PREPARING FOR ICD-10 IDENTIFYING THE STEPS TO BE TAKEN AND THE TIMELINE MAY 2014

Transcription

1 PREPARING FOR ICD-10 IDENTIFYING THE STEPS TO BE TAKEN AND THE TIMELINE MAY 2014 Diane Taylor, BSN, RN Selman-Holman & Associates LLC, Senior Associate

2 Selman-Holman & Associates, LLC Diane Taylor, BSN, RN Home Health Insight Consulting, Education and Products CoDR Coding Done Right 606 N. Bell Ave. Denton, Texas phone; fax

3 Implementation DateChange: October 1, That s 1 year, 5 months from today!!

4 Code Freeze No new codes for ICD-9-CM No new codes for ICD-10-CM But does that mean no changes? ICD-10-CM changes to tabular and indices have been issued ICD-10-CM guideline updates A few new changes in tabular and index for October 1, 2014 First REAL update to ICD-10-CM codes will be October 1, 2016

5 What about ICD-11? AHIMA House of Delegates adopted a policy to evaluate ICD-11 as a potential alternative to replace ICD-9 It took the US eight years to adapt the WHO version of ICD-10 and create ICD-10-CM for use in this country Regardless of the benefits of ICD-11, the US would need a national version to allow for the annual updating required by Congress and US stakeholders. Assuming that the development timeline for a national version or clinical modification of ICD-11 could be cut in half down to four years, it would then take an additional two years to get through the HIPAA rulemaking process. As with ICD-10-CM/PCS, the industry would want at least a three year period for converting systems to ICD-11. Assuming that ICD-11 becomes available on schedule from WHO in 2016, then the earliest the U.S. could move to ICD-11 would be 2025, or 13 years from now.

6 Comparison 6 ICD-9-CM diagnosis codes ICD-1Ø-CM diagnosis codes Limited space for adding new codes Flexible for adding new codes Lacks detail Very specific Lacks laterality Has laterality Difficult to analyze data due to nonspecific codes Specificity improves coding accuracy and richness of data for analysis Codes do not adequately define diagnoses needed for medical research Detail improves the accuracy of data used for medical research Doesn t support interoperability with other countries Supports interoperability with other countries

7 Comparison 7 ICD-9-CM diagnosis codes ICD-1Ø-CM diagnosis codes 3-5 characters in length 3-7 characters in length First character is numeric or alpha (E or V) First character is alpha (all letters except U) Characters 2-5 are numeric Use of decimal required after 3 characters No placeholders Alpha characters are case sensitive Incomplete code titles Character 2 is numeric Characters 3-7 are alpha or numeric Use of decimal required after 3 characters Use of dummy place holder X Alpha characters are NOT case sensitive Complete code titles 14,315 diagnosis codes (Volumes 1,2) 69,Ø99 diagnosis codes (Volumes 1,2) 3,838 procedure codes (Volume 3) 71,957 procedure codes (Volume 3)

8 8 ICD-10-CM What are we waiting on?? 5010 already implemented OASIS C-1 changes finalized question on implementation date Case mix diagnoses finalized Grouper logic changes July 1, 2014 For hospice: HIS ready July 1, 2014 Testing and dual coding underway So what do we do with an extra year?

9 OPERATIONAL PREPARATION

10 ICD-10 is NOT just about CODING! Impact ALL healthcare entities across the care continuum including: hospitals, physicians, ambulatory care and all payer sources (Medicare, Medicaid, insurance) Impact entire agency Do not assume current processes are adequate and effective Know where your agency currently stands operationally ICD-10-CM is NOT just a clinical operational issue

11 Don t underestimate the impact of this transition Failure to be fully prepared for ICD-10 can result in the following: Increased claims rejections and denials Increased delays in processing authorization and reimbursement claims Improper claims payment Cash flow issues Coding backlogs Compliance issues Decisions based on inaccurate data

12 Cost of the transition to ICD-10 CMS expects the home health industry as a whole to have an overall transition cost at $16.58 million dollars You will need to determine the impact on your agency s budget in the following areas: Cost of training/education Updating forms/printing Consulting costs Staff time/loss of productivity Temp or contract staffing Data conversion Additional operational tools

13 Revise ICD-10 Timeline NOW NOW nd Quarter th Quarter st Quarter rd Quarter October 1, 2015 Preparation and Planning Update Evaluate Transition Team Revise Timelines Assessment Update Current Operations Assessment ICD-10 Impact Assessment and Analysis Identify Areas for Improvement/Modification Development Phase Develop Operational Solutions and Strategies Initial Training Implementation Phase Execute Operational Strategies and Solutions Testing Intense Training for Staff NEW ICD-10-CM Implementation Date!

14 Establish Realistic Timelines for the Transition Utilize time between now and January 1, 2015 to conduct a thorough agency assessment, identify operational challenges, develop and implement operational solutions and provide highlevel ICD-10-CM education You will not only be well prepared for ICD-10, but your agency will operate much more smoothly and effectively in the meantime!

15 GAP Analysis 15 What are current processes being done in each department/task? Determine where agency needs to be to be ready for ICD-10 Identify gaps - What needs to be done Establish a Transition Team that will develop an action plan.. Plan, Do, Check, Act

16 Transition Team Purpose Gather information and provide input through a multi-disciplinary team approach Oversee and drive all phases of the project Meet regularly with a specific to-do list Meetings should be purposeful and effective

17 Establish your ICD-10-CM Transition Team Depends on the size of your agency Choose people that others naturally follow (leaders) and have a positive attitude towards change All departments should be represented Consider outside vendors/consultants Identify a Program Chairman

18 Assessment Phase Q Q12013 Current Operations Assessment ICD-10-CM Impact Assessment & Analysis Identify Areas for Improvement and/or Modification This should be happening now!

19 Operations Assessment The importance of having strong, effective systems in place PRIOR to the implementation of ICD-10-CM cannot be overemphasized Any operational or clinical weaknesses or inefficiencies that currently exist within your agency will only be magnified during the transition and implementation of a change with the magnitude and scope of ICD-10-CM

20 What to do first. A thorough assessment of both internal and external processes, policies, people and technologies Establish your agency s current level of efficiency and compliance Some processes will need little or no adjustments Some processes will need to undergo major modifications

21 Be prepared! The importance of having strong, effective systems in place PRIOR to the implementation of ICD-10-CM cannot be overemphasized Any operational or clinical weaknesses or inefficiencies that currently exist within your agency will only be magnified during the transition and implementation of a change with the magnitude and scope of ICD-10-CM

22 What to do first. A thorough assessment of both internal and external processes, policies, people and technologies Establish your agency s current level of efficiency and compliance Some processes will need little or no adjustments Some processes will need to undergo major modifications

23 Everyone will be affected: Intake Process Billing/accounting Quality Assurance Clinical processes Data entry/administrative support Leadership/management Coders

24 Systems that will be affected: IT systems Agency management software Other outside vendors (billing services, clearinghouses) Payers (Medicare, Medicaid, private insurance)

25 Referral Intake Process Who is affected? Nurses and admin staff that process referrals received from outside sources (hospitals, SNF s, rehab facilities, physicians) What is the potential impact? Inaccurate coding and information from referral source Preliminary coding Data entry of referral information

26 Intake process- Operational Analysis Does your agency have an effective Intake Process? Is it documented as part of a Process Manual? Is it updated as the process, systems or people change? How are referrals received? Fax, ? What criteria are used to evaluate appropriateness of a referral for evaluation? How is payer information verified and documented? Once the referral is accepted, what process exists to staff the evaluation? How is communication with clinician, referral source and patient handled? Who is responsible?

27 Clinical Case Management Operational Analysis What clinical processes does your agency currently have in place? Are they up to date? Do they work?? What method of training and orientation exists for new clinicians? Does your agency utilize standardized care pathways and patient teaching materials? How is your clinical department structured? What care model do you utilize? (office based Case Management, Field Case Managers, etc.) OASIS-C and coding training a key component of training, education and evaluation for clinicians?

28 Billing and Accounting Who is affected? Staff responsible for: Pre billing audits Claims reviews Collections Appeals and denials Insurance verification and authorizations Potential Impact? Temporary increase in coding errors resulting in rejected claims. CMS estimates 10% increase Need to be prepared to handle increased rejections, denials, incorrectly submitted claims, MAC issues and cash flow issues

29 Billing/Accounting Process Operational Analysis Does your agency have a documented, effective claims/billing/collections process? Do you conduct a pre-billing audit? What does that audit consist of? Who is responsible? How are audit findings communicated to billers? Who is responsible for handling identified problems and resolving them? How are claims rejections handled and by whom? What is your process for working A/R and ensuring payments are accurate and current? What is your average days to RAP? To Final Claim?

30 Clinical Case Management Process Who is affected? Nurses and Therapists who provide direct patient care and/or case management Potential impact? Accurate completion of OASIS-C and narrative assessment Diagnosis based 485/Plan of Care development

31 Clinical Case Management Operational Analysis What clinical processes does your agency currently have in place? Are they up to date? What method of training and orientation exists for new clinicians? Does your agency utilize standardized care pathways and patient teaching materials? How is your clinical department structured? What care model do you utilize? (office based Case Management, Field Case Managers, etc.) OASIS-C and coding training a key component of training and education for clinicians?

32 Quality Assurance Process Operational Analysis Does your agency have a documented, effective QA process? What is it comprised of? Who is responsible? Is there a Utilization/Review (UR) piece? What process exists to ensure appropriate and accurate completion of documentation, including OASIS-C and coding? Who is responsible for ensuring compliance with rules and regulations, keeping up with changes? What types of outcomes reports are run routinely? Who is responsible? How used?

33 Agency Leadership/Management Clinical managers may be affected by changes in documentation requirements, forms, processes, 485/POC development, OASIS-C changes as well as the actual ICD-10 coding changes CFO will need to budget and monitor ICD-10 conversion costs from software upgrades and training to form revisions, as well as model for cash flow disruptions. May need to consider securing lines of credit Administrators need to consider staffing needs, productivity impacts, and contingency plans like outsourcing partnerships. Strong project management will be key given all the moving parts necessary to make this transition successful

34 Leadership/Management Operational Analysis Do the managers in your agency have authority to identify problems AND make changes within their departments? Does your agency have a working organization chart clearly defining who is responsible for what? Do your non-clinical managers have a basic understanding of the home health industry? What kind of training and education process exists for Managers? Are they provided with the tools needed to be successful in their management role?

35 Agency Leadership/Management Clinical managers may be affected by changes in documentation requirements, forms, processes, 485/POC development, OASIS-C1 changes as well as the actual ICD-10 coding changes CFO will need to budget and monitor ICD-10 conversion costs from software upgrades and training to form revisions, as well as model for cash flow disruptions. May need to consider securing lines of credit Administrators need to consider staffing needs, productivity impacts, and contingency plans like outsourcing partnerships. Strong project management will be key given all the moving parts necessary to make this transition successful

36 Coding Operational Analysis Is accurate and appropriate ICD coding considered a high priority at your agency? If not, then why not? Who is responsible for coding in your agency and are they qualified? Do you employ or contract with certified and/or experienced coding specialists? Is coding just one more task added on to very busy field RNs/Case Managers?

37 Coding Operational Analysis How confident are you that the coding in your agency is accurate and appropriate? What QA and review processes take place prior to OASIS-C and claims submission? What is the quality and quantity of the training your agency provides to staff responsible for this critical function? Is there a coding piece in orientation process? How does your average HHRG compare to those agencies that utilize certified coders? Are you leaving revenue on the table through inaccurate coding practices?

38 Benefits of certified coders and coding specialists Purpose of home health agencies is to provide appropriate, quality patient care to those we serve. There is an expectation that agency field staff will provide the highest level of quality care Is it realistic to also expect those same clinicians to have abilities as a coding specialist? Utilizing certified coding specialists will improve your coding accuracy and compliance and likely your reimbursement as well It will also afford your clinicians more time and resources to care for their patients

39 Impact Assessment & Analysis Documentation changes Reimbursement Structures Systems and vendor contracts Business practices Testing

40 Documentation Changes Increased specificity of ICD-10 codes, compared to ICD-9 codes, will require more detailed and comprehensive descriptions of patient clinical conditions Are your clinicians able to provide this more specific assessment documentation??

41 41 GAP Analysis on Clinical Documentation How does the documentation compare between referrals from hospital and referrals from community? Will your intake person need to know more about A&P and coding to be able to query the referral source better? Does your referral source know what you need? Do they provide the info? Do your intake and assessment forms have the right prompters and cues to encourage more detailed documentation?

42 42 GAP Analysis on Clinical Documentation How often do you have to go back to the clinician for more information before you can complete diagnosis coding? How often do you have to add diagnoses the clinician missed? How often do you have to delete diagnoses that are not documented in the medical record or verified with the physician? How often do you have to change the sequencing of diagnoses? How often are OASIS items answered incorrectly? What are the top 5 items that clinicians assess/answer wrong?

43 Reimbursement Structures Coordinate with payers on contract negotiations and new policies that reflect the expanded ICD-10 code set Consider physician work flow and patient volume changes Revise forms, documents, encounter forms to reflect ICD-10 codes Evaluate process for ordering/reporting lab/diagnostic services to health plans

44 Systems and Vendor Contracts Can vendors meet ICD-10 needs Check how and when your vendors plan to update your existing systems Review current and new vendor contracts for ICD-10 capabilities Work with vendors to draft schedule for needed tasks

45 Business Practices How will ICD-10 codes affect processes for referrals, patient intake, authorizations, pre-certifications, physician orders, F2F encounter documentation, patient visits, data entry, billing, tracking accounts receivable, development of ADR s

46 Testing Work with vendors to determine the amount of time needed for testing of ICD-10 implementation processes and schedule accordingly Have they revised testing dates?

47 Don t put it off This is just the beginning of the dialog for the upcoming ICD-10-CM transition. It is important that you stay abreast of what is happening, as this change will have a tremendous impact on your agency. Delaying putting this transition on your radar will only contribute to the challenges that will eventually need to be faced.

48 Just do it! ~ "The best way to get something done is to begin." ~

49 OASIS-C Revisions OASIS-C1 is ready now however, there is uncertainty what to do with the coding section Modifications: To accommodate ICD-10 Deletion of some items in Transfer, DC Changes to some items to decrease confusion One suggestion is to implement OASIS C1, but that requires OMB approval..so we ll have to wait and see

50 October 1, 2015 Clinical staff with assessment skills, A&P knowledge, documentation skills and familiar with OASIS-C changes Clinical managers with necessary intake information, scheduling support, case management skills Coding staff competent in ICD-10

51 October 1, 2015 Smooth, timely work flow processes Data entry, billing and accounting familiar and competent with process Vendors and payers integrated into agency systems All agency services initiated on/after Oct. 1 coded correctly using ICD-10

52 ICD-10 Resources AHIMA: ICD-10 Implementation Toolkits Clinical Documentation Improvement Toolkit ICD-10 Readiness Assessment and Prioritization Tool ICD-10 Vendor questionnaire ICD-10 Transition Planning and Preparation Check Lists (Phases 1-4) Training and Education

53 Remember - When the course is rough, still steer Jimmy Buffett The Captain and the Kid

54 Questions?? 54