ICD-10 TRANSITION. The Road to Readiness ebook

Transcription

1 ICD-10 TRANSITION The Road to Readiness ebook

2 TABLE OF CONTENTS Click any link below to view the topic. MN ICD-10 Collaborative ICD-10 Legal Requirements ICD-10 Transition ICD-10 Action Steps ICD-10 Road to Readiness ICD-10-CM (Clinical Modification) What to do if Vendor Isn t Ready ICD-10-PCS Procedure Coding System ICD-10 Resources Benefits of ICD-10 2

3 PURPOSE The ICD-10 Road to Readiness ebook was prepared by the Minnesota ICD-10 Collaborative. It is intended to assist small providers in meeting the October 1, 2015 compliance date for implementing ICD-10. This ebook is for general information purposes only and represents no statement, guarantee or promise concerning ICD-10 compliance. It is not intended as legal advice or intended to replace additional, more detailed business reviews or training published and provided by other readily available resources. Readers are encouraged to definitely access these additional resources. The ICD-10 Road to Readiness ebook provides information about the ICD-10-CM and ICD-10-PCS coding and includes examples of the differences in coding and formats for both code sets and links to resources to access education and training. Disclaimer: The links or any organizational reference within this document is not to be assumed as an endorsement by the Minnesota ICD-10 Collaborative or any of its individual members. 3

4 ABOUT THE MINNESOTA ICD-10 COLLABORATIVE- 1 The Minnesota ICD-10 Collaborative (the Collab) is a consortium of providers and payers brought together to identify and evaluate opportunities to minimize the disruption in health-care billing, reporting, and related processes for a variety of stakeholders in the health-care industry in connection with the ICD-10 conversion. The Collab is not an advocacy group. Its objective is to achieve compliance with the ICD-10 mandate on its effective, October 1, 2015 and to adapt publicly available information to Minnesota s unique needs. 4

5 ABOUT THE MINNESOTA ICD-10 COLLABORATIVE- 2 Organization of the Minnesota ICD-10 Collaborative The Collab s membership is limited to providers and payers (click link to view list of member organizations). However, the group engages in dialog with clearinghouses and vendors relevant to specific ICD-10 initiatives (e.g. testing). The Collab members focus on key shared issues and opportunities; organizational structure/overhead. Two of the Collab key focus areas are: Testing The goal of testing is to develop a practical common approach to testing the reimbursement cycle with each other (provider and payer) in order to understand potential reimbursement shifts. 5

6 ABOUT THE MINNESOTA ICD-10 COLLABORATIVE- 3 Communications and education The Collab s communication and education goal is two-fold: 1) To ensure a common understanding of what providers and payers need from each other in order to approach October 1, 2015 with a reasonable chance of success; and 2) To share knowledge and information with larger Minnesota provider community to assist in statewide compliance. Since its inception, the Collab acknowledged that it should also assist the smaller Minnesota provider community in achieving ICD-10 compliance; thus the creation of the ICD-10 Road to Readiness ebook, and other outreach activities and educational materials. 6

7 ABOUT THE MINNESOTA ICD-10 COLLABORATIVE -4 Minnesota ICD-10 Collaborative Partners The Collab is partnering with the Minnesota Administrative Uniformity Committee (AUC) and the Minnesota Department of Health (MDH) to assist in raising awareness of ICD-10 and in providing ICD-10 planning and implementation education. As part of our partnership, the AUC is hosting the Collab s webpage on their website that is managed and updated by the Minnesota Department of Health. The Minnesota ICD-10 Collaborative Webpage The MN ICD-10 Collaborative webpage is hosted by the AUC and features links to past ICD-10 webinar presentations, the Collab s 2015 event calendar and meeting materials, a list of ICD-10 recommended testing codes and diagnostic related groups, a list of MN payers with links to their ICD-10 website, and additional ICD-10 information and resources. Click this link to access ICD-10 information: MN ICD-10 Collaborative ( borative.html.) 7

8 WHAT IS ICD-10 What is ICD-10 The ICD-10 (International Classification of Diseases) is a medical classification system originally developed by the World Health Organization (WHO). ICD-10 is an updated version of the ICD-9 code sets. It is the standard diagnostic tool for epidemiology, health management and clinical purposes and is used to monitor the incidence and prevalence of diseases and other health problems. Several countries have taken this code set and modified it for use in their medical systems. ICD-10 has been used in the United States to code and classify mortality data for death certificates, having replaced ICD-9 for this purpose, since Source: International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) 8

9 WHAT IS ICD-10 1 What is ICD-10 (continued) The WHO permitted the United States to modify the ICD-10 code sets for its use. ICD-10 CM and ICD-10- PCS was adapted for coding by the U.S and is required for use in administrative transactions, effective October 1, ICD-10 Code Sets The National Center for Health Statistics, developed the ICD-10-CM (or clinical modification) of the code set for use by all healthcare providers in all settings for diagnosis coding. The Centers for Medicare and Medicaid Services created a new code set, ICD-10-PCS (procedure coding system), for inpatient hospital coding procedures only. The ICD-10-PCS was developed as a replacement for ICD-9-CM, Volume 3. Source: International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) 9

10 WHO NEEDS TO TRANSITION Who Needs to Transition All Health care providers, payers, clearinghouses, and billing services must be prepared to comply with the transition to ICD-10. For Minnesota, this includes workers compensation payers, property and casualty, and auto carriers licensed or doing business in the state. ICD-10 will affect diagnosis and inpatient procedure coding for everyone covered by HIPAA, not just those who submit Medicare or Medicaid claims. Note: The change to ICD-10 does not affect CPT coding or outpatient procedures. 10

11 WHY CHANGE TO ICD-10 Why change to ICD-10 The transition to ICD-10 is occurring because ICD-9 produces limited data about patients medical conditions and hospital inpatient procedures. ICD-9 is 30 years old, has outdated terms, and is inconsistent with current medical practice. The structure of ICD-9 limits the number of new codes that can be created and many of its categories are full. Inability to compare morbidity data to mortality data Source: 11

12 WHY CHANGE TO ICD-10-2 Why change to ICD-10 (continued) ICD-10 codes allow for greater specificity and exactness in describing a patient s diagnosis and in classifying inpatient procedures. ICD-10 will also accommodate newly developed diagnoses and procedures, innovations in technology and treatment, performance-based payment systems, and more accurate billing. ICD-10 coding will make the billing process more streamlined and efficient, and this will also allow for more precise methods of detecting fraud. 12

13 IMPACT ON CLINICAL DOCUMENTATION ICD-10 Impact on Clinical Documentation Providers should be aware that their inpatient medical record documentation will be affected because documentation requirements under ICD- 10-CM/PCS are quite different and presents new clinical documentation opportunities. The new code sets are considerably more detailed than ICD-9-CM. Some examples are: laterality; encounter type (initial, subsequent, sequela); anatomical detail; type of injury; severity; and approach. 13

14 ICD-10 BASIC STRUCTURE Basic Structure of ICD-10 An illustration of the basic structure of the new ICD- 10 code sets is shown below and described on the next page: 14

15 ICD-9-CM AND ICD-10 CODE SETS DIFFERENCES Differences between ICD-9-CM and ICD-10 Code Sets ICD-9-CM codes are very different than ICD-10- CM/PCS code sets and will require significant changes in the way services are reimbursed, and in the way that coverage for services are determined. ICD-10-CM/PCS are considerably more detailed than ICD-9-CM as presented later in further detail. ICD-10 has alphanumeric categories instead of numeric ones. The ICD-10 code set has also been organized somewhat differently than ICD-9, primarily to bring it up to date with modern medicine and the requirements of the industry to clearly identify particular conditions. 15

16 ICD-9-CM & ICD-10 CODE SETS ILLUSTRATION There are also nearly 5 times as many diagnosis codes in ICD-10-CM than in ICD-9-CM and more than 19 times as many procedure codes in ICD-10-PCS than in ICD-9-CM volume 3 as shown below. Source: 16

17 ICD-9-CM AND ICD-10-CM STRUCTURAL DIFFERENCES ICD-9-CM has three to five digit codes and ICD-10-CM has three to seven character codes. One significant difference between ICD-9-CM and ICD-10-CM is the need to assign a seventh character, also called an extension. For codes less than six characters that require a seventh character, a placeholder X should be assigned for all characters less than six. The 7 th character must always be the 7 th character of a code. 17

18 ICD-10-CM About ICD-10-CM (Clinical Modification) ICD-10-CM was developed following a thorough evaluation by a Technical Advisory Panel and extensive additional consultation with Provider groups, clinical coders, and others to assure clinical accuracy and utility. It replaces ICD-9-CM, volumes I and II contains additional information relevant to ambulatory and managed care encounters. ICD-10-CM provides for greater definition and the details of a patient condition including severity, complexity, comorbidities, complications and other important parameters of the patient health state. 18

19 ICD-10-CM FEATURES Other ICD-10-CM features include: Expanded injury codes; Creation of combination diagnosis/symptom codes; Reduction in number of codes to fully describe a condition; Addition of sixth and seventh characters; Incorporation of common 4th and 5th digit subclassifications; laterality; and Greater specificity in code assignment 19

20 ICD-10-CM FORMAT Certain ICD-10-CM categories have applicable 7 th characters and the applicable 7 th character is required for all codes within the category, or as instructed in the Tabular List notes. Below is an illustration of the ICD-10-CM format: ICD-10-CM DIAGNOSIS CODES FORMAT Alpha Numeric Numeric Numeric or Alpha Numeric or Alpha Numeric or Alpha X Category Etiology, Anatomical Site, Severity Extension 20

21 SAMPLE ICD-10-CM DIAGNOSIS CODE Source: 21

22 ICD-10-CM CLASSIFICATION SYSTEM CHAPTERS 1-6 The ICD-10-CM coding system (Tabular List of Diseases and Injuries) listed below consists of 21 chapters and can be accessed at: loads/6_i10tab2010.pdf 1. Certain infectious and parasitic diseases (A00- B99) 2. Neoplasms (C00-D48) 3. Diseases of the blood and blood forming organs and certain disorders involving the immune mechanism (D50-D89) 4. Endocrine, nutritional and metabolic disorders (E00-E90) 5. Mental and behavioral disorders (F01-F99) 6. Diseases of the nervous system (G00-G99) 22

23 ICD-10-CM CLASSIFICATION SYSTEM CHAPTERS Diseases of the eyes and adnexa (H00-H59) 8. Diseases of the ear and mastoid process (H60- H95) 9. Diseases of the circulatory system (I00-I99) 10. Diseases of the respiratory system (J00-J99) 11. Diseases of the digestive system (K00-K94) 12. Diseases of the skin and subcutaneous tissue (L00-L99) 13. Diseases of the musculoskeletal system and connective tissue (M00-M99) 14. Diseases of the genitourinary system (N00-N99) 23

24 ICD-10-CM CLASSIFICATION SYSTEM CHAPTERS Pregnancy, childbirth and puerperium (O00-O9A) 16. Certain conditions originating in the perinatal period(p00-p96) 17. Congenital malformations, deformations and chromosomal abnormalities (Q00-Q99) 18. Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00- R99) 19. Injury, positing and certain other consequence of external causes (S00-T88) 20. External causes of morbidity (V01-Y99) 21. Factors influencing health status and contact with health services (Z00-Z99) 24

25 ICD-10-PCS CODE SET ICD-10-PCS (Procedure Coding System) As stated previously, ICD-10-PCS will replace ICD-9- CM, volume 3 for facility reporting of inpatient procedures and is not related to the ICD-10-CM code set. Other code sets, Healthcare Common Procedural Coding System (HCPCS) and Current Procedural Terminology (CPT-4), will continue to be used to report procedures for other types of claims. Common procedures that are not unique to the inpatient setting, such as laboratory tests and educational sessions, were omitted from PCS. Remember that this code set will only be used to report procedures on inpatient hospital claims. 25

26 ICD-10-PCS This is a totally new code set developed in the United States by the Centers for Medicare and Medicaid Services. It is not yet used elsewhere. Key Attributes of ICD-10-PCS Completeness: A unique code for each substantially different procedure Expandability: Structure should allow easy expansion Multiaxial: Should contain independent characters and an individual axis that maintains its meaning across ranges of codes Standardized Terminology: Definitions are well defined, with no multiple meanings, and each term is assigned a specific meaning 26

27 ICD-10-PCS -1 ICD-10-PCS provides significant room for expansion, allowing for the code set to incorporate new procedures and devices. ICD-10-PCS codes provide more clinically relevant procedure descriptions that can be more readily understood by Providers. It demonstrates consistency in coding from chapter to chapter. The multi-axial structure of the system, combined with its detailed definition of terminology, permit a precise specification of procedures for use in health services research, epidemiology, statistical analysis and administrative areas. 27

28 ICD-10-PCS -2 Characteristics of ICD-10-PCS ICD-10-PCS is designed to better accommodate the rapidly changing world of procedures. Procedures are divided into sections that identify the general type of procedure (e.g., medical and surgical, obstetrics, imaging). All ICD-10-PCS codes consist of seven characters with a seven character alphanumeric code structure; any character can be alpha or numeric. All letters, except I and O, and digits 0-9 comprise each character. The letters I and O are not used to eliminate confusion with the digits 1 and 0. There are no decimals in ICD-10-PCS. Source: 28

29 ICD-10-PCS -3 ICD-10-PCS Structure The coding structure of the ICD-10-PCS and sections are shown below. Each of the seven characters is unique with a defined meaning; however both the characters and meaning change within a particular section. Source: 29

30 ICD-10-PCS -4 Description of the ICD-10-PCS Structure As shown on the previous page, the first character of the code identifies the section. The first through fifth characters are always assigned a specific value. For any ICD-10-PCS code, the 4 th position, for example, always refers to the body part involved in the procedure. The sixth character indicates whether any device was used and remained at the end of the procedure (e.g., synthetic substitute). The seventh character is a qualifier that may have a specific meaning for a limited range of values. However, the device (sixth character) and the qualifier (seventh character) are not applicable to all procedures. 30

31 ICD-10-PCS -5 Character 6 Device Not all ICD-10-PCS codes utilize the sixth character to identify devices that are left at the operative site. Some procedures do not require devices, so the sixth character is assigned a value of Z. Devices fall into four basic groups: Grafts and prostheses Implants Simple or mechanical appliances Electronic appliances Source: 31

32 ICD-10-PCS -6 Character 7 Qualifier All ICD-10-PCS codes must have seven characters and, like with the sixth character, the letter Z is used when there is no additional information about the procedure to be coded and indicates that a character is not applicable to a specific procedure performed. Some examples of qualifiers are: Types of transplant Second site for bypass procedures Diagnostic procedures (biopsy) Source: 32

33 ICD-10-PCS -7 ICD-10-PCS Guidelines To ICD-10-PCS guidelines are available at no cost and can be downloaded from the CMS website by clicking on this link: -ICD-10-PCS-and-GEMs.html. ICD-10-PCS General Organization ICD-10-PCS is composed of 16 sections, represented by the numbers 0 through 9 and the letters B through D and F through H. The broad procedure categories contained in these sections range from surgical procedures to substance abuse treatment. The 16 sections are subdivided into three main sections: Medical and Surgical section, Medical and Surgical-related sections and Ancillary sections. 33

34 SAMPLE ICD-10-PCS Below is an example of a medical and surgical procedure: Laparoscopic appendectomy ODTJ4ZZ ICD-10-PCS Code Character Character Descriptor Description O 1st Section Medical and Surgical D 2nd Body System Gastrointestinal system T 3rd Root Operation Resection J 4th Body Part Appendix 4 5th Approach Percutaneous Z 6th Device No Device Z 7th Qualifier No Qualifier 34

35 BENEFITS OF ICD-10-1 Why Does ICD-10 Matter? Diagnosis codes and procedure codes permeate almost every business process and system in both plan and provider organizations. The ICD-10 diagnosis code set captures much more specific information on a patient s condition (diagnosis). The procedure code set (ICD-10-PCS) provides a more specific and modern approach to classifying and recording inpatient hospital procedures performed and devices used. From plan design to statistical tracking of disease, these codes are a crucial part of the way CMS and health plans run their programs. 35

36 BENEFITS OF ICD-10-2 ICD-10 Benefits ICD-10 will enable providers: 1) to more quickly to identify patients that need care management; 2) to track severity of disease (conditions) and measure patient s progress if disease becomes less severe; and 3) to evaluate quality assurance of clinical and administrative processes. 36

37 MORE BENEFITS OF ICD ICD-10 will provide more accurate data about patient and improve disease management. The granularity of ICD-10 will enable greater specificity in identifying health conditions and improving patient care. It will enhance the quality of data for measuring outcomes and care provided to patients and making clinical decisions. 2. Enhance PH surveillance The greater level of detail in the code sets enables more precise identification and tracking of specific conditions. Improved data for epidemiological research as well as improved collection and tracking of new diseases and technology. Source: 37

38 MORE BENEFITS OF ICD The improved quality of data will reduce ambiguity and identify fraud and abuse with increased transparency for reimbursement and group methodologies. ICD-10 will also result in fewer rejected and fraudulent claims. 4. Meet HIPAA 5010 code set standards in designing electronic payment systems/processing electronic claims; terminology and disease classification will be consistent with new technology and current clinical practice. ICD-10 will result in more accurate payments. Source: 38

39 ICD-10 IS THE LAW The Department of Health and Human Services mandated that all entities covered by the Health Insurance Portability and Accountability Act (HIPAA) must begin using the ICD-10 code sets for electronic health care transaction on October 1, This mandate also requires HIPAA-covered entities to continue using ICD-9-CM through September 30, ICD-10 represents a significant change that impacts the entire health care community in a myriad of areas, for example: Reimbursement - would enhance accurate payment for services rendered Quality - would facilitate evaluation of medical processes and outcomes Flexibility would incorporate emerging diagnoses and procedures Exactness would identify diagnoses and procedures precisely Source: Federal Register/Vol. 74, No. 11, January 16, 2009/Rules and Regulations, 45 CFR Part 162 HIPAA Administrative Simplification: Modifications to Medical Data Code Set Standards to Adopt ICD-10-CM and ICD-10-PCS. 39

40 FEDERAL REQUIREMENTS The Department of Health and Human Services (HHS) published the final rule on January 16, 2009 that adopted the ICD-10-CM and ICD-10-PCS code sets as HIPAA standards. This rule required the use of ICD- 10 code sets in all HIPAA transactions. A new ICD-10 compliance date of October 1, 2015 was issued by HHS on July 31, The federal requirements mandate all HIPAA-covered entities transition from ICD-9 to ICD-10 using ICD-10-CM for diagnoses and ICD-10-PCS for inpatient hospital procedure codes as described in 45 CFR Medical data code sets, and includes: All health plans, clearinghouses and providers using electronic transactions State Medicaid agencies Source: Administrative-Simplification/HIPAAGenInfo/Downloads/HIPAALaw.pdf 40

41 FEDERAL REQUIREMENTS- 1 ICD-10 Final Rule and Guidelines The new ICD-10 compliance date of October 1, 2015 published in the final rule can be found at: 04/pdf/ pdf. ICD-10-CM Guidelines - The 2015 ICD-10-CM and ICD- 10-CM Coding Guidelines are now available for download and viewing, the codes are not valid for any purpose or use until October 1, 2015.(Click this link: to access). ICD-10-PSC Guidelines and Reference Manual The ICD-10-PCS Official Guidelines for Coding and Reporting can be viewed and accessed at: ads/2015-pcs-guidelines.pdf or ICD-10-PCS-and-GEMs.html 41

42 ICD-10 COMPLIANCE FOR PAYERS CMS Says Payers must Also Comply with ICD-10 There is no transition period * when both ICD-9 and ICD- 10 codes can be used; the requirement for use is based on service date. The table below describes specific specifications Payers must take to be compliant with the ICD-10 mandate. *An exception to the ICD-10 transition period is described on the next slide. 42

43 ICD-10 COMPLIANCE FOR HOME HEALTH ICD-10 Compliance Date Comes Early for Home Health The transition to ICD-10-CM for home health is August 3, 2015, not October 1 st as for other healthcare entities. Claims will require mandatory dual coding beginning nine weeks prior to the October 1, 2015 transition date with ICD-9 codes used for a portion of the bill and ICD-10 codes listed on the final claim. In-patient settings will use the date of discharge as their transition compliance date. Homecare is reimbursed per a 60 day episode, corresponding to multiple dates, not one. Source: 43

44 ICD-10 COMPLIANCE FOR HOME HEALTH -2 CMS Says Home Health must Also Comply with ICD-10 (continued) At the end of the 60-day period, agencies are required to submit the end of episode claim (EOE), which also includes the patient s diagnoses. The industry as a whole, must take advantage of home health specific educational resources, not only for transition date readiness, but to successfully navigate the reimbursement cycle. Note: The August 1, 2015 transition date and requirements for Home Health are for Medicare business only and does not apply to commercial business. Additional information regarding home health can be found at: Source: 44

45 MINNESOTA REQUIREMENTS- 1 Minnesota Statutes, section 62J.536 and related rules require the standard, electronic exchange of health care transactions and apply to all Healthcare providers providing a service in Minnesota for a fee/eligible for reimbursement under Medical Assistance. All Group purchasers (payers/insurers), including workers compensation; property and casualty; and auto carriers, licensed or doing business in the state are subject to Minnesota Statutes 62J.536 and related rules. Minnesota also has complementary statutes for the electronic exchange of health care transactions: Minnesota Workers Compensation e-billing requirements and medical component of auto nofault requirements. 45

46 MINNESOTA REQUIREMENTS -2 Minnesota Department of Health The Minnesota Department of Health administers MS 62J.536 state law and related rules and is responsible for oversight, compliance and enforcement. Compliance with state law also requires compliance with implementation of ICD-10 by October 1, 2015 as mandated by the federal requirements. Minnesota Department of Labor and Industry The Minnesota Department of Labor and Industry (DLI) administers Minnesota Statutes, section , subdivision 7 and related rules for workers compensation e-billing. Minnesota Statutes, section , subdivision 7 (b), (c) requires ICD-10 transition, in accordance with federal mandate, on October 1, Minnesota Department of Commerce The Minnesota Department of Commerce administers Minnesota Statutes, section 72A.201, subdivision 14 and related rules for property and casualty e-billing. 46

47 ACTION STEPS Action Steps ICD-10 transition will require staff education and training; business-process analysis of health plans contracts, coverage determinations and documentation; changes to Superbills; and IT systems changes. Further the ICD-10 transition may cause increased documentation costs and cash flow disruption. In order to be prepared for the transition, below are recommended action steps. Develop an action plan Train your team Conduct business process anlaysis Engage your vendors and payers Test internal systems and processes Source: 47

48 ADDITIONAL ACTION STEPS Additional Action Steps Engaging with your vendors and payers now is critical. They will be essential in helping you navigate and understand what is needed most and essential to help you meet the October 1, 2015 implementation deadline. 1 - Engage with your vendor/payer Is your vendor prepared for transition? Is payer prepared? Any contract changes? 2 - Identify top 25 ICD-9 codes 3 - Educate your staff Highest volume Low-cost Problematic training and denials available Develop test ERA codes scenarios No-cost with highest resources Identify denial available medical claims with most used ICD-9 codes 4 - Perform internal testing 15 - Obtain line of credit At least 3-6 months operating expenses 48

49 ENGAGE WITH VENDORS & PAYERS- 1 Engage with Vendors & Payers Vendors and trading partners are an essential part of an ICD-10 implementation plan. Contact them and make them aware of your implementation schedule. Get commitments from vendors for delivery of their ICD-10 products. Vendors should make commitments to follow your implementation schedule. Testing with trading partners is the only way to determine if your ICD-10 implementation is successful, so schedule that testing to allow enough time to make necessary system corrections. 49

50 ENGAGE WITH VENDORS & PAYERS- 2 Engage with Vendors & Payers (continued) If you are unable to test with your payer, visit your payer website or contact providers with similar practices who have begun their ICD-10 transition to learn from them. This is not uncommon. Many Payers only test with a handful of large providers or health systems. There is or will be extensive testing results available through the MN ICD-10 Collaborative if you were unable to find testing partners. You need to obtain answers to the following questions: How will the system work with both ICD-9 and ICD- 10 codes? Is new hardware needed? When will upgrades be available for installation? Is there a mapping or crosswalk between ICD-9 and ICD-10 code sets? Source: 50

51 ENGAGE WITH VENDORS & PAYERS- 3 Engage with Vendors & Payers (continued) What is the estimated downtime for the upgrade/installation? Will the vendor assist with or complete the upgrade required to make your systems ICD-10 compliant? Will customer support and training be provided? How much will it cost? Will ICD-9 data be accessible after October 1, 2015 implementation date? For how long? Who can access it? What does the implementation process include? Are any contract terms being changed? What medical policies are changing? When can I test? Source: 51

52 IMPROVE CLINICAL DOCUMENTATION- 1 Clinical Documentation Improvement (CDI) Organizations should perform audits on health record documentation. The audit should focus on high cost, high volume, problem prone (high risk) diagnoses. The identification of these diagnoses and the associated documentation supporting the diagnoses will allow organizations to identify documentation gaps required for ICD-10 reimbursement. Audit Examples: Providers Name: Dr. Q. Smith Chart Patient ID Documented Diagnosis 1 Jody Marsh Gastroesophageal reflux (GERD) Reviewer: Anne Doe, CPC, CPMA ICD-9-CM ICD-10-CM Notes Reported Documented K21.9 Gastroesophageal reflux disease without esophagitis To meet higher specificity required for ICD-10-CM the documentation needs to indicate with our without esophagitis 52

53 IMPROVE CLINICAL DOCUMENTATION- 2 CDI Examples (continued) Diabetes Mellitus Audit Tool (partial) Example Based on ICD-10-CM Guidelines 53

54 EDUCATE YOUR STAFF- 1 ICD-10 will affect every area of your practice. One of the most critical aspects of your preparation will be to communicate and educate your staff about ICD- 10 and provide training resources. Providers Documentation: The need for specificity dramatically increases by requiring laterality, stages of healing, weeks in pregnancy, and episodes of care, and much more Code Training: Diagnosis codes increase from 17,000 to 140,000. Providers must be trained on diagnosis codes unique to their specialty or used most often by in practice. This is not always the case. If your organization uses a diagnosis management vendor like IMO providers will likely work with more specific clinical terms, but not necessarily actual ICD-10 codes. Source: 54

55 EDUCATE YOUR STAFF- 2 Nurses Forms: Every order form containing ICD-9 codes must be revised or newly created Documentation: Must use increased specificity Prior Authorizations: Policies may change, requiring training and updates. Laboratory Services Documentation: Must use increased specificity Reporting: Health plans will have new requirements for the ordering and reporting of services Source: 55

56 EDUCATE YOUR STAFF- 3 Managers New Policies and Procedures: Any policy or procedure associated with a diagnosis code, disease management, tracking, or PQRI must be revised Vendor and Payer Contracts: All contracts must be evaluated and updated Budgets: Costs for changes to software, training, new contracts, new paperwork Training Plan: Everyone in the practice that works with diagnosis codes will need training on the changes Coders Code Set: Codes will increase from 17,000 to 140,000. As a result, code books and styles will completely change. Source: 56

57 EDUCATE YOUR STAFF- 4 Coders (continued) Clinical knowledge: More detailed knowledge of anatomy and medical terminology will be required with increased specificity and more codes. Concurrent Use/Dual Coding: Coders may need to use ICD-9-CM and ICD-10-CM concurrently for a period of time until all claims are resolved. Billing Staff Policies and Procedures: All payer reimbursement policies may be revised. Training: Billing department must be trained on policies and procedures and the ICD-10-CM code set. Source: 57

58 EDUCATE YOUR STAFF- 5 Clinical Area Patient Coverage: Health plan policies, payment limitations, and new Advanced Beneficiary Notification (ABN) forms are likely Superbills: Revisions are required and paper superbills may be impossible ABNs: Health plans will revise all policies linked to LCDs or NCDs, etc. ABN forms must be reformatted and patients will require education Front Desk HIPAA: Privacy policies must be revised and patients will need to sign the new forms really? We need to have HIPAA forms re-created and have all patients sign the new version? Is this a requirement? Systems: Updates to systems are likely required and may impact patient encounters Source: 58

59 TESTING ICD-10 testing is the only accurate way to gauge your readiness and it s vital for effective contingency planning. CMS outlines the ICD-10 testing process that is most effective for medical practices as follows: Prepare Test Scenarios Identify at least 25 medical claims with the most used ICD-9 codes Assign ICD-10-CM codes for each medical claim Prioritize and sequence efforts to support critical paths Negative Testing - Create errors with different dates of service: ICD-9 on or after October 1 ICD-10 before October 1 Test split claims inpatient admitted before Oct. 1, discharged after Oct. 1, same encounter Source: testing-o 59

60 WHAT TO DO IF VENDOR ISN T READY- 1 Perform Internal Assessment Identify what systems will be impacted by ICD-10 and what staff needs to be trained Determine financial needs and focus on contingency planning Focus solely on ICD-10 - Do not try to address other issues with systems or process at this time Communicate with colleagues in similar practices to understand barriers and obstacles Work at improving documentation Research and review other online ICD-10 publications that contain case studies, tips and training for ICD- 10 coding and compliance 60

61 WHAT TO DO IF VENDOR ISN T READY- 2 Perform Internal Testing Internal testing of each system within your practice is vital and must be performed to identify training issues or to detect errors that may result in privacy/security breaches. Eligibility and benefits verification Scheduling: office visit, outpatient procedure, inpatient admission Update a patient s history and problems Enter and process an order Verify that diagnosis-dependent clinical decision support rules issue alerts Prepare clinical notes for an encounter an code the encounter Generate and process a claim Perform a claim status inquiry Reconcile and post a payment Run frequently used reports Perform other key tests as needed 61

62 DETERMINE POTENTIAL FINANCIAL IMPACT Function Description Risk Areas Patient Access Claims/Backend management Financial services Provider, nurses, lab, imaging Training Prior authorization and referrals Submission of claims and Claims management Cash on hand and the AR/payer Clinical documentation Providers, coders, billing staff, front desk No-show areas; insurance verification rate Denied claims; Payer turnaround time AR per payer; AR greater than 90 days Required reporting (PQRI, meaningful use/reimbursement/d GRs Documentation gaps; Decreased productivity HIM IT hardware/software, computer-assisted coding technology Loss of productivity; Compatibility issues w/ existing hardware/software 62

63 ICD-10 IMPACTS ON THE PROVIDER- 1 Coverage and Payment As ICD-9 codes are replaced with ICD-10 codes, health plans (Medicaid State agencies included) will be revising coverage policies, medical review procedures, and plan design and reimbursement schedules to take advantage of the better information being collected. It is expected that providers will need to change their processes to adapt to the changes, and that there may even be a need to discuss treatment changes with patients. For example, certain conditions may not be covered to the same extent if they can be better identified in terms of specificity. Payments may also change. This will need to be explained to patients. Source: Topics/Data-and-Systems/ICD-Coding/ICD-10-Final-Regulation-and-Training.html 63

64 ICD-10 IMPACTS ON THE PROVIDER- 2 Documentation of diagnoses and procedures Codes must be supported by medical documentation. ICD-10-CM codes are more specific and require more documentation to support the increased specificity of the code set. Relationship with Plans Plan contracts, coverage and payment policies will change. It is important for providers to begin dialogue with their Payer about ICD-10 to determine what the changes will mean to overall reimbursement. Billing and Eligibility Transactions Providers who are just beginning to prepare for the ICD-10 transition must be prepared for claim rejections, denials and pended transactions once you begin using the ICD-10 code sets, and health plans begin processing claims using ICD-10 codes. Source: Topics/Data-and-Systems/ICD-Coding/ICD-10-Final-Regulation-and-Training.html 64

65 ICD-10 IMPACTS ON THE PROVIDER- 3 Laboratory and Pharmacy Laboratories and pharmacies depend on other providers to submit the specific diagnosis codes so they can bill appropriately. Due to the expected changes in coverage as well as the learning curve on ICD-10 for providers, a lab or pharmacy may not get paid when a diagnosis code does not support the drugs or lab tests ordered by another provider. Prior authorization or prescription refills presents an additional ICD-10 transition issue if the original order or prescription was done with an ICD-9 code prior to October 1, The lab or pharmacy must be able to submit an ICD-10 code once a service is provided on or after October 1, Source: Topics/Data-and-Systems/ICD-Coding/ICD-10-Final-Regulation-and-Training.html 65

66 ICD-10 RESOURCES CMS We strongly encourage you to take advantage of the free Road to 10: CMS Online Tool for Small Practices, an online resource built with input from providers in small practices that helps providers build ICD-10 action plans tailored specifically for their practice needs. Helpful ICD-10 Resources such as FAQs, Tips, ICD-10 implementation toolkits and preparation checklists, and upcoming events can be found for clinicians, HIM coding professionals, and other healthcare stakeholders. The ICD 10 PCS code set is available at no charge on the CMS Website at PCS.asp#TopOfPage. The ICD 10 CM code set is also available free of charge on the NCHS Website at Please note that although the 2015 ICD-10-CM/PCS code sets are available for public download and viewing, the codes are not currently valid for any purpose or use. The effective implementation date to begin using these codes is October 1,

67 ICD-10 RESOURCES (CONT.) Webinars & Training Description CMS.gov/ICD10 Minnesota ICD-10 Collaborative Webinar Road to 10 CMS s dedicated website featuring information about ICD-10 to assist providers with implementation Minnesota ICD-10 Collaborative Educational Webinar for Minnesota providers ( ) CMS online tool to assist small practices in preparing for ICD-10 transition. Road to 10 includes specialty references and helps providers build ICD-10 action plans tailored for their practice needs. Transitioning to ICD-10 (November 5, 2014) go.css.edu/icd10 CMS and AHIMA webinar: ICD-10 and Clinical Documentation ( ) Self-paced ICD-10 training and resource for providers and coders. 67

68 ICD-10 RESOURCES & BASIC EDUCATION SITES Organizatio n NCHS CMS AHIMA WEDI HIMSS AAPC Coalition for ICD-10 AHA Central Office Resource Basic ICD-10 Information ( 10.htm) ICD-10-PCS ( 10-PCS.asp) ICD-10 Education ( ICD-10 Implementation ( ICD-10 Playbook ( ) ICD-10 Education ( ICD-10 Resources ( About ICD-10 Coding ( 68

69 ABBREVIATIONS Abbreviation AAPC AHA AHIMA CMS HIMSS NCHS WEDI CDC Name American Association of Professional Coders American Hospital Association American Health Information Management Association Center for Medicare and Medicaid Services Healthcare Information and Management Systems National Center for Health Statistics Workgroup for Electronic Data Exchange Center for Disease Control & Prevention 69