Overview of ICD10 Transition Impact on Physician Practices Presented by Theresa Mendoza Director of Quality, BI and Data Services

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1 Overview of ICD10 Transition Impact on Physician Practices Presented by Theresa Mendoza Director of Quality, BI and Data Services

2 What is ICD10? ICD10 is a diagnostic/procedural coding system implemented by the World Health Organization (WHO) in 1993 to replace ICD9 Actually developed in the 1970s and has been implemented in almost every country in the world with the exception of the United States ICD-10-CM is the diagnosis codes set to replace the ICD-9- CM. ICD-10-PCS is the procedural codes set to replace what is known as Volume 3 of the ICD-9-CM The final rule stated that CPT would remain the coding system for physician services Page 2

3 Why? ICD-9-CM is basically out of room The classification is organized scientifically where each three-digit category can have only 10 sub-categories Most numbers in most of the categories have been assigned diagnosis Medical science keeps making new discoveries and there are no more numbers to assign the new diagnosis The more detailed codes will allow for better analysis of disease patterns and treatment outcomes Page 3

4 When? CMS (Centers for Medicare & Medicaid Services) announced in January of 2009 that ICD-10-CM and ICD-10-PCS will be implemented into the HIPAA mandated code set on October 1, 2013 Additionally, starting January 1, 2012you must be ready to submit your claims electronically using the X12 Version 5010 as a prerequisite for implementing ICD-10 codes Page 4

5 Rumors of a Grace Period There is NO GRACE PERIOD CMS Website the following are excerpts: October 1, 2013 Compliance date for implementation of ICD- 10-CM (diagnosis) and ICD-10-PCS (procedures) No delays No grace period CMS Myth and Fact Sheet MYTH -Implementation planning should be undertaken with the assumption that the Department of Health Human Services (HHS) will grant an extension. FACT -HHS has no plans to extend the compliance date for implementation and covered entities should plant to complete the steps required in order to implement ICD10 on October 1, Page 5

6 AMA Vote & Concerns In November the AMA s House of Delegates voted to vigorously work to stop the implementation of the ICD-10 codes due in just 20 months Dr. Carmel stated the 2013 timing is terrible when physicians are working to implement electronic health records. Another main concern was cost and they quoted that it would cost an estimated $28,000 per physician. Page 6

7 How do we address these concerns? Physicians and the healthcare industry can learn a lot form much more precise codes. ICD-10 will provide better information on patient outcomes which should be more advantageous to physicians Can identify more clearly when a procedure is more complicated and might have higher risks Specificity can be used to support the medical necessity of the physician s service which might have been denied under ICD-9 coding An extensive public debate about ICD-10 has occurred over the last years and the government has been responsive to those concerns by delaying the implementation for several years now the final regulation was approved and it is time to move forward. ICD-10 transition will not get easier or cheaper as time moves Page 7

8 What do Physicians Need to Know? There are many daily chores to being a good physician. Patient care, nursing staff issues, medical decision making, patient paper work and referrals, constant prescription refills requests; the list goes on and on. Patient charting is one of those crucial daily tasks, which cannot be overlooked, and which you must complete to the best of your ability, all the while seeing other patients, and dealing with all of your other responsibilities in the office. Different patient visits will require different types of documentation. If your documentation does not include all of the different necessary aspects, your claims will not be going out correctly, which will end up affecting the bottom line for your practice. Page 8

9 Page 9

10 ICD-10 Major Modifications Expanded codes (e.g., diabetes, reasons for encounters, other factors influencing health) Added code extensions for injuries and external causes of injuries Expansions for laterality Combination codes for diagnosis and symptoms Full code titles Not otherwise specified (NOS) codes still included Page 10

11 General Equivalence Mapping Categories Page 11

12 Structural Differences ICD-10-CM codes have 3 7 digits A78 Q fever A69.20 Lyme disease, unspecified O9A.311 Physical abuse complicating pregnancy, first trimester S42.001A Fracture of unspecified part of right clavicle, initial encounter for closed fracture Page 12

13 Structural Difference Cont d ICD-10-CM has 3 7 digits Digit 1 is alpha Letters A Z, except U (not case sensitive) Digits 2 is numeric Digits 3-7 are alpha (not case sensitive) or numeric Page 13

14 Solo Practitioner Or Small Group Practice Implementation Planning Take a step-by-step approach Enlist help from manager, coding, and billing staff Early planning will make transition smoother Can be accomplished in 12 steps Use a team approach Page 14

15 12 Steps 1. Organize Implementation Effort 2. Establish Communication Plan 3. Conduct Impact Analysis 4. Contact System Vendors 5. Estimate Budget 6. Implementation Planning 7. Develop Training Plan 8. Analyze Business Processes 9. Education and Training 10. Policy Change Development 11. Deployment of Code 12. Implementation Compliance Page 15

16 STEP 1 Organize Implementation Enlist staff person (coder, biller, manager) to oversee effort who will be key point person Prepare information to share with other providers and staff Identify work and scope for implementation Should be a team effort involving all medical practice staff Look at all areas that will impact practice and identify each one that will be affected: Practice management system Electronic Medical Record (EMR), if applicable Super bills Clinical areas Schedule regular meeting to share information with physicians and discuss progress and barriers of implementation Page 16

17 STEP 2 Communication Plan How will point person communicate with all staff? Most small practices communicate via meetings or memos. No need to change method of communications. Develop regular schedule Monthly until 6 months prior to implementation Bi-weekly thereafter Include information, publications, and articles Page 17

18 STEP 3 Impact Analysis Take this step prior to development of budget In depth look at resources required for implementation Helps determine what costs might be involved as well as work processes What systems will be affected? Practice management Coding look up programs (if applicable) EMR Hardware space What are the potential costs involved? Develop reasonable timeline that can be accomplished in the solo or small medical practice. Map out a project plan on a simple Excel spreadsheet with benchmarks and status of completion Page 18

19 STEP 3 Sample Project Plan Page 19

20 STEP 4 Contact Vendors Will they be able to accommodate the need to move to ICD-10? Will they be ready for 5010 on January 1, 2012? What costs will be involved with the transition to 5010 and ICD-10? What plans do they have in place for implementation? When will they have software available for testing? Will we need new hardware or is current hardware sufficient? Page 20

21 STEP 5 Estimate Budget Budget considerations should include Process Analysis Hardware costs Software costs and licensing Education and Training Increased Documentation Cost Page 21

22 STEP 6 Implementation Planning Begin planning early (should already be started) Break down planning into stages Training for a small practice does not need to begin until 6 months prior to implementation should be a just in time plan Review super bills and remove rarely used codes Crosswalk common codes from ICD-9-CM to ICD-10- CM Look up codes in ICD-10-CM book and use GEMs if necessary Where you may have just had 10 common codes you used there may be 20 or more now Page 22

23 STEP 7 Training Plan Who needs training? Physicians Coders Billing staff Administrative staff Clinical Staff Required number of hours depends on their role What resources are available? Web-based training Community Colleges Workshops Conferences Books Establish a training schedule. Will temporary staff or overtime be necessary during the training period. What office materials will the office need for on-going support? Books Software (Code Lookup) Page 23

24 STEP 8 Analyze Business Process Identify all systems and processes that currently use ICD-9-CM. Review existing medical policies related to ICD-9- CM. Which contracts tied to reimbursement are tied to a particular diagnosis? Modify any contract agreements with health plans accordingly to new diagnosis structure. Page 24

25 STEP 8 Analyze Processes Page 25

26 STEP 9 Begin Education Education should begin approximately 6 months prior to implementation Large practices may need to begin earlier to accommodate all staff who need training Use various methods of training Training time depends on their role Physicians and coders/billers will need more training time than administrative staff Page 26

27 STEP 10 Policy Change Development After health plans complete and change medical policy for procedures and services a specialty provides Review new payment policies Identify opportunities to improve coding processes Communicate policy changes to applicable staff Page 27

28 STEP 11 Deployment of Code Vendor delivers software update with ICD-10-CM Vendors should: Test system Integrate software into your systems Make internal customizations Test systems with clearinghouses, payers, electronic claims transmission (end to end) Ensure that the vendor will maintain updates to code during transition period Page 28

29 STEP 12 Implementation Compliance Compliance date for implementation October 1, 2013 Monitor compliance activities to identify any problems Page 29

30 COST IMPACT Nachimson Advisors, LLC (October 8, 2008) Page 30

31 Benefits of ICD-10-CM For Physician Practices Updated medical terminology and classification of diseases to be consistent with current clinical practice Reduction in requests for additional documentation to support claims Better support of medical necessity of services provided Page 31

32 CMS Web Resources ICD-10 General Information ICD-10 Educational Resources (fact sheets) and 2008 ICD-10 CMS Sponsored Calls (discussion materials and transcripts) asp Page 32

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