health Data Consulting

25 Changes in detail and content Code Examples Post traumatic Stress Disorder: More Codes ICD-9 Code Description Posttraumatic stress disorder ICD-10 Code F4310 F4311 F4312 Description Post-traumatic stress disorder, unspecified Post-traumatic stress disorder, acute Post-traumatic stress disorder, chronic Health Data Consulting

26 Changes in detail and content Code Examples Childhood Emotional Disorders: Less Codes ICD-9 Code Description 3130 Overanxious disorder specific to childhood and adolescence 3131 Misery and unhappiness disorder specific to childhood and adolescence Shyness disorder of childhood Introverted disorder of childhood 3133 Relationship problems specific to childhood and adolescence Identity disorder of childhood or adolescence Academic underachievement disorder of childhood or adolescence Other emotional disturbances of childhood or adolescence 3139 Unspecified emotional disturbance of childhood or adolescence ICD-10 Code F930 F938 F939 Source: Health Data Consulting Description Separation anxiety disorder of childhood Other childhood emotional disorders Childhood emotional disorder, unspecified 26

27 Changes in detail and content Code Examples Conversion Disorders: More Codes ICD-9 Code Description Conversion disorder ICD-10 Code F444 F445 F446 F447 F4489 F449 Description Conversion disorder with motor symptom or deficit Conversion disorder with seizures or convulsions Conversion disorder with sensory symptom or deficit Conversion disorder with mixed symptom presentation Other dissociative and conversion disorders Dissociative and conversion disorder, unspecified Source: Health Data Consulting 27

28 Changes in detail and content Code Examples Other substance abuse: ICD-9 Code Description Other, mixed, or unspecified drug abuse, episodic More Codes ICD-10 Code F550 F551 F552 F553 F554 F558 Description Abuse of antacids Abuse of herbal or folk remedies Abuse of laxatives Abuse of steroids or hormones Abuse of vitamins Abuse of other non-psychoactive substances Health Data Consulting

29 Changes in detail and content Code Examples Attention Deficit Disorders: ICD-9 Code Description Attention deficit disorder without mention of hyperactivity Attention deficit disorder with hyperactivity More Codes ICD-10 Code F900 F901 F902 F908 F909 Description Attention-deficit hyperactivity disorder, predominantly inattentive type Attention-deficit hyperactivity disorder, predominantly hyperactive type Attention-deficit hyperactivity disorder, combined type Attention-deficit hyperactivity disorder, other type Attention-deficit hyperactivity disorder, unspecified type Source: Health Data Consulting 29

30 Business Impacts 30

31 Business Impacts Coding EHR updates Super Bill??? Training Coding software Contracting Billing Scope of services Case rates Carve outs Billing code updates Charge masters Billing Edits Benefits and coverage determinations Health Data Consulting

32 Business Impacts (Cont.) Compliance HIPAA Reporting National State Regional Initiatives Contract requirement Accreditation Reimbursement Audits Pay for performance POA, never events, re-admissions, HACs, tiered payment models Network inclusion Denials RAC Fraud and abuse Coding Health Data Consulting

33 ICD diagnosis codes are irrelevant to my business. ICD-9 codes factor into: Payer processing rules The determination of appropriateness Measures of quality (pay for performance) Compliance (meaningful use) Contracting decisions Risk adjustments Fraud waste and abuse Audits Authorizations Health Data Consulting

34 ICD diagnosis codes are irrelevant to my business. ICD-10 codes are likely to factor into: Changes in reimbursement based on both what was done and why Managing financial risks for contracted populations (ACO s) Changes in reimbursement based on more robust models of payment adjusted for risk and severity More sophisticated weighting of payments based on DRGs, episodes or other groupers of care. Health Data Consulting

35 Business Impacts Compliance HIPAA Reporting o o o National State Regional Initiatives Contract Accreditation Reimbursement Audits Pay for performance POA, Never Events, Tier Models Network inclusion Denials RAC Fraud and abuse Coding 35

36 Cash Flow Impacts inbound and outbound Lack of Provider Preparation Payment Delays Increased Cost 36

37 Cash Flow Impacts inbound and outbound Source: CMS 37

38 Implementation Getting your ducks in a row 38

39 Implementation Strategy Short term goals with a long term visions What solution do I need today? Will that solution extend to tomorrows needs? Awareness of touch points with other initiatives Overlap and conflicts Down Stream Impacts What works well for one business area, may bring another business area to it s knees Positioning for competitive advantage Can you predict risk better than you competitor? Are you perceived as a supporter and facilitator for the transition challenge to providers and other stakeholders? Can you manage the burden of illness of your population better than your competitors? 39

40 Phases of Transition 1. Assessment Inventory of impacted systems and processes Identifying risk 2. Analysis/Planning Prioritizing focus Establishing business area specific approaches Creating specifications for mapping to support implementation 3. Implementation and Operations Translating codes from 9 to 10 and from 10 to 9 using crosswalks Changing analytic models to support both codes Operationalization of coding to ICD-10 from source information Changing processing logic to operate directly from ICD-10 codes 4. Leveraging ICD10 capabilities Using the enhanced information within ICD-10 codes to improve processing and analysis based on improved concepts buried within the ICD-10 codes 40

41 Scenario-Based Testing What is it? The scenario: The identification of some event or condition that we are familiar with today Recreating that event virtually through some verbal or data representation Defining a variety of assumptions and variables around this virtual representation Applying one or more of these scenarios in a Reference Implementation Model (RIM). Walk through current systems or processes using these scenarios with varying assumptions and variables to determine if expected results can be achieved and the required changes to achieve those expected results. 41

42 Leveraging ICD-10 A changing world of cost containment Accurate and complete documentation and coding provides opportunities to support the transition into a value-based, accountable care reimbursement environment. Better representation of severity and risk Recognition of varying levels of complexity Better claim information to support automated processing and more rapid reimbursement Opportunities to reduce audit risk exposure Improved business intelligence to support population risk management More accurate measures of quality and efficiency 42

43 Q&A Review of Q&A from Attendees If you have a question that has not been addressed, please send it to us at the ICD-10 Questions Mailbox: icd10questions@noblis.org 43

44 Online Resources Review of Q&A from Attendees CMS - Coding Documentation (Indexes, Coding Guidelines, Code Files): General Equivalency Mapping [GEM] (Mapping files, Guidelines, Procedure and Diagnosis) GEMs Crosswalk documents: GEMs.html GEMs 2014 General Equivalence Mappings: Medicare Learning Network Articles: Education/Medicare-Learning-Network- MLN/MLNGenInfo/index.html?redirect=/mlngeninfo Implementation Guides: 44

45 Online Resources Review of Q&A from Attendees CMS - (Continued) Implementation Guides: ICD-10 National Provider Calls: Teleconferences.html National Coverage Determinations (NCDs): Medicare Testing Week: Education/Medicare-Learning-Network- MLN/MLNMattersArticles/Downloads/MM8465.pdf Medicare Claims Processing Guidance for ICD-10: Network-MLN/MLNMattersArticles/downloads/MM7492.pdf 45

46 Online Resources Review of Q&A from Attendees CMS - (Continued) Medicare Reimbursement Mappings 2014 Reimbursement Mappings Diagnosis Codes and Guides Reimbursement Mappings Procedure Codes and Guides Links to ordering the ICD-10 Pilot Version 31.0 Mainframe and PC version of the ICD-10 MS-DRGs and Medicare Code Editor (FY 2014 version) from NTIS have been placed on the CMS website under the Related Links section at Project.html MLN/MLNGenInfo/index.html?redirect=/mlngeninfo FAQ, Coordination and maintenance Committee minutes 46

47 Online Resources Review of Q&A from Attendees CDC - ICD-10-CM files (Alphabetic Indexes, Tabular List, Coding Guidelines, Codes and Descriptions Files, FY2014 Addenda) General Equivalency Mapping [GEM] (Mapping files, Guidelines, Procedure and Diagnosis) GEMs Crosswalk documents: GEMs 2014 General Equivalence Mappings: Detailed List of Codes Exempt from Diagnosis Present on Admission Requirements Public Health Transition to ICD-10-CM/PCS 47

48 Online Resources Review of Q&A from Attendees WEDI - List serves Workgroups White papers Implementation forums Industry advocacy and issue Access to standards leaders AHIMA - Training and certification Extensive documentation libraries Bookstore Communities of practices ICD-10 focused conferences 48

49 Online Resources Review of Q&A from Attendees HIMSS - White papers Bookstore Webinars Vendors Consulting Organization Online news Blogs 49

50 Online Resources Review of Q&A from Attendees Health Data Consulting white papers: ICD-10 A Primer ICD-10 Physician Impacts Scenario Based Testing ICD-10 The Case for Moving Forward ICD-10 Clinical Documentation The Role of the Clinician in Capturing Accurate Data ICD-10 Specified or Unspecified? 50