Preparing Your Revenue Cycle for ICD-10. Carrie Aiken, CHC Compliance and Consulting Manager

Transcription

1 Preparing Your Revenue Cycle for ICD-10 Carrie Aiken, CHC Compliance and Consulting Manager Today s Presenter Carrie Aiken SVA Healthcare Services, LLC aikenc@sva.com 1

2 Objectives Seeing Revenue Cycle through ICD-10 Eyes Identifying ICD-10 Impacts and Influences Understanding EHR and Documentation Understanding Software Challenges for Review Know the Revenue Cycle 2

3 Three Phases Phase I - Patient Scheduling to Check In Phase II Patient Care/Service - Charge Capture to Accounts Receivable Resolution Phase I Patient Scheduling, Eligibility, Initial Registration Establish care needed and status - new, continuing or emerging problem Sets tone for appointment Helps prepare practitioner for developing chief complaint Allows staff to review payer policies Launch point for prior authorization 3

4 Phase I How are staff gathering and recording patient info to tie to the scheduled visit? Needed for payer research Needed for preliminary identification of diagnosis for prior authorization How are staff flagging and recording the patient status (new problem, etc)? Are there triggers for practitioners to see in the medical record? Phase I Referral and Prior Authorization Coordinate payer policy and supporting diagnosis information Prepare prior authorization with appropriate ICD-10 codes Submit and follow up on prior authorization Assimilation of information from referral source to transfer or transfer treatment 4

5 Phase I How are staff accessing policies now and are policy resources available? Are staff assigned to reviewing policies knowledgeable to interpret? Are staff assigned to prior authorizations familiar and skilled with ICD-10 codes? Can these staff discuss/defend with payers? Who is verifying that incoming referral diagnosis is consistent with background records? Phase I Other Considerations Incorporating diagnosis information with schedule Be mindful of HIPAA Developing a secondary handling/escalation process for certain diagnosis/problems Prior authorization Complex conditions Multidisciplinary needs medical, therapy, labs Connectivity and continuity between pre-visit activities and medical record 5

6 Phase I - Exercise Sample 10 patients from point of schedule to check in Highlight and discussions of diagnosis, condition, symptoms Check history, status, and past visits of patient Checkpoint Is there more information you need to gather? Is there more information that must be communicated to practitioner or patient? Phase II Patient visit Documentation Patient Info Forms Contributes patient context and background Chief Complaint Establishes medical necessity and foundation for ICD-10 diagnosis Problem lists starts record of diagnosis History Supports ICD-10 diagnosis and ancillary conditions - Capture of co-morbidities, chronic conditions, etc. 6

7 Phase II Patient visit Documentation (Con t) Diagnostic tests - Ordering diagnosis list compels medical necessity that contributes to medical decision making and complexity of visit Return visits review of past history and conditions Charge documents/route Slips tracking patient visit and marking diagnosis Macros/Templates Construction and content Phase II Who is reviewing patient info forms for critical information that may contribute to diagnosis? How are problem and ordering diagnosis lists structured? Frequently used diagnoses? Order of diagnoses? EHR vendor or FQHC controlled? 7

8 Phase II What are the most common diagnosis codes? Are diagnosis codes including appropriate extensions for ancillary conditions or factors that influence primary diagnosis? How is information from past visits being incorporated into subsequent visits? Be cautious with pull forward in EHR without review Ensure transition in stage of care is captured initial, acute, etc Phase II Are charge documents/route slips aligning with medical record? Are diagnoses aligned with each service provided? Is final diagnosis for visit consistent with prior authorization? Is diagnosis on AVS consistent with visit? Who is reviewing EHR templates/macros? 8

9 Phase II - Exercise Identify top diagnosis codes Select 10 encounters with those diagnosis codes Evaluate full encounter Checkpoint Can ICD-10 be successfully coded? Is all information present to support the diagnosis? Does EHR align with final billing? Charge Capture and Coding Verifying service against schedule - Harmonizing schedule with diagnosis/service Reviewing diagnosis selection Ensuring maximum specificity - Extending diagnosis to most complete level - Reviewing any unspecified codes Matching CPT modifiers to diagnosis - Laterality and anatomy 9

10 Who is verifying policy for coverage? Who is reconciling schedule against visits? - Is diagnosis is a factor in the review? Are communiques going back to practitioners? Are there flags in billing or EHR software to flag incomplete or unspecified diagnosis for review? Who is evaluating CPT vs diagnosis conflicts? What productivity accommodations are you considering? - Practice time - Instruction time 10

11 Claim Submission and Clearinghouse Application and management of edits - Source and review - FQHC and Clearinghouse programs Timely review and working of rejections - Identifying coding related issues Review edits associated with diagnosis codes. - Are these Clearinghouse, Billing Vendor or FQHC controlled? - Can you add payer specific or FQHC specific edits? Are coders involved in review of diagnosis related edits or rejections? 11

12 Payment Posting Electronic remittance and manual posting Posting of payments with adjustments including adjustment codes Identifying and recording all denials including zero-payment claims Posting of all message, reason and remark codes Review your software s ability to capture denial and adjustment codes Review your software s ability to capture message, reason, and remark codes Ensure remittance posting auto-posts this level of detail Verify staff understand EOB info Ensure manual posters record this detail 12

13 Does your reporting provide detail on denial, adjustment, message, reason and remark codes? Can you sort these codes by payer, practitioner, or CPT code? What is payment percentage before and after ICD-10? What is payment lag before and after ICD-10? Claim Adjustment Reason and Remittance Advice Remark Codes Communicate adjustments and reason why it was paid differently than the charge amount Almost 350 CARC codes Almost 1000 RARC codes At WPC-EDI 13

14 Denial Management and Appeals Staff need to know meaning of denials Staff need to know which denials need coding review Staff need to know processes for refiling claims and time limits Staff need to understand payer appeal processes and time limits Address any backlogs Can staff access medical record for supporting details? Identify coding related denials and benchmark before and after ICD-10 Trend denials before and after ICD-10 14

15 Do staff have access to payer policies to verify and review coverage under ICD-10 for appeal? How will you monitor appeal success? Insurance Follow-Up Contacting payers to follow up on denials or outstanding accounts receivable Determining what is still needed to resolve the claim Identifying what requires coding input 15

16 Follow pathway of claim to current status Compare charges for prior coverage Will payers accept additional info? Will portals and payer contacts have ICD- 10 info? Can staff navigate? Patient billing and collections Patients may have up front payments/forms for services Patients receive statements for services Patients may have payment plans Delinquent charges may go to collection agency 16

17 If upfront payment is based on diagnosis, who will be determining? Do your statements contain diagnosis information? Patients may have coverage changes due to ICD-10 that may not be planned Are payment plans determined by condition or diagnosis code? Can collection agency handle ICD-10 codes? Prepare for corrections volume 17

18 - Exercise Sample 10 charges with top diagnosis codes Confirm payment and reason/remark codes Review payer policies for code(s) Evaluate denials for top codes Checkpoint Do you need to expand the test? Do you have information you need from payers? Can staff interpret? Is process for resolution understood? What else could be left? Mental exhaustion? F

19 Ancillary Revenue Cycle Influences Systems Identify every diagnosis touch point or dependency in technology tools EHR, billing software, scheduling software Prioritize systems and sections Software sources for ICD-10 GEM dependency Evaluate proportion of automation Ancillary Revenue Cycle Influences Contracts, Payers and Payer Updates Review timelines and expectations in terms? Communicate with payers in advance What will payer demands be? Records Data Who is reviewing list serves, bulletins, and manual updates? 19

20 Ancillary Revenue Cycle Influences Vendors Software, outsource, QA, clearinghouse? What ICD-10 dependencies are present? Can you benefit from their prep activities? Can they provide extra support? What is scope of involvement? Ancillary Revenue Cycle Influences Fee Schedules and Diagnosis Lists Are there fees tied to certain diagnosis codes? Have you developed homegrown diagnosis codes for reporting, internal tracking? 20

21 Revenue Cycle Impacts Reimbursement/revenue stream Compliance Productivity Patient care and satisfaction Monitoring and financial analysis Final Thoughts Review your revenue cycle best practices Identify key participants in revenue cycle Review edits and tools within software, clearinghouse Network and learn Be vigilant with vendors Test your cycle against ICD-10 21

22 Q & A References CMS ICD-10 Implementation Planning mentationplanning.html AHIMA ICD-10 Planning AMA ICD-10 Examining the New Code Sets Revenue Cycle Implications. ma/bok1_ hcsp?ddocname=bok1_ Medscape ICD-10 Guide for Small and Medium Practices 22

23 Thank You 23