ICD 10 ESSENTIALS. Debbie Sarason Manager, Practice Enhancement and Quality Reporting

Transcription

1 ICD 10 ESSENTIALS Debbie Sarason Manager, Practice Enhancement and Quality Reporting October 29, 2015

2 CHANGING FROM 1CD 9 TO ICD 10 IN 2015 Rest of world has been using ICD 10 for decades World Health Organization (WHO) required US to adopt by 2011 (US delayed until 2015) Why the change? WHO is charged with looking at Population Health worldwide. WHO needs the continuity of the same international coding system to look at improvements or declines in health conditions, as well as outbreaks of infectious diseases, etc. In an effort to avoid more delays, US agreed to launch ICD 10 in 2015, but make Oct.2015 Sept a grace period ; no ICD 9 codes permitted, but some flexibility allowed on ICD 10 coding For October 1, 2015 to September 30, 2016: Need to code in ICD 10 exclusively, but if selected code in family of codes which are valid for the disease/injury, then CMS will accept them. For every one ICD 9 code, there are now five to twelve more specific ICD 10 codes (approximately)

3 HOW TO MANAGE ICD 10 CODING IN 2015 Example: Under the 2015 CMS rules, any one of a family of codes listed below for Back and Neck Pain would satisfy the requirement for payment for a patient presenting with back pain: The family is defined as those codes starting with M54... Unspecified or other codes will be accepted during the next year. M54.2 Cervicalgia M54.5 Low Back Pain M54.6 Pain in the thoracic spine M54.89 Other dorsalgia M54.9 Dorsalgia, unspecified Starting Oct. 1, 2016 when specificity is required, code descriptions ending in unspecified, like M54.9 Dorsalgia, unspecified, may trigger an audit Remember for Oct forward: Use the code that is most descriptive of the condition before selecting an unspecified code

4 LIST OF COMMON CODES FOR FAMILY MEDICINE 2015 The following conditions are commonly seen by Family Medicine. They be found on the CMS website under, Road to 10: The small physician Practice Route to ICD plan/phase 2 train/common codes family practice/ Codes listed on site are acceptable codes to describe the diseases/injuries below: Abdominal Pain Acute Respiratory Tract Infections Back and Neck Pain Chest Pain Diabetes Mellitus General Medicine Examination (under Encounters) Headache Hypertension Pain in Joint Pain in Limb Other forms of Heart Disease Urinary Tract Infections, Cystitis

5 OTHER COMMON CODES FOR FAMILY MEDICINE A closer look at Diabetes Codes: Type I codes start with code: E10. ( E10 family, with complications) and Type 2: E11. ( E11 Family, with complications) Many of the diabetes codes include complications such as renal insufficiency, diabetic foot ulcer, retinopathy, etc. According to AMA/CMS rules, any code in a family will be accepted for Oct Sept Insulin dependence is not listed in the same section as diabetes codes It is under the section, Factors influencing Health Status Long Term Drug Therapy The code for insulin dependence is: Z79.4 Long term (current use) of insulin can be used with any of the diabetes codes, and should follow, in sequence, the type of diabetes code. For example, E10.621, Z79.4, is Type 1 diabetes with diabetic foot ulcer, with insulin dependence. Regardless of which code you select, you can always add Z79.4 to describe insulin dependence. ** E10.9 Type 1 without complications; E11.9 Type 2 diabetes without complications *AMA. The Complete Official Draft Codebook ICD 10 CM. 2015, pg **AMA. The Complete Official Draft Codebook ICD 10 CM. 2015

6 TIPS FOR CODING IN ICD 10 If a disease is not diagnosed; code the symptoms only (i.e. waiting on test results) Now that you have test results, or have made a diagnosis, only code the diagnosis, not the symptoms Do not use a code unless you have the medical documentation to back it up if you have documentation then do not down code to avoid an audit Each practice should preform its own annual audit to be compliant with OIG guidelines include any new physicians, new coders, as well as established clinical personnel You may want the audit record review to be performed by an outside coding consulting firm Accurately reflect in E & M coding the amount of time spent with the patient, based on time and number of organ systems you examined. Don t code all of your encounters as an average of the time you spend with your patients, this could lead to an audit. (And you are missing out on revenues..) *AMA. The Complete Official Draft Codebook ICD 10 CM. 2015

7 CODERS, ENCODERS, CROSS WALKS, AND DO IT YOURSELF Depending on the size of the practice, the best solution to ensure that your codes are accurate is to hire a Certified ICD 10 Coder. Qualifications: Trained at an AHIMA* accredited school in a 1 year Coding Certificate or 2 year Health Information Technology program Has been certified through testing by either AHIMA or AAPC** for a CCS P designation, for physician practices. (Proficient in ICD 10, CPT, and HCPCS.) Assess if it is cost effective to have a coder on staff: Advertise for a coder who is ICD 10 certified, maybe you can start the person part time, or pay hourly until you can see if it is a good decision. *American Health Information Management Association **American Association of Professional Coders

8 CODERS AND HOW TO FIND ONE THAT FITS YOUR PRACTICE NEEDS Contact an agency who recruits coders for practices and hospitals. This includes part time, full time or contract coders Most coding schools are looking for physician practices that will provide internships for Medical Coding students who have completed their ICD 10, CPT, and HCPCS coding classes. Internships are often free for the practice and give valuable experience to the student! To set up a preceptorship, use link to the accredited coding schools in the US ask for the Medical Coding Internship Office, or Coding Director s Office *American Association of Professional Coders, October 21, 2015

9 CODERS, ENCODERS, CROSS WALKS, AND DO IT YOURSELF Encoders are software that interpret medical terminology to select the best code to describe the condition Coders may use encoder software to keep productivity high (it is faster than coding via code books). Use of encoders do not always guarantee that the correct code will be assigned. Physicians in small practices may also use encoders if they do not have a coder on staff Coding Cross walks: An example of a coding Crosswalk between ICD 9 and ICD 10 is listed below: There are many companies who make these cross walks which can be found online. None of them offer perfect ICD 10 coding. They are not long term substitutes for learning ICD 10, or having access to a certified coder *American Health Information Management Association **American Association of Professional Coders

10 WHAT IS NEW FOR 2016 IN ICD 10 The only thing constant is change Heraclitus October 2015 launches the newly revised 2016 ICD 10 codes. See link below for the 10 changes which are different from ICD * 10 cm coding guideline changes for 2016 what werethey thinking/ *American Association of Professional Coders, October 21, 2015

11 SITES FOR INFORMATION AND QUESTIONS ON ICD 10 CMS now has an ICD 10 Ombudsman who will triage inquiries and return messages within 3 days: send questions to: ICD10_Ombudsman@cms.hhs.gov Contact the (MAC Medicare Administrative Contractors) office for your area. List of MAC contact information is listed at: Statistics Data and Systems/Monitoring Programs/Medicare FFS Compliance Programs/Review Contractor Directory Interactive Map/ A list of all ICD 10 codes in tabular form is located at: ICD 10 CMand_GEMs.html CMS ICD 10 CM Tabular List of Diseases and Injuries: uploads/2015/09/2016 ICD 10 CM Tabular Listof Diseases and Injuries.pdf

12 MONITORING YOUR CHRONIC PATIENTS IN NON FACE TO FACE INTERACTIONS NEW CPT CODE Practices are seeing more and sicker patients, many physicians, NPs, and Physician Assistants are using telehealth means to monitor chronically ill patients wouldn t it be nice to be paid for this service? CMS now provides a code for Chronic Care Management Services. To qualify: Patient has to have 2 or more chronic conditions Chronic conditions put the patient at significant risk of exacerbation or death Comprehensive Care Plan has been established for patient/annual Physicals Performed CPT Chronic Care Management Service $42.00/patient/month CMS Medicare Learning Network, ICN: Chronic Care Management Services. and Education/Medicare Learning Network MLN/MLNProducts/Downloads/ChronicCareManagement.pdf Means of communication include: private phone calls, secure confidential e mails, or other telehealth means, as long as patient privacy is preserved American Association of Professional Coders, October 21, 2015

13 CODE CASE STUDY Physician protocol with hypertensive patients is to measure blood pressure when they come to office for check ups. If BP high, patient is required to take blood pressure readings at home 3x per day and report daily to physician office (usually to a Nurse Practitioner). If patient does not see a decrease in BP in one week, they return to the office for adjustment to their medication(s). Physician had not been billing for the Chronic Care Management Service, despite having qualified healthcare professionals time dedicated to these patient calls and recording of patient information. Once informed of the code, physician started billing for the services he (or qualified healthcare professional) provided to his chronically ill patients. American Association of Professional Coders, October 21, 2015 Modern Healthcare, October 28, 2015

14 QUALITY MARKERS 7.0 DATA ANALYTICS FOR MEETING PQRS REQUIREMENTS NEW VERSION Quality Markers can extract patient data from your EMR and format it so you can view how your practice population is performing vs the 16 PQRS quality markers. See videos and application at: Benefits to Your Practice: Avoid having to manually calculate your Physician Quality Reporting System (PQRS) data Avoid having to hire an expensive outside consulting group to do it for you Avoid non reporting penalties 2% this year if 2015 measures not reported by end of March 2016 Ensure you know where your patient population is relative to PQRS benchmarks i.e COPD, Diabetes, High BP patients (in order to improve, you have to know your starting point!) No surprises when it is time to report avoid non performance penalties; ensure your practice gets financial incentives they deserve No additional data needs to be entered into Quality Markers 7.0 Easily gives you daily snapshots of your patient populations by disease groups and how they are performing vs CMS benchmarks. For example, patients with diabetes: Two markers for reporting are Hemoglobin A1c, and Comprehensive Diabetes Care: Eye Exam. American Association of Professional Coders, October 21, data informs physician payment adjusters, positive or negative, for 2017

15 QUALITY MARKERS 7.0 DATA ANALYTICS FOR MEETING PQRS REQUIREMENTS NEW VERSION Meet CMS Quality Requirements for 2015 at least 50% of Medicare patients need to have 6/16 quality markers, representing 3 Quality System domains, into CMS by the end of March 2016 (for 2015 data). For 2016, CMS requires practices to declare their reporting markers/domains at the start of the year, 9 out of 16 are required for at least 50% of CMS patient s in the practice. Actual data is reported at the end of the year data informs physician payment adjusters, positive or negative, for QUALITY MARKERS 7.0 CAN KEEP YOU ON TRACK TO ACCESS, ANALYZE AND REPORT YOUR PATIENT OUTCOMES DATA TO CMS AND YOUR PAYERS. DON T LET DATA REQUIREMENTS NEGATIVELY AFFECT YOUR REVENUES!!! Quality Markers Premium Plus PQRS subscription automatically sends your PQRS data to CMS!

16 PQRS QUESTIONS AND ASSISTANCE Physicians and medical professionals may get the latest information about PQRS on the website, via the PQRS listserv and also on Twitter. Help Desk support is also available Monday Friday from 7:00 AM 7:00 PM CST at (TTY: ) or at: Qnetsupport@hcqis.org. For an Oct updated guide on PQRS implementation, see pdf on site below: initiatives patient assessmentinstruments/pqrs/downloads/2015_pqrs_implementationguide.pdf

17 QUESTIONS, QUESTIONS, QUESTIONS Thank you for joining this webinar Please contact me at: to order Quality Markers 7.0, provide feedback on this program or to suggest topics for future webinars. A document with links of those contained in this presentation was sent out earlier today. For a copy of the slides or the link document, please e mail debbies@acofp.org.