Preparing Your Organization for a Successful Implementation to ICD-10-CM and ICD-10-PCS

Transcription

1 Preparing Your Organization for a Successful Implementation to ICD-10-CM and ICD-10-PCS Nelly Leon-Chisen, RHIA Director, Coding and Classification, American Hospital Association

2 Objectives Describe key elements required in a plan for successful transition to the ICD-10-CM and ICD-10-PCS systems Explain how a change to ICD-10-CM/PCS can affect your clinical, financial, quality and other systems Make recommendations to organize your ICD-10-CM/PCS transition team and develop the team s to-do list Describe real-life ICD-10-CM/PCS planning activities from hospitals and selectively apply those activities to your own facilities Discuss and review a timeline model for ICD-10-CM/PCS HIM implementation 2

3 Objectives (cont.) Gain a practical understanding of the requirements for the ICD-10-CM/PCS planning and impact analysis stage Position your organization to take advantage of strategic opportunities created by the transition to ICD-10-CM/PCS Better anticipate challenges and solutions that will be encountered along the way 3

4 Medical Coding Sits Right In The Middle Public Health Epidemiology Decision-making Clinical Care Med Record Document Medical Coding Reporting Healthcare Policy Reimbursement Benchmarking /Quality Clinical Quality Appropriateness Utilization Performance improvement Financial Risk-adjustment Care monitoring Research 4

5 Context for Change ICD-9-CM is almost 30 years old No room to add new codes to keep pace with current classification of medical conditions or technological advances Not always precise or unambiguous Many countries have already adopted ICD-10 U.S. mortality data (vital health statistics) already being reported using ICD-10 difficulty comparing mortality vs. morbidity data HIPAA Electronic Transactions and Code Sets notice of proposed rule 1998: it is inevitable that there will be changes to coding and classification standards after the year For example ICD-10-CM may replace ICD-9-CM. 5

6 Context for Change (cont.) Greater interest in more specific coding system Increasing interest in using administrative data for quality reporting, value-based purchasing, biosurveillance Reimbursement: would enhance accurate payment for services rendered Quality: would facilitate evaluation of medical processes and outcomes Provide better data to support performance measurement, outcome analysis, cost analysis and monitoring of resource utilization 6

7 Benefits of Adopting the New Coding System Incorporates much greater specificity and clinical information, which results in Improved ability to measure health care services Increased sensitivity when refining grouping and reimbursement methodologies Enhanced ability to conduct public health surveillance Decreased need to include supporting documentation with claims 7

8 Summary Comparison of ICD-9-CM vs. ICD-10-CM (Diagnosis) ICD-9-CM Limited space for adding new codes Lacks detail Lacks laterality Difficult to analyze data due to nonspecific codes Does not adequately define diagnoses needed for medical research Does not support interoperability because it is not used by other countries ICD-10-CM Flexible for adding new codes Very specific Allows laterality and bilaterality Specificity improves coding accuracy and richness of data for analysis Detail improves the accuracy of data used for medical research Supports interoperability and the exchange of health data between the U.S. and other countries 8

9 Summary Comparison of ICD-9-CM vs. ICD-10-PCS (Procedures) ICD-9-CM Based on outdated technology Limited space for adding new codes Lacks detail Lacks laterality Generic terms for body parts ICD-10-PCS Reflects current usage of medical terminology and devices Flexible for adding new codes Very specific Has laterality Detailed descriptions for body parts 9

10 Who is Impacted? Payers Reimbursement systems Contracts Claim systems Providers Hospitals Physicians Home health agencies Skilled nursing facilities Vendors Clearinghouses Employers Other business partners 10

11 Significance of ICD-10-CM/PCS The failure to successfully implement ICD-10-CM/PCS can Create coding and billing backlogs Cause cash flow delays Increase claims rejections/denials Bring about unintended shifts in payment Place payer contracts and/or market share arrangements at risk due to poor quality rating or high costs Inaccuracy in clinical coding creates distorted or misinterpreted information about patient care which can also result in faulty investment decisions to improve health delivery 11

12 Impact of Coding System Change Data trending challenges Maintenance of crosswalks among coding systems for longitudinal data analysis Clinical care Research Potential for faulty decisions due to distorted, inaccurate, or misinterpreted data (codes) when change is ignored 12

13 ICD-10-CM/PCS Timeline Source: American Hospital Association, HIPAA Code Set Rule: ICD-10 Implementation, Executive Briefing 13

14 Implementation Phases Implementation is divided into four phases: Phase 4 Phase 1 Organizing the Effort Phase 2 Planning and Impact Analysis Phase 3 Implementation Postimplementation Evaluation and Ongoing Efforts 14

15 Communication! Organizational awareness Sharing of information Communicating and more communicating 15

16 Strategic Planning and Opportunities Successful transition requires careful strategic planning and coordination of resources across the entire hospital Begin by examining every application where diagnosis or procedure codes are captured, stored, analyzed or reported Engage executive leadership Address challenges across a wide-range of functional areas Address implications to current and future information systems Review current work flow and medical documentation practices 16

17 Phase 1 - Organizing the Implementation Effort This phase will involve: Organizing your cross functional Steering Committee Selecting a Steering Committee leader Developing a meeting schedule Identifying required tasks and developing timelines Assigning tasks and responsibilities 17

18 Organizing Your Cross Functional Steering Committee Not just a coding thing Who is in charge? Collaboration among departments will be necessary to identify information systems affected Members across clinical, financial and information systems area Get support from administration Be sure to involve both HIM department leaders as well as coders 18

19 Cross-functional Team Convene a cross functional Steering Committee to: Identify system applications affected Assign tasks and responsibilities to carry-out the necessary changes The approach taken will differ among hospitals based on the size and organization of the hospital, level of automation, the number of electronic databases and the functional areas affected 19

20 ICD-10-CM/PCS Steering Committee Composition Leadership Sponsorship and support from a senior level manager to ensure coordination across departments Core Steering Committee Members Health Information Management Information Systems and Technology Billing Finance Compliance Revenue Cycle Management 20

21 ICD-10-CM/PCS Steering Committee Composition (cont.) Ad Hoc Team Members Quality Registration Nursing Clinics Emergency Department Pharmacy Medical Staff Affairs Outpatient Surgery Ancillary services such as: Imaging Laboratory Services Cardiology Rehabilitation Home Health Urgent Care Therapies Utilization Review 21

22 Organizing the Implementation Effort Tasks Develop implementation goals Develop plan for assessing implementation impact Develop implementation strategy Develop tools to assess impact on affected functional areas Identify Steering Committee s required tasks Develop timelines Assign responsibility for tasks Educate IS staff on code sets 22

23 ICD-10-CM/PCS Implementation Meeting Bring together IT and HIM - leaders Include other key stakeholders Develop a contact list Agenda to include what the 5010 and ICD-10 initiatives are IT areas of concern discuss IT tasks for next days HIM areas of concern discuss HIM tasks for the next days Other areas of concern discuss Action to be taken Develop assessment tool(s) Working project plan and timelines Budget considerations Next meeting 23

24 Steering Committee and Work Groups Work Group Communications Work Group - HIPAA v5010 Work Group Budget and Standardization Work Group IT Enterprise Planning Work Group IT Integration Work Group - ICD-10 Coding Work Group ICD-10 Business Process Change Work Group Vendor Relations Work Group Patient Financial Service/Business Office Work Group Managed Care Contracting Work Group - Clinical 24

25 ICD-10-CM/PCS Awareness Important to have the correct awareness and facts about ICD-10 Prepare an Executive Summary (1-2 pages) What is ICD-10 What is the impact How do we prepare Distribute to Executive Management Prepare a high level overview for HIM Coding staff 25

26 Create a ICD-10 readiness spreadsheet HIM SAMPLE 26

27 Important Decisions Ahead Comply? Update systems by the deadline so that claims will process smoothly and there is no disruption in cash flow Optimize? Analyze and capitalize on the opportunities that the more detailed classification system can provide 27

28 Important Decisions Ahead (cont.) Comply? Create awareness among affected departments and establishing timeliness and a budget Optimize? Create an organization-wide vision to also strategically evaluate the opportunities for improved workflow in the clinical, financial and operational areas. 28

29 Implementation Phases Implementation is divided into four phases: Phase 4 Phase 1 Organizing the Effort Phase 2 Planning and Impact Analysis Phase 3 Implementation Postimplementation Evaluation and Ongoing Efforts 29

30 Phase 2 - Planning and Impact Analysis This phase will involve performing an organizational assessment and developing an implementation schedule including: Conducting an information systems inventory Assessing vendor readiness and support Conducting staff awareness sessions Assessing and planning for staff training needs Identifying necessary tools Identifying areas requiring operational and policy changes Evaluating health plan contract implications, Budget planning Identifying gaps in health record documentation 30

31 Organize Departmental Assessment ICD-10-CM/PCS will impact different departments differently Each department should conduct internal assessment and report findings back to the ICD-10-CM/PCS Steering Committee Develop a detailed master to-do list Departmental assessment to include Inventory of information systems Assessment of training needs Identification of areas requiring operational and policy changes Identification of necessary tools 31

32 Sample ICD-10-CM/PCS Implementation Department Assessment Department: Health Information Management Application Name Vendor Application Maintainer Frequency of Regular Updates Under Maintenance Contract Diagnosis or Procedure Codes, or Both Codes Entered Directly Into Application or Downloaded from Other Systems? Lead Person Encoder ABC, Inc. ABC, Inc. Quarterly Yes Both Entered directly K. Jackson Abstracting System DEF DEF Quarterly Yes Both Downloaded from encoder DRG Grouper GHI GHI Annual Yes Both Downloaded from encoder Outpatient Code Editor Present on Admission Database Quarterly Yes Diagnosis Entered directly In-house IS&T Annual No Diagnosis Downloaded from abstracting system Birth Registrations State State Annual Yes Diagnosis Entered directly Trauma Registry State State Annual Yes Diagnosis Entered directly 32

33 Payer Accountin g /Billing HIM System HIM Department PM Transcripti on Lab, Rad, Etc. Physician Clinical Care Admission Patient Provider Value Chain Areas Affected by ICD-10-CM/PCS Provider Billing Value Chain Identifying I-10 Change Points Goes to hospital for care Enters Patient data Determines Inpatient/ Outpatient Evaluates Patient Orders tests Evaluates Test data Diagnoses Treats Documents Test, Diagnoses and Treatment Performs tests Documents Results Transcribes Dicatation/ Charts Quality / Performance Management Record Assembly Coding/ Editing Grouping Patient Admissions Data System Abstracting Reports Chargemaster Data Editing/ Bill Scrubbing UB 04 Transmission Claims Clearinghouse Optional Reports Source: 3M All rights reserved. Payer Audits Claim Pay, Deny, Reject 33

34 Public Reporting Across the Continuum- Where are ICD-9 and ICD-10 Codes? AHRQ Publication: EF March

35 Systems Likely To Be Affected Accounting systems Advanced Beneficiary Software Birth defect registries Billing Case management system Claims submission Clinical data reporting Clinical department systems Clinical protocols Clinical reminder systems Compliance checking systems Databases Decision support systems Disease management DRG grouper Electronic processing systems Encoder software E-prescribing Financial systems Hospital information system Interface engines Inpatient rehab facility patient assessment instrument data collection 35

36 Systems Likely To Be Affected (cont.) Managed care (HEDIS) reporting system Medical abstracting system Medical necessity Minimum data set collection system OASIS system Outpatient Code Editor Pharmacy systems POA systems Provider profiling Quality management Reports Registration and scheduling Research databases State birth registration systems State reporting systems Test ordering systems Utilization management 36

37 Commercial vs. Homegrown Software Work with major commercial vendors to ensure they are aware Technical issues Contractual issues Costs Homegrown Systems Technical issues Costs Copyright (c) 2010 by American Hospital Association. All rights reserve 37

38 Data Conversion Decisions, decisions, decisions Cost/benefit analysis regarding database uses Convert? Cross-walk? Dual systems? Copyright (c) 2010 by American Hospital Association. All rights reserve 38

39 Assessing Legacy Systems Question Answer/Comments Is the system still currently in use? What is the system used for? Does the system work satisfactorily? Is there another application currently available that can perform a similar function as the current system? Is there current staff capable of redesigning the system? Is the system documented fully enough to allow another designer to update the system? On what hardware does the system run? On what software platform does the system run? Is the system difficult to maintain or improve? Can the system be integrated with newer systems? What is the cost of updating the system? What is the cost of replacing the system with a new application? 39

40 Assessing Vendor Readiness and Support Identify which vendor systems are affected Develop a master list of all vendors affected Contact vendors to determine whether changes to existing systems are forthcoming and when they plan to have available upgrades to support ICD-10-CM/PCS Determine whether the upgrade to ICD-10-CM/PCS is included with your maintenance agreement Ask vendor to share their plans for readiness Make certain that the vendor intends to continue to provide support for the application Determine whether the application requires any special or custom developed edits Identify special terms in contracts to cover custom edits, if any 40

41 Sample I-10 Project Plan Project Planning: [Activities may occur in a different order. Note the date each item has been completed] Project costs have been estimated The relative cost/benefit ratio has been assessed Project team has been formed Project team has been provided with all known information Project team has planned the project details as outlined below Several steps to this element Project work has started Many steps to this element Initial project work completed and reviewed Middle phase of project work completed and reviewed/assessed Final report completed and delivered Assessment after go-live Recap project and new issues resolution Ongoing follow-up 41

42 IT Implementation Issues Interact with all vendors to ensure each one provides an ICD-10-CM/PCS update for current system assessments and readiness Evaluate interfaces that lie between code entry in HIM and electronic billing Inventory department databases and decision support systems Patient Financial Services Determine retention needs for ICD-9-CM 42

43 Consider Storage Capabilities Consider storage capabilities of all systems and plans for maintaining both code sets for a period of time Determine need to store historical data Consider expanded number of available codes for ICD-9-CM vs. ICD-10-CM/PCS. 43

44 Field Size Changes Field size changes associated with ICD-10-CM/PCS codes will also impact storage capabilities. 44

45 Changes Classifications ICD-9-CM Structured Format Numeric or Alpha (E or V) Numeric VX 85E X0 X5. X0 X0 Category 3 5 Characters Etiology, anatomic site, manifestation 45

46 Changes Classifications ICD-10-CM Structured Format Alpha (Except U) 2-7 Numeric or Alpha Additional Characters S X X A Category Etiology, anatomic site, severity Added code extensions (7 th character) for obstetrics, injuries, and external causes of injury 3 7 Characters 46

47 Change: ICD-10-PCS Structured Format ICD-9-CM X5 X1. X2 X3 ICD-10-PCS X3 10 XE F0 HX T0 XF 04 X8 74 XZ 03 X Z4 47

48 Evaluate Health Plan Contract Implications Prepare list of largest health plans Review existing health plan contracts Diagnosis or procedure based? DRG based? Other basis? Contact health plans and schedule meetings (can be done collectively with other providers; if possible work with state associations to schedule meetings) Share hospital plans for readiness and dates when hospital will be ready to begin external testing Host periodic follow-up meetings to share implementation progress and to validate plans for future testing 48

49 Important Decisions Ahead Comply? Hold discussions with payers regarding claims processing and testing to make sure systems are ready on the golive date Optimize? Review existing contractual agreements with payers and determining how the more granular ICD-10-CM/PCS codes will affect your bottom line 49

50 Payer Interactions Payers are busy planning how they will convert their adjudication logic to ICD-10. Plan to devote time and energy to ensure their translations are accurate and you re not adversely affected. Is the payer using the general equivalence mappings (GEMs)? What methodology is the payer using for situations where it is not possible to map to ICD-10-CM/PCS codes because the concepts don t exist in ICD-9-CM or vice-versa? 50

51 Budget Considerations for Key Areas How much will it cost? How to spread out the cost? 51

52 Budgetary Impact Operational Education, staffing Capital System/interface modifications Replacement/new systems MS-DRG reimbursement Potential effect of delays, decrease in coder productivity Lack of specificity in documentation Payer not ready to process Contingency planning 52

53 Provider Costs Personnel costs -- lost productivity, training Hardware and software changes Commercial vs. homegrown systems Vendor awareness Technical issues Contractual issues Costs Data conversion Decisions, decisions, decisions Cost/benefit analysis regarding database uses Convert? Cross-walk? Dual systems? 53

54 Looking at Possible Implementation and Costs 1 st- Year 2009 to 10/ nd Year 10/2010 to 10/ rd Year 10/2011 to 10/ th Year (GO-LIVE) 10/2012 to 10/ th Year 10/ /2014 Communication across system Int. Training Coders awareness Education Coders (Anatomy/Disease Process, etc.) Increased Education/Training Test knowledge Follow-up Education/Training Assess HIM Form ICD-10 (& 5010) Steering Committee and subgroups. Begin Hospital/organizational Impact Analysis Consulting (?) Consulting (?) IT & HIM System Testing & GO-LIVE Follow-up IT System corrections and changes - IT Assessment Begin IT Assessment tools for Programming, Upgrades, Servers, etc. IT Programming Changes Testing IT Programming Changes Practice & Test Coding & GO-LIVE IT Assessments/ & Audits Assess Other Depts. System inventory develop tool and begin process HIM Assessment and HIM Systems HIM Systems preparedness Test systems, grouper, etc. Impact to AR & Productivity HIM Assessments & Audits Impact to Productivity Est. Costs - Budget Budgeting Budgeting Budgeting External Users Readiness Resolve Issues with External Users Project Mgmt. Establish Key Leadership Project Mgmt. & Status Reports Payer Assessments to accept ICD- 10 Payer Readiness - testing Project Mgmt. & Status Reports 5% 15% 20% 50% 10% (+inflation) 54 54

55 Assessing and Planning for Staff Training Needs Accounting Ancillary departments Auditors Performance improvement Business office Claims analysts Clinicians Clinical department managers Compliance Patient access & registration Data analysts Infection control Medical staff Other HIM department employees Coders Information systems Billing Quality management Senior management Utilization review 55

56 Determine Need for Level of Understanding Source: AHA 56

57 Operational and Policy Changes As you make your plans for ICD-10- CM/PCS implementation also review existing operations and policies. There may be a need to change these - especially those dealing with coding and documentation instructions. 57

58 Useful Tools Commercial tools Translation tools Conversion tools Comparative assessment tools Compliance tools Free tools currently available General Equivalence Mappings (GEMs) Reimbursement mappings Designed to be used by all providers, payers, and data users Tools to assist in converting data Publicly available on the CMS & CDC websites 58

59 Other Tools Data analysis and decision review tools For example, a translation tool may be used to evaluate revised health plan contracts (decision support, revenue cycle, claims adjudication applications) and the translation tool may convert the vast majority of the codes. There are, however, a small number of codes that will still require manual evaluation and expert decision making about code list relationships to determine the most accurate mapping. The manual evaluation may require data analysis support and other tools that can look at the provider s patient population, past contracts, or other pertinent information. 59

60 ICD-9-CM and ICD-10-CM/PCS Mapping To facilitate the transition from ICD-9-CM to ICD-10-CM and ICD-10-PCS mapping between the two coding systems has been developed. Forward and backward mappings The General Equivalence Mappings (GEMs) are used to facilitate linking between the diagnosis codes in ICD-9-CM and the new ICD-10-CM and ICD-10-PCS code sets. The GEMs as well as the documentation and user s guide are available online at: OfPage OfPage 60

61 Bidirectional Mapping 61

62 ICD-9-CM and ICD-10-CM Mapping (cont.) Documentation and user s guide available online. User s guide provides information on structure and relationships contained in the mappings to facilitate correct usage. General interest: Section 1. More detailed information for professionals on mappings: Sections 1 and 2. Technical details of file format: Appendix A. Glossary of terms and conventions used in the mapping along with their accompanying definitions. Intended audience includes professionals working in health information, medical research, and informatics. 62

63 General Equivalence Mappings The GEMs are a comprehensive translation dictionary that can be used to accurately and effectively translate any ICD- 9-CM-based data, including data for: Tracking quality; Recording morbidity/mortality; Calculating reimbursement; or Converting any ICD-9-CM-based application to ICD-10- CM/PCS. The GEMs can be useful for projects to convert large data sets. They are not a substitute for learning how to use ICD-10-CM or for selecting ICD-10-CM/PCS codes. 63

64 Find and Replace Diagnosis Codes Source: CMS 5/19/09 Outreach call 64

65 Find and Replace Procedure Codes (cont.) Source: CMS 5/19/09 Outreach call 65

66 Why Do We Need the GEMs? Source: CMS 5/19/09 Outreach call 66

67 Why Do We Need the GEMs? (cont.) Source: CMS 5/19/09 Outreach call 67

68 Why Do We Need the GEMs? (cont.) Source: CMS 5/19/09 Outreach call 68

69 Why Do We Need the GEMs? (cont.) Source: CMS 5/19/09 Outreach call 69

70 Why Do We Need the GEMs? (cont.) Source: CMS 5/19/09 Outreach call 70

71 Why Do We Need the GEMs? (cont.) Source: CMS 5/19/09 Outreach call 71

72 ICD-10-CM/PCS MS-DRG Conversion CMS illustrated use of GEMs by developing ICD-10-CM/PCS version of MS-DRGs Conversion goals: Coded in ICD-9-CM or ICD-10-CM/PCS, the same patient is assigned to the same MS-DRG Clinically equivalent Definitions manual has familiar look and feel Over time DRGs could be refined to take advantage of additional specificity. Adoption of final ICD-10-CM/PCS version of MS-DRGs will be subject to rulemaking 72

73 ICD-10-CM/PCS MS-DRG Conversion (cont.) CMS used the General Equivalence Mappings (GEMs) to convert the MS-DRGs v26.0 to ICD-10-CM and ICD-10-PCS. Draft ICD-10-CM/PCS MS-DRG V26 Definitions Manual available in both text and HTML versions with condensed and full title formats: Project.asp#TopOfPage Detailed paper on converting Medicare Severity -Diagnosis Related Groups (MS-DRG) 26.0 to ICD-10-CM and ICD-10-PCS _Project.asp 73

74 Undertaking Similar Conversion Projects Basic Steps 1. Find the lists of ICD-9-CM codes in an application 2. Using the ICD-10-CM/PCS to ICD-9-CM GEMs in reverse lookup, find the translation of each ICD-9-CM code on a list 3. Using the translations found in the previous step, replace the ICD-9-CM based lists with lists of their ICD-10-CM/PCS code counterparts 4. Identify and resolve ICD-10-CM/PCS list conflicts in an application 5. Resolve list conflicts by choosing which list the ICD-10- CM/PCS code will be assigned to in the converted application 6. Identify general ICD-9-CM Procedure Codes that lead to inappropriate list assignment and tailor the list assignment accordingly 74

75 Undertaking Similar Conversion Projects Basic Steps (cont.) 7. Identify ICD-10-CM/PCS clusters that are necessary to fully replicate application logic 8. Perform final review of translated ICD-10-CM/PCS and ICD- 9-CM lists to identify any additional issues specific to the requirements of the application (e.g., the ICD-10-CM coronary atherosclerosis with angina codes are assigned to the appropriate with MCC/CC MS-DRG, even if there are no secondary diagnoses recorded) 9. Create an ICD-10-CM/PCS based copy of the application by replacing the ICD-9-CM lists in the application with the final translated ICD-10-CM/PCS lists Source: CMS 11/19/2009 Outreach call 75

76 Implementation Phases Implementation is divided into four phases: Phase 4 Phase 1 Organizing the Effort Phase 2 Planning and Impact Analysis Phase 3 Implementation Postimplementation Evaluation and Ongoing Efforts 76

77 Phase 3 Implementation This phase will involve executing, monitoring and overseeing the implementation schedule including: Outlining specific tasks and monitoring timeline for completion Reviewing budget requirements Developing metrics and monitoring progress Routine reporting of progress towards completion Implementing changes to system design and development Testing and validation of system changes Conducting the staff training 77

78 Phase 3 Implementation (cont.) Conducting physician training to address documentation gaps Monitoring current work flow volumes during the training period so backlogs are a minimum prior to go live. This will result in less time needed to maintain dual coding systems if old accounts are processed prior to implementation. 78

79 Execute Implementation Schedule Outline of the specific tasks to work on. Develop a master to-do list with specific timelines for completion. Identify responsible individuals Identify required tools Appoint project manager to ensure timing and interdependent milestones are flawless for on time implementation. The ICD-10-CM/PCS Steering Committee can assist with prioritization of tasks in collaboration with the affected departments. 79

80 Budget Requirements Consider multi-year budgeting and reassess financial support that is needed on an annual basis. Budgeting requirements should include consideration for the following areas: Training and education System changes Staffing for internal changes Updating of existing commercial software applications Purchasing replacement applications that will not be upgraded internally Data conversion Purchasing of electronic tools to assist in mapping or conversions 80

81 Metrics and Monitoring Progress Establish and monitor timelines and progress. Report findings to the ICD-10-CM/PCS Steering Committee on a monthly basis. Timelines may need to be adjusted as necessary. 81

82 Routine Reporting Routine reporting on implementation progress Integral component of the ICD-10-CM/PCS Steering Committee meetings. Report progress at organization-wide meetings Share among departments to ensure staff is apprised of progress. Manager and Department Involvement Specific tasks for individual departments will be completed by department managers and their staff. Whenever possible, activities should be incorporated into individual performance evaluations. 82

83 System Design Development Internal Testing Process Populate files used for testing purposes. Examine whether all of the format configuration changes have been properly modified. Validate whether these changes are properly recorded in the specific section of the HIPAA transaction standard. Test the accuracy of the changes by creating edits that specifically focus on these changes and how and when they should occur as information flows during the population of data into the files. 83

84 System Design Development Internal Validation Process Examine whether supporting documentation is gathered and is available to support the coded information. Monitor whether appropriate security methods are used, including log-in and tracking of individuals. Ensure that the appropriate communication protocols are being utilized during the transmission of data. 84

85 System Design Development External Testing Process Prepare for external testing by communicating with the health plans. Register with the health plans for testing. Establish dates for conducting testing Identify the various production scenarios that should be used during the testing period. 85

86 System Design Development External Validation Process Consider the results that should be achieved from a reimbursement perspective. Validate that the results should yield similar reimbursement results to that of using ICD-9-CM. Ensure health plans demonstrate that they are processing the claim using the ICD-10-CM/PCS information rather than relying on the GEMS to convert an ICD-10-CM/PCS code back to an ICD-9-CM and then process the claim for payment. Verify that the health plan has not redone their edit logic for reimbursement using ICD-10-CM/PCS as their basis to drive the reimbursement formula. This is important because the GEMS will not be maintained indefinitely and at some point in the near future the maintenance for these GEMS will cease. 86

87 System Design Development External Validation Process Ensure the production scenarios reflect real-world situations typical billing scenarios reflecting the most common type of claims. Generate reports on the results of the external testing process. Review the security and connectivity profiles as well as any additional resulting transaction that is generated from the submitted transaction. That includes the acknowledgment transaction as well as other transactions. For instance if the claim is submitted it then is processed using the ICD-10- CM/PCS codes, once processed it produces the remittance transaction to describe how reimbursement occurred. This end-to-end testing is needed to ensure appropriate changes have been made. 87

88 Staff Training Staff training should be carried out on the basis of the individual staff roles. Engage the physicians and work with them to improve physician documentation as well as responding to coding queries. Some physicians will find training helpful since they will need similar support for their own billing practices. Training can take different forms: Face-to-face training Audio seminars Webinars Quick coding tips could be provided to users leading up to the implementation date. 88

89 Timing of Training Basic training - During the initial phase All departments should receive awareness training to ensure there is awareness of the magnitude of the change. Advanced training During implementation phase Moderate level training should be conducted beginning with FY2010. Expert training In-depth detailed training of coding professionals should be conducted 6-9 months prior to go-live date. It s not too early for them to become familiar with ICD-10- CM/PCS concepts and guidelines in advance (such as starting with FY 2010) in order to ease the transition and allay any potential fears. It is estimated that expert training will require 40 hours for both diagnosis (2 days) and procedure (3 days) coding. 89

90 HIM Implementation Issues Team participation Awareness Assessment Increased education of the coding staff Anatomy Disease process Assess productivity and accounts receivable impact Plan Expansion of clinical data collected by coder Query process Clinical impact physician documentation Awareness and education Budgetary impact $$ 90

91 HIM ICD-10-CM/PCS Educational Plan Survey Coding staff Needs assessment Start with awareness education High level overview of ICD-10-CM/PCS and the implementation plan Tailor education to address varying needs New Coding Guidelines review and note the differences Targeted educational model for defined ICD-10-CM/PCS audience segments HIM and executive level leadership Educators and current students Experienced coders Managers of data Care providers, etc 91

92 Sample Coder Survey Decrease anxiety and gather feedback/input from coding staff Create a word document or use a web based survey tool ie. Zoomerang Survey Monkey Prepare your short list of questions QUESTIONS: Have you had some ICD-10 coding training before? Yes * No If yes, how many hours? I believe that I need additional anatomy, physiology and disease process education to better code with ICD-10: Yes No Don t Know With an implementation date of 10/10/2013, when would you like to receive actual coding training on ICD-10? 6 months prior to 10/1/ months prior to 10/1/ year prior to 10/1/ /2 years prior to 10/1/ years prior to 10/1/ years prior to 10/1/

93 Coder Survey (cont.) The industry states that experienced coders will need between 3-5 days of actual ICD-10 training. What is your opinion? How many days would you like to see provided? 2 days 3 days 4 days 5 days If more than 5 days, please comment: How do you prefer your educational programs to be presented? Video Audio In Person Seminar On-Line/ Webinar Combination 93

94 Coder Survey specific areas to focus The following is a list of the 25 MDCs (or body systems used with MS- DRGs). Please select the TOP 4 (only) that you feel you need additional education for diagnosis coding: Nervous (MDC 1) Ear/ Nose Throat (MDC 3) Respiratory (MDC 5) Hepatobil & Pancreas (MDC 7) Skin, Subq Tissue (MDC 9) Kidney/Urinary (MDC 11) Preg/Childbirth (MDC 13) Blood Dis/Immuno (MDC 16) Infect/ Parasitic (MDC 18) Alcohol/Drug Use (MDC 20) Burns (MDC 22) Trauma (MDC 24) Eye (MDC 2) Circulatory (MDC 4) Digestive (MDC 6) Musculoskel (MDC 8) Endocrine, Nutr, Metabol. (MDC 10) Male Reprod (MDC 12) Newborns (MDC 15) Myeloprolif/Neoplasms (MDC 17) Mental Dis. (MDC 19) Injury/Poison'g (MDC 21) Other Factors Infl Health Status (MDC 23) HIV (MDC 25) Results will feed your education 94

95 ICD-10-CM/PCS HIM Coding 8 Weeks Prior to Go-Live Weekly ICD-10-CM/PCS Coding information and tips Code records using ICD-10-CM/PCS, bring issues to Coding HIM Leadership Encoder shows dual coding system Field questions and concerns 95

96 Coding Impact at Go-Live Go-Live preparation Keeping discharged not final billed low Additional coding coverage and help may be needed Productivity impact and action to take Prepare and plan 96

97 ogether your ICD-10-CM/PCS Timeline 97

98 Implementation Phases Implementation is divided into four phases: Phase 4 Phase 1 Organizing the Effort Phase 2 Planning and Impact Analysis Phase 3 Implementation Postimplementation Evaluation and Ongoing Efforts 98

99 Phase 4 Post-implementation Evaluation and Ongoing Efforts Software Upgrades Evaluate software applications to ensure applications are working appropriately. Training If necessary, software upgrades or enhancements may be needed to correct any post implementation glitches or system errors. Conduct additional training based on findings of quality coding audits. Conduct physician training based on coding staff identification of high volume areas requiring additional physician queries. 99

100 Phase 4 Post-implementation Evaluation and Ongoing Efforts (cont.) Quality Improvements Conduct an audit of coded data post implementation to identify any potential coding errors or areas. Work with coding staff to determine the high volume areas requiring additional physician queries and develop physician documentation training accordingly. Comparative Assessments Review coded data to ensure that cases continue to be reimbursed at the same rate or grouped to the same MS-DRG they would have been with ICD-9-CM. Monitor reimbursements to avoid any unintended consequences of coding change. 100

101 Roles by Function Organizational ICD-10-CM/PCS Sponsor Assist in prioritizing ICD-10-CM/PCS activities over other organization-wide initiatives Ensure collaboration among departments Ensure budgeting issues are considered organizationwide Report progress of ICD-10-CM/PCS implementation to CEO and senior management Report progress to rest of senior management group 101

102 Roles by Function ICD-10-CM/PCS Steering Committee Lead Convene ICD-10-CM/PCS Steering Committee meetings Set ICD-10-CM/PCS Steering Committee meeting agendas Report progress to ICD-10-CM/PCS sponsor Keep track of implementation progress 102

103 Roles by Function HIM/Coding Participate as a member of ICD-10-CM/PCS Steering Committee Conduct ICD-10-CM/PCS awareness training throughout organization Complete information systems assessment inventory Identify training and budgeting issues for department Determine physician documentation areas requiring improvement Identify areas in coding and documentation requiring operational and policy changes Identify gaps in health record documentation 103

104 Roles by Function Billing Participate as a member of ICD-10-CM/PCS Steering Committee Attend ICD-10-CM/PCS awareness training sessions Complete information systems assessment inventory Identify training and budgeting issues for department Identify areas requiring operational and policy changes 104

105 Roles by Function Finance Participate as a member of ICD-10-CM/PCS Steering Committee Attend ICD-10-CM/PCS awareness training sessions Complete information systems assessment inventory Identify training and budgeting issues for department Identify areas requiring operational and policy changes Review current contractual agreements with health plans Analyze impact of ICD-10-CM/PCS on health plan agreements 105

106 Roles by Function Information Systems Participate as a member of ICD-10-CM/PCS Steering Committee Attend ICD-10-CM/PCS awareness training sessions Complete information systems assessment inventory Assess vendor readiness and support Review contractual agreements with software vendors Ensure ICD-10-CM/PCS implementation is considered in all future software application purchases Identify training and budgeting issues for department Identify areas requiring operational and policy changes 106

107 Roles by Function Quality Participate as a member of ICD-10-CM/PCS Steering Committee Attend ICD-10-CM/PCS awareness training sessions Complete information systems assessment inventory Identify training and budgeting issues for department Identify areas requiring operational and policy changes Identify areas where physician documentation improvement may be necessary Assess opportunities with availability of granular data for quality improvement 107

108 Roles by Function Medical Staff Liaison Participate as a member of ICD-10-CM/PCS Steering Committee Attend ICD-10-CM/PCS awareness training sessions Complete information systems assessment inventory Identify training and budgeting issues Participate in documentation improvement training 108

109 AHA Resources AHA ICD-10-CM/PCS Advisory Task Force ICD-10-CM/PCS audioseminar series ICD-10-CM/PCS CEO Briefing ICD-10-CM/PCS Member Regulatory Advisories ICD-10-CM/PCS Chapters in Faye Brown s ICD-9-CM Coding Handbook Coding Clinic for ICD-10-CM/PCS (in development) ICD-10-CM/PCS Coding Handbook (available 2011) AHA Central Office ICD-10-CM/PCS Resource Center 109

110 Other ICD-10-CM/PCS Resources Centers for Medicare & Medicaid Services (CMS) National Center for Health Statistics (NCHS), Centers for Disease Control and Prevention (CDC) American Health Information Management Association (AHIMA) 110

111 Questions? 111