The Road to ICD-10 Transition Success

Transcription

1 The Road to ICD-10 Transition Success MEDIWARE Mediware.com

2 Table of Contents Executive Summary 3 Business Challenges Associated with the ICD-10-CM Transition 4 Preparing to Address the Challenges 5 Managing the Challenges Effectively 5 THE CHALLENGE Software tools are only part of the answer to ICD-10. Your transition may also require education, staff training, process evaluation and provider communication. Educating Staff 6 Examples 7 Developing Operational Solutions 8 Software Options and Tools to Navigate the Transition 8 Successful ICD-10-CM and PCS Code Implementation Benefits 9 References 10 Executive Summary In today s homecare market, the ability to be agile with constantly changing billing and regulatory requirements is essential. Having a solid and experienced software partner becomes key in navigating these changes successfully and without impact to your overall cash flow. Business Challenges Associated with the ICD-10- CM Transition The challenges providers will face are three-fold. First, operational changes required to contend with ICD-10-CM transition and working through the review of clinical information and diagnosis recoding will be disruptive to day to day operations. Software tools can help you leverage these changes and minimize their disruption to your operations. However, providers must recognize that the utilization of these tools is only one piece in navigating these changes. ICD-10-CM transition potentially requires education, staff training, process evaluation and software features implementation. We will explore all of these challenges that providers will face in 2014 during this transition. Second, the need to add follow up time and standard procedures with referral sources and physicians may extend the initial referral process in the early days of the transition and until all providers get up to speed with the changes and utilization of the new codes. Your ICD-10 transition extends outside your business. You will need to work with referral sources and physicians until all your providers are up to speed. Third, training and education on the codes, as well as, software tools and potential implementation of new features within provider s software solutions will be necessary. REACHING OUT 1

3 Preparing to Address the Challenges Software tools and implementation of features to allow for standardized identification of ICD-10-CM codes, using the GEMs (Generic Equivalence Mappings), will be essential in making this an efficient transition for any organization. Proper reimbursement is typically dependent upon proper diagnosis coding, so the impact will be great if the transition is not managed properly. Furthermore, the solution, much like the challenges presented to providers regarding this transition, should address the following: Staff training on new coding standards and any core practice management software changes inherent in these changes. Planning for the recoding of existing data, including the implementation of software upgrades and training on features available to assist, as well as, the actual task of recoding all of your existing data. Operational process modifications, if any, to accommodate the transition in the short term and then support proper coding in the long term. The opportunity to engage an individual in your organization as a project leader or manager, might be something to consider in a project of this size. Managing the Challenges Effectively Educating Staff Education of key staff will be essential in two ways. They will need to learn the basics of the ICD-9 to ICD-10-CM transition, in addition to the changes in the software solutions they utilize to accommodate those changes. As of October 1, 2014, providers will be required to use ICD-10-CM rather than ICD-9 codes on all HIPAA transactions including: PHEW! Software companies were required to implement the ICD-10 format in 2012, so your vendor solution should be fully prepared. Authorizations Eligibility Claims The new electronic formats (x and NCPDP D.0) allow you to report either ICD-9 or ICD-10-CM codes. The good news is that the requirements of software vendors to implement these formats in 2012 ensures that providers are already prepared to submit properly formatted claim files, once the relative software applications allow for ICD- 10-CM coding. OPPORTUNITY See it as an opportunity to engage the right person in your organization as a project leader or manager. 2

4 A related question has been raised in the industry regarding whether ICD-10-CM codes will be required on electronic prescriptions. If the resulting claim submitted for that prescription to a reimbursement entity requires a diagnosis code for processing and/or a diagnosis code would have been required on a paper prescription, then an ICD-10-CM code would need to be submitted on the electronic prescription as well. (NCPDP, n.d.) The new format for ICD-10-CM codes is as follows: 3 to 7 digits Digit 1 = alpha Digit 2 = numeric; and Digits 3 7 are alpha or numeric (alpha are not case sensitive) Some, but not all contain decimal points Examples Examples of ICD-10-CM codes would be A69.21 = Meningitis due to Lyme disease O47K04Z = Angioplasty (dilation of the right femoral artery) The new coding supports the identification of the disease, etiology, body part, severity and includes the 7th digit placeholder for additional specificity if required. This new coding approach provides much more specific information, unlike ICD-9. There are 3,824 ICD-9-PCS codes. These will be replaced with 72,589 ICD-10-PCS codes a 19-fold increase! ICD-9-CM TO ICD-10-CM There are 14,025 ICD-9-CM codes today, transitioning to 68,069 ICD-10-CM codes. There are 3,824 ICD-9-PCS codes today and 72,589 ICD- 10-PCS codes. Obviously there is not a one-to-one match in all cases, when recoding ICD-9-CM to ICD-10-CM. That s why it s essential to understand the tools provided in your software applications to recode existing data. In addition, it will not be an exact conversion of ICD-9-CM to ICD-10-CM within those applications. Some form of human intervention will be required to make decisions when there is a many to one match or a collapse of ICD-9-CM to ICD-10-CM codes possible. Providers need to ensure that they are prepared with tools, training and information for their staff to educate them on these changes and so that they are prepared to make the appropriate decisions in recoding existing data. There are many online seminars, industry related training sessions, and other resource available via the internet. Simply search for ICD-10 education tools in your favorite browser. Some websites to consider: FACT

5 Developing Operational Solutions To prepare for these changes, the following operationally focused steps might be considered based on AMA recommendations and modified for use in a Homecare provider environment (AMA, 2012): Step 1 Impact Analysis Review information about the ICD-10 code set in order to gain a basic understanding of the changes from ICD-9 to ICD-10. This understanding will be needed in order to conduct an impact analysis and determine how the move to ICD-10 will affect your business practices and systems. You will also need to complete an inventory of all your systems, electronic and manual, that use the ICD-9 codes. These same systems will need to be upgraded to ICD-10. Step 2 Contact your Vendors Contact your vendors for specific details on the installation of the ICD-10 upgrades to your systems, including dates and any costs. Be sure to ask your vendor if they will maintain updates to the ICD-9 and ICD-10 code sets during the transition period and if they will be providing any crosswalk tools between the two code sets. THE HUMAN TOUCH Some form of human intervention will be required to make decisions when there is a many to one match or a collapse of ICD-9-CM to ICD-10-CM codes possible. Step 3 Contact your Payers, Billing Service and Clearinghouse Contact your clearinghouses and/or billing service, if you use either, and payers for preliminary information on when they expect their ICD-10 upgrades will be completed and when they will be ready to begin testing transactions using the ICD-10 codes. You will want to contact them again when you have a date for the installation of your system upgrades. You also should to talk to your payers about any possible contract negotiations that may need to be done as a result of moving to the ICD-10 code set. Be sure to ask about any changes they may be making to their review, auditing, coverage, and medical policies and how the changes will impact coverage decisions and reporting requirements. Step 4 Installation of Vendor Upgrades Undergo installation of upgrades from your vendor. Keep in mind that the timing of the system upgrades will be dependent on your vendor s readiness, both with respect to product development and scheduling. Other systems not related to your administrative transaction systems, such as quality or public health reporting, will need to have any necessary upgrades for ICD-10 completed as well. Step 5 Internal Testing Once the upgrades are completed, you will need to conduct internal testing of your systems to ensure you can generate necessary transactions with the ICD-10 codes. Allow extra time to resolve any issues that may arise and work with your vendor to address these. 4

6 Step 6 Update Internal Processes Any internal processes used to support coding need to be updated, such as superbills, encounter forms, quality data collection forms, public health data collection forms, etc. Take this time to review clinical documentation to ensure it captures the necessary details of the patient s diagnosis. Practices may want to look at the most common diagnoses reported in the practice. Step 7 Conduct Staff Training Coding staff will need to receive training on the ICD-10 code set prior to the compliance date. You will want to determine the best time to have staff trained so they are well prepared when the implementation date arrives. You may also need to consider staggering staff training to prevent down time in the practice. Coding staff may wish to practice internally using the ICD-10 codes on sample claims, such as current claims, prior to the compliance date. Clinical staff must also receive training on ICD-10, although it does not need to be at the same detail as training for the coders. Software Options and Tools to Navigate the Transition Software solutions will most likely navigate the transition in the following ways: In either case, the utilities or tools that a software vendor will provide will need to be executed by staff, and then decisions will need to be made when an exact match is not possible. Either many to one ICD-9-CM to ICD-10-CM or vice versa. How your software vendor will approach the ability to manage this recoding is essential to understand and then how these codes will exist in your current software solutions and be presented is also important for continued use of your applications and staff training. Be sure to reach out to your vendors to understand their development approach, sooner than later. SOFTWARE SOLUTIONS APPROACH PROS CONS Convert ICD-9-CM codes No requirement for Dual There may be some to ICD-10CM codes going Maintenance by the user inconsistency when billing forward ICD-9-CM codes Convert ICD-9-CM codes to Bill using either ICD-9-CM Must maintain both code ICD-10-CM codes and allow or ICD-10-CM codes sets for a period of time both to co-exist for each No loss of integrity via (however your software patient s records backward mapping solution should help) 5

7 Successful ICD-10-CM and PCS Code Implementation Benefits To summarize some of the key benefits per CMS regarding the implementation of ICD-10-CM and ICD-10-PCS, according to the Centers for Medicare and Medicaid Services (CMS, 2013): ICD-10-CM codes have much greater clinical detail and specificity than ICD-9-CM codes ICD-10-CM codes are more consistent with current clinical practice ICD-10-CM codes provide a much better data set needed for measurement, setting policy, etc. Some direct benefits to the home health provider who is adequately prepared for this transition, include the hope that once the transition is complete, simpler coding will provide for improved and more specific tracking of outcome data relative to the provision of homecare services. More accurate payment processing by reimbursable sources and fewer rejected claims will be experienced, based on more specific coding of diagnosis and medical necessity information. Finally, a reduction in the need for additional attachments to explain a patient condition will result in more-timely processing of claims. References AMA. (2012, September 12). Retrieved from AMA: icd10-timeline-fact-sheet.pdf CMS. (2013, April). Retrieved from CMS: ICD-10QuickRefer.pdf NCPDP. (n.d.). Retrieved from Mediware Information Systems, Inc West 79th St., Lenexa, KS Mediware