Medical Billing and ICD-10 - Know Your Patients

Transcription

1 AHLA N. ICD-10 Transition: What Health Lawyers Need to Know Julie E. Chicoine Senior Assistant General Counsel OSU Wexner Medical Center Columbus, OH Denise J. Hall PYA Atlanta, GA Institute on Medicare and Medicaid Payment Issues March 26-28, 2014

2 ICD-10 Transition Update: What Health Lawyers Need to Know American Health Lawyers Association Institute on Medicare and Medicaid Payment Issues Page 0 Learning Objectives What is ICD 10 and why is it important to the healthcare community? What is the current regulatory status of ICD 10? Organizational Impact Operational and Finance Readiness and Implementation Strategies Page 1 1

3 What is ICD 10 and why is it important to the healthcare community? Page 2 What Are ICD Codes? The International Classification of Disease (ICD) codes are the international classifications for all diseases and many other health problems for purposes of health management, including: Analysis of the general health of population groups Monitoring of the incidence and prevalence of diseases Monitoring other health problems in relation to other variables such as the characteristics and circumstances of the individuals affected, reimbursement, resource allocation, and quality ICD codes are now recorded on many types of health records and is a key component in reimbursement, quality and utilization review and other data management activities Page 3 2

4 What is ICD-10? Replaces ICD-9 Not a revised version of ICD-9 ICD-10 represents a complete change from one coding system to a new one structured in an entirely new way Like all medical coding systems, it provides a way to condense textual clinical information into codes that can be used for billing and other data-based applications Page 4 ICD-10 Is Really Two Different Code Sets ICD-10-CM International Classification of Diseases, 10th Revision, Clinical Modification ICD-10-PCS International Classification of Diseases, 10th Revision, Procedure Coding System There is no relationship between the two code sets they have completely different structures and uses Page 5 3

5 What s ICD-10-CM? ICD-10-CM Diagnosis Coding System Used to report the patient s condition (i.e., what s wrong with the patient) Direct replacement for ICD-9-CM Volumes 1 & 2 Will be used in all settings hospital inpatient, hospital outpatient, physician office, etc. Like ICD-9-CM, developed and maintained by the World Health Organization (WHO) and the National Center for Health Statistics within the Centers for Disease Control Page 6 What s ICD-10-PCS? ICD-10-PCS Procedure Coding System Used to report surgical procedures performed Direct replacement for ICD-9-CM Volume 3 Only used in a hospital inpatient setting (and only for reporting facility services) Like ICD-9-CM Volume 3, ICD-10-PCS was developed and is maintained by CMS Page 7 4

6 How Big Could It Be? ICD-9-CM Diagnosis: 14,000 Procedures: 4,000 ICD-10-CM & ICD-10-PCS Diagnosis: 68,000 Procedures: 87,000 Page 8 Key ICD-10-CM Changes Alphanumeric codes Expanded injury codes grouped by anatomic site not injury type Laterality (right vs. left) Obstetric codes include trimester Diabetes codes differentiate between I, II, drug, chemical induced diabetes, or due to an underlying condition (chemotherapy) Intraoperative and postoperative complications Visits initial or subsequent Page 9 5

7 ICD-10 vs. ICD-9 Issue ICD-9-CM ICD-10-CM Volume of codes Approximately 13,600 Approximately 69,000 Composition of codes Mostly numeric, with E and V codes alphanumeric. Valid codes of three, four, or five digits. All codes are alphanumeric, beginning with a letter and with a mix of numbers and letters thereafter. Valid codes may have three, four, five, six or seven digits. Duplication of code sets Currently, only ICD-9-CM codes are required. No mapping is necessary. For a period of up to two years, systems will need to access both ICD-9-CM codes and ICD-10-CM codes as the country transitions from ICD-9-CM to ICD-10-CM. Mapping will be necessary so that equivalent codes can be found for issues of disease tracking, medical necessity edits and outcomes studies. Source: Page 10 ICD-10 Code Comparison Tobacco Abuse ICD-9-CM: 1 Code ICD-10-CM: 5 Codes Diabetes Mellitus ICD-9-CM: 10 Codes ICD-10-CM: 318 Codes Fracture of Radius ICD-9-CM: 33 Codes ICD-10-CM: 1,818 Codes Page 11 6

8 What are the benefits of ICD-10? The new, up-to-date classification system will provide much better data needed to: Measure the quality, safety, and efficacy of care Improved quality reporting and scoring Reduce the need for attachments to explain the patient s condition Design payment systems and process claims for reimbursement Conduct research, epidemiological studies, and clinical trials Set health policy Support operational and strategic planning Design health care delivery systems Monitor resource utilization Improve clinical, financial, and administrative performance Prevent and detect health care fraud and abuse Track public health and risks Page 12 What can we learn from other countries implementation? Planning and preparation are the keys to success Start now to allow time to understand the impact and come up with solutions Education and training are all important Prepare for productivity loss and longer turn around times Collaborate with others Share information and experiences to learn what works and what to avoid Page 13 7

9 What is the current regulatory status of ICD 10? Page 14 When is it official? Per the Department of Health and Human Services, the compliance date for implementation of ICD-10-CM and ICD-10-PCS is October 1, January 1, 2010 December 31, 2010 January 1, 2011 December 31, 2011 January 1, 2012 October 1, 2014 Payers and providers should begin internal testing of Version 5010 standards for electronic claims Internal testing of Version 5010 must be complete to achieve Level I Version 5010 compliance Providers should form ICD-10 sponsorship team Payers and providers should begin external testing of Version 5010 for electronic claims CMS begins accepting Version 5010 claims Version 4010 claims continue to be accepted External testing of Version 5010 for electronic claims must be complete to achieve Level II Version 5010 compliance All electronic claims must use Version 5010 Version 4010 claims are no longer accepted Claims for services provided on or after this date must use ICD- 10 codes for medical diagnosis and inpatient procedures CPT codes will continue to be used for outpatient services Page 15 8

10 National Coverage Determinations (NCDs) CMS is responsible for converting approximately 330 NCDs Not all are appropriate for translation Edits based on HCPCS Older obsolete technology or considered outdated CMS has determined which NCD should be translated and is in the process of completing system changes for those NCDs Page 16 Local Coverage Determinations (LCDs) According to CMS, LCDs are made by the individual Medicare Auditing Contractor (MAC i.e. CAHABA) Contractors shall publish all ICD-10 LCDs and ICD-10 associated articles on the Medicare Coverage Database (MCD) no later than April 10, Page 17 9

11 Industry Readiness Survey The Workgroup for Electronic Data Interchange (WEDI), the leading authority on the use of Health IT to improve the exchange of healthcare information, announced submission of the latest ICD-10 industry readiness survey results to the Centers for Medicare & Medicaid Services (CMS). Some key results from the survey include: All industry segments appear to have made some progress since February 2013, but have not gained sufficient ground to remove concern over meeting the October 1, 2014 compliance deadline. About three-fifths of health plans have completed their impact assessment- and another onefifth are nearly complete. This shows moderate progress since the February 2013 survey where approximately one-half had completed their assessment. Although the number of providers that responded unknown to when they would complete their impact assessment, business changes and begin external testing is down significantly from the February 2013 survey, responses indicate the majority will not complete these steps until About three-fifths of vendors indicate they are already doing, or plan to begin customer review and beta testing by the end of this year. This is down slightly from the two-thirds indicated in the February 2013 survey. Sources: Page 18 Fact or Fiction ICD-10-CM-based super bills will be too long or too complex to be of much use Fiction (sort of) Practices may continue to create super bills that contain the most common diagnosis codes used in their practice. ICD-10-CM-based super bills will not necessarily be longer or more complex than ICD-9-CM-based super bills. Neither currently-used super bills nor ICD-10-CM-based super bills provide all possible code options for many conditions. The super bill conversion process includes: Conducting a review that includes removing rarely used codes Cross walking common codes from ICD-9-CM to ICD-10-CM, which can be accomplished by looking up codes in the ICD-10-CM code book or using the General Equivalence Mappings (GEM) Vendors electronic superbill and posting scrubber that assist physicians in the transition to ICD-10 Source: Page 19 10

12 What do I need to do to get the claim out the door? Medicare will begin accepting a revised 1500 (version 02/12) on January 6, 2014 Allows for reporting of ICD-10 codes Use as many as 12 codes in the diagnosis field (the current limit is four) Qualifiers to identify the following providers role (on item 17) Ordering, Referring, Supervising Starting April 1, 2014, Medicare will accept only the revised version of the form The revised form will give providers the ability to indicate whether they are using ICD-9 or ICD-10 diagnosis codes Page 20 What do I need to know to get the claim out the door? Reporting ICD-10 diagnosis codes Claims Submission of diagnosis codes ICD-9 codes no longer accepted on claims with date of service after October 1, 2014 ICD-10 codes will not be recognized/accepted on claims before October 1, 2014 Claims cannot contain both ICD-9 and ICD-10 codes will be returned as Unprocessable Date span requirements Outpatient claims-split claim form and use from date Inpatient claims-use only through date/discharge date for ICD-10 code submission Page 21 11

13 Once I get this claim out of the door, am I going to get paid? The Department of Health and Humans Services (HHS) anticipates that the percent of returned claims following the ICD-10 implementation could be more than double of what we have seen in the past with ICD-9 updates. Page 22 DRG Assignment CMS did not address the impact of ICD-10 on DRG assignment in the ICD-10 Final Rule However, CMS and 3M have used the GEMs to convert the MS-DRG definitions from ICD-9-CM to ICD-10 CMS and 3M found that the GEMs were 95% to >99% effective in converting the MS-DRGs to ICD-10 Page 23 12

14 ICD 10 Impact Page 24 Scope of ICD-10 Impact All HIPAA covered providers and entities Includes, payers, health plans, DME, pharmacy, vendors Other Code Sets No impact» Current Procedural Terminology (CPT) Codes» Healthcare Common Procedure Codes (HCPCS) Page 25 13

15 ICD-10 Industry Impact Hospitals Physicians Home Health Pharmacy Payers/ Health Plans Laboratory Research Vendors Business Associates Page 26 ICD-10 Transitional Impact Clinical Documentation Accurate diagnosis Improved quality of care Quality Pay-for-performance Public Reporting Financial Utilization management Cost containment Page 27 14

16 ICD-10 Organizational Impact Scheduling, ED & Access Areas DNFB, Coding, CDI Case Management Billing, Reimbursement Health Information Management Documentation Analysis ICD-10 Education & Training Coding Production Impact Physician Office Revenue Process Information Technology Post Acute Services ICD-10 IT Systems Capability, Communication Functionality Vendor Preparedness Staffing Effectiveness Revenue Impact Assessment Process Flow & Improvement Decision Support Impact Operational Planning Physician Physician Documentation Physician Integration Physician Performance Page 28 Estimated Financial Impact: Revenue Cycle Notes: See Key Assumptions for information on assumptions underlying these estimates. Figures may not add to Totals due to rounding. Page 29 15

17 30 Provider Impact Value-based compensation Increased documentation time up to 15% May affect patient volume Quality Measures/P4P need to be determined based on ICD-10 codes Difficult to measure impact of change is it because of code set or because of changes in underlying practice? Page 30 Payers, Health Plans Impact: Coverage determinations Payment determinations Medical review policies Actuarial projections Quality measurements Page 31 16

18 Compliance Impact A huge potential for double billing exists if two systems (ICD-9 and ICD-10) remain in use during the transition period: This scenario could potentially create unintentional billing compliance risks. The shortage of experienced coding professionals also poses a risk since medical coders nearing retirement age may elect to retire rather than learn a new system. Additionally, the General Equivalency Mappings (GEMS) do not provide a definitive map from ICD-9 to ICD-10 with only 5% mapping accurately 1:1 with ICD-10 codes: Because ICD-9 codes could map into multiple ICD-10 codes, this risk rises even more. Page 32 Coder Impact Need to know anatomy and physiology Need to know new code sets Decreased productivity ICD-10 Watch: Some studies suggest a 50% drop in coding productivity Industry demand for more coding professionals! Page 33 17

19 ICD-10 Potential Financial Impact Decrease in Cash Flow / Loss of Revenue Industry experts from CMS and AHIMA estimate the following: According to CMS, Estimated Organizational Cost by Bed Size Bed Size Denial rates will increase by 100% to 200% Accounts receivable days will be extended by 20% to 40% Healthcare organizations will be hindered with payment declines for more than 2 years after the implementation Date of October 1, 2014 Claims-error rates will increase from 6% to 10 % (The average current rate is close to 3%) Cost $1.5 Million $5 Million $500,000 $1.5 Million < 100 $100,000 $250,000 Page 34 Expected Denial Reasons Minich-Pourshadi, Karen. ICD-10 Puts Revenue at Risk. HealthLeaders Media Intelligence (July 2011), p. 22. Page 35 18

20 Readiness and Implementation Strategies Page 36 Strategy Convene Implementation Taskforce Designate Physician Champion Multi-disciplinary Clinical, IT, HIM, Finance, Compliance, Communications, Payer/Managed Care Contracting, Operations Key stake holders Identify who is impacted and what needs to be done Establish timeline and designate leaders Page 37 19

21 Assessment Organizational readiness Map a patient s encounter and look at every piece in the organization touched by ICD-9 Affected Areas Financial/HIM/IT Billing systems, DRG grouper, claims software, medical record abstracting, encoding software, case mix systems Clinical Patient care protocols, medical necessity, laboratory and pharmacy systems, utilization, quality and case management Patients Patient registration and scheduling systems, advance beneficiary notice, preauthorization Page 38 Implementation Process Analysis of all Departments Processes Reports Work Flow Information Systems and Software All Forms of Documentation Page 39 20

22 Roles Role Administrators IT Staff Providers Billers Coders Task Confirm capabilities, provide training, review processes Confirm integration in system and documentation Outpatient: Document in support of ICD-10 code selected Inpatient: CM and PCS codes will have to be supported Understand how to look up codes, understand how to query physicians, pull new LCDs Understand ICD-10 guidelines and how to properly select ICD-10 codes base on documentation Page 40 Vendor Readiness Identify vendors affected by ICD-10 (billing companies, medical transcription, home health, DME start with your Business Associate Agreements) What system changes/upgrades are needed? What costs are involved? Are they included in existing vendor agreements? What customer support (implementation, testing, training) will the vendor be offering? Page 41 21

23 Vendor Readiness Our billing software vendor indicates they will be ready for these transitions. What can I do in the meantime, besides train for ICD-10 coding? Ask your billing software vendor for a detailed schedule of deliverables and begin preparing to test implementation of the modified software at your location. Be sure to verify the following: The vendor is addressing the ICD-10 upgrades The number and schedule of planned ICD-10 software releases Their ICD-10 conversion plan accommodates your clearinghouse testing schedule Any related costs to your organization Customer support and training they will provide Page 42 Payer Readiness As with vendors establish dedicated contact Evaluate payer readiness What s their implementation plan/timeline? Are they implementing new rules for claims submission or re-submission? Will contract terms for coverage and billing change? Will they require the provider to report the code with the highest specificity? Will their payment and reimbursement schedules change? Will the claims appeal process change? Add language to current contracts to require ICD-10 compliance Share your plans for ICD-10 changes with them Establish regular meetings, compare implementation plans, review and update contracts as necessary Medicare and Medicaid - Are they on track? When will they be ready for end-to-end testing? What are their contingency plans? Page 43 22

24 Code Analysis Review top diagnosis codes Evaluate documentation currently in the notes Crosswalk them to ICD-10 Review new codes for additional required codes, additional code descriptions and code also requirements Identify areas where additional documentation will be required Page 44 ICD-10 Impact on Physician Work Flow Will the EMR allow the physician to enter a descriptive diagnosis rather than a specific diagnosis code? Is the physician prepared for the dramatic increase in diagnosis codes now displayed on the drop-down list? How will the physician s workflow change when more time is needed to assign the appropriate diagnosis code? Can the EMR support a workflow that sends patient encounters to coders for review and assignment of the most specific diagnosis code based on the physician s documentation? Page 45 23

25 Budget Determine financial impact, budget, resources, cash reserve needed for ICD-10 migration Cost of training/decreased staff productivity Cost of hardware/software upgrades Forms redesign Testing costs/consulting services Vendor readiness external testing Temporary maintenance of dual systems Cash reserves for denials increase, payment delays, decreased productivity Page 46 Budget How much emergency cash should providers keep in case of cash flow disruption? Review what happened to your organization with HIPAA 5010, this would be a good baseline; with the transition of ICD-10 there will be delays in reimbursement Vendors and Clearinghouses have been working hard, but we will not know the true effects until Oct 1, 2014 It is recommended that you have up to several months' cash reserves or access to cash through a loan or line of credit to avoid potential headaches. The amount of reserves needed to set aside will be impacted by the preparation work you do for ICD-10 Will need to cover at a minimum practice operation expenses for three to six months: Medical supplies Payroll Rent Page 47 24

26 Implementation Issues Training Will be required for various users Will require coder retraining Coding rules and conventions are similar, but not exactly the same Some short-term loss of productivity is expected during the learning curve Will require changes in data retrieval/analysis Will require changes to data systems Page 48 Coding and Billing Staff Training Assess training needs and develop a plan Professional coding staff ICD-10-CM Determine who will train staff and how this will be accomplished Factor in time away from work, consider post-testing and ongoing support Make ICD-10 proficiency part of your coding staff s performance goals» ICD-9-CM to ICD-10-CM Dual Coding Assign staff members to be the ICD-10 Expert looking at the impact from the billing to the clinical side Page 49 25

27 Training Clinicians Physicians focus on codes germane to their practice Review clinical documentation improvement efforts and develop new strategies Incorporate documentation improvement as component to compliance training Ancillary staff identify needs and level of training needed, nursing, financial services, quality, utilization, ancillary departments Information Technology Training to ensure that codes are accurately cross-walked in organization s IT systems Page 50 Tiered Training Structure Page 51 26

28 ICD-10 & EHR Analyze EHR for functionality and compliance Review templates, interfaces, default documentation, and level of detail Can the system accommodate the data format changes for ICD-10? What is the EHR vendor s timeline for the transition? When will their upgrades be available for installation? Make sure that installation of upgrades is far enough in advance to facilitate early testing Will there be additional costs for the upgrade? Will multiple upgrades be required? Is there a waiting list? Is the EHR vendor training its staff on ICD-10 system upgrades? Can they ensure that the right components are in place to select the more specific code? Will they have specialty specific codes? Will ICD-9 still be available for use and comparison? Does the system allow for dual coding? Page 52 ICD-10 Go Live, The Day After Plan for dual ICD-9 and 10 codes for a brief period to address services rendered before October 1, but discharged after October 1 Monitor physician documentation to ensure ICD-10 compliance Monitor impact on claim-processing activity, claim denials, and rejections Audit coder productivity and accuracy Monitor patient satisfaction Post-transition Review What s working? What needs fixing? Schedule 30-day post-conversion claims assessment Page 53 27

29 Priority List Create an ICD-10 impact awareness throughout the organization Ensure your foundational IS structure is actively preparing for the transition Define your change approach to ensure you have defined the proper structure and sponsorship Develop projections of operational needs, including staffing and internal educational training Identify specific documentation gaps to determine focused educational needs Calculate potential impact on financial results Page 54 ICD-10 is not just a coder s issue! This transformation entails foundational changes to ALL HIPAA-covered entities and providers In a nutshell, here are some key points to keep in mind going forward: Senior management s involvement is critical to successful implementation! Risks of late or no implementation must be understood Problems should be expected! Develop action plans to manage them Have a back-up plan Establish a budget. Develop a timeline and follow it! Page 55 28

30 The future? WHO is currently working on ICD-11 They will build upon ICD-10 The first draft was made available online in July 2011 for review The final draft is expected to be submitted to WHO's World Health Assembly for official endorsement by 2017 Page 56 Key Resources ICD-10 Proposed and Final Rules CMS Website on ICD-10 CDC Website on Classification of Diseases CMS ICD-10-CM Quick Reference Guide sp#topofpage Page 57 29

31 Contact Information Thank you for allowing us to share our thoughts and expertise with you. Denise Hall, RN, BSN Principal Pershing Yoakley & Associates, P.C Julie Chicoine, Esq., RN, CPC, CPCO Wexner Medical Center at The Ohio State University Page 58 30