Lessons Learned from the ICD-10-CM Testing Front Lines

Transcription

1 Lessons Learned from the ICD-10-CM Testing Front Lines Cindy Cain, BSHA, CPC, CPC-H, CCS-P, CHC Senior Manager, Consulting March 17,2015

2 Objectives Identify the Challenges of ICD-10 Implementation Assess your organizations readiness for Implementing ICD-10 Define the Steps Necessary to Improve Clinical Documentation Share Lessons Learned from Early Adopters 2

3 Implementation Challenges 3

4 What About the Delay? U.S. Senate Passes H.R Enacting SGR Patch and Postponing ICD-10 Implementation on March 31, 2014 Most providers and vendors plan to stay the course Delay allows more time for: Testing Training Dual Coding Readiness 4

5 Overall Impact An INDUSTRY change Every PRODUCT (EMR/EHR & Practice Management) will be affected Every HOSPITAL & MEDICAL PRACTICE will experience this change 5

6 Polling Question #1 How far along are you in your transition to ICD-10? (Select one) % 2. 50% 3. 75% 4. Greater than 75% 6

7 Is Your Organization Ready? 7

8 ICD-10 will change everything Will you be ready? 8

9 ICD-10 will change everything Will you be ready? Office Managers New Policies and Procedures Updated Vendor & Payer Contracts Budget for Software Upgrades 9

10 ICD-10 will change everything Will you be ready? Coders & Billers Learning curve of new ICD-10 codes Payer reimbursement policy changes Use both code sets (ICD-9 & ICD-10) for a period of time 10

11 ICD-10 will change everything Will you be ready? Nursing and Clinical Staff More Specific Documentation Authorization policy changes Form changes 11

12 ICD-10 will change everything Will you be ready? Physicians and Providers More Specific Documentation 5x Code Set Increase 12

13 A Day in the Life. 13

14 Are You Prepared For This? Today Day 1 Day Day Day Day Claim file to payer Payer processes claim file Remit rec d; pmts & adjs posted $5, Pmts - $3, Adjs - $1, Pat $ Not processed $1, Post ICD-10 Implementation Follow-up done on $1, Day 1 Day Day Day Day Day 36 - Claim file to payer Payer processes claim file Remit rec d; pmts & adjs posted $5, Pmts - $2, Adjs - $ Pat $ Not processed $1, Follow-up done on $1,

15 Improving Clinical Documentation 15

16 Polling Question #2 Are your coders fully trained and prepared to code in ICD- 10? (Select one) 1. Yes 2. No 3. Don t Know 16

17 The ICD-10 Timeline JAN APR 2015 Evaluate current situation Set goals Train APR SEPT 2015 Develop workflow Verify all testing has been completed OCT Ongoing Manage all claims reports Conduct coding reviews 17

18 January April 2015 Timeline Immediate Action Items Evaluate current cash flow (age of account balances, billing lag time) Set goals and plan to correct/prevent recurring errors/issues and optimize cash flow Determine impact on quality initiatives (e.g., PQRS, EHR) Complete ICD-10 training at all levels Follow-up with electronic system vendors Other Questions to Consider Are upgrades completed or scheduled? Should 2014 reporting be completed prior to system upgrades? Is training on upgraded system necessary and if so, scheduled? Note payer news regarding ICD-10 claims testing requirements/opportunities Review insurance contracts for diagnosis-based payment impact Revise/develop/purchase internal coding resources (encounter forms, coding quick references) 18

19 April - September 2015 Timeline Action Items Develop and assign workflow and processes effective 10/01/14 Verify that all testing was successfully completed Consider direct-to-payer or other alternative claims submission resources (if testing has not been successful) Continue to monitor payer news regarding readiness and changes to payment policies 19

20 October 2015 Ongoing Timeline Action Items Monitor all claims acknowledgement (997) and acceptance/rejection (277) reports Promptly correct and resubmit all rejected/denied claims Evaluate post-implementation cash flow until claims filed with ICD- 10 are consistently paid Evaluate need for contingency activities (e.g., overtime, consultant, credit line) Conduct coding review for accuracy and compliance Monitor reimbursement accuracy and timeliness of payer per contract Continue to monitor payer news regarding claims adjudication issues and resolutions 20

21 ICD-10-CM Testing ICD-10 testing should be qualitative, not quantitative, in order to depict a validated end-to-end testing event, beginning with peer-reviewed clinical scenarios that establish a baseline for all downstream testing. There should be a standard methodology for coding in ICD-10, and standard and reusable test data between trading partners. ICD-10 testing must include all ICD-10 impacted HIPAA transaction sets such as the electronic claims transaction known as the

22 ICD-10-CM Testing There should be validation of mapping between providers and payers who are using General Equivalence Mappings (GEMs) translation processing. ICD-10 testing must include Medicare Part A, B, C, D and DME with the correct version of DRGs. The testing should validate health plan payment rules, pricing and adjudication when remediation is complete; providers will validate payment. The pilot should show common use of the EMR represented in various test data formats across all key industries. 22

23 Polling Question #3 Which do you think will impact your staff productivity the most? (Select one) 1. Increase in volume of codes 2. Requirement to dual code in both ICD-9 and ICD Inadequate documentation of medical records 4. Staff unclear of roles during implementation 5. Lack of certified staff 6. New technology systems 23

24 Lessons Learned 24

25 Lessons Learned Scope Provide a document that gives the detailed testing requirements and definitions up front for each phase of the pilot Define a smaller number of scenarios from participants in the beginning and then build on the starting point Provide all the medical record documentation that was used for coding in the initial case Define what should be provided for complete coding of a test case, with a deep understand the coding policies of the facility and the reasoning of the coding 25

26 Lessons Learned Schedule Ensure all participants complete their chart analysis prior to initiating the pilot Provide time estimates from the peer review process for coding test cases Facilitate an actual schedule session with everyone that will allow the creation of a time line for phase 2 Provide a trending report on the phase and outcomes of the phase to show which tasks are ahead of schedule, on time or behind schedule Include trending capability in the project schedule, and publish the schedule prior to each meeting. Create a de-identified repository for test cases and results to enable participants to review cases at any point in the process. Publish a test case template and tracking tool to ensure the integrity of all spreadsheets is maintained. Given the potential revenue cycle impact to provider facilities and the need to ensure proper patient care by health plans, it is imperative to execute a methodology that tests the patient care process until the claim is satisfactorily paid. 26

27 ICD-10 The Impact on Billing Identify your current systems which will need to migrate to ICD-10, such as clinical documentation, electronic health records, contracts and vendors, and reporting protocols. Contact your payers as ICD-10 may mean a modification of contracts, payment schedules, or reimbursement. Assess your facility to determine how the transition may disrupt or slow the billing process. ICD-10 implementation and readiness testing should be discussed with everyone in your billing chain to ensure a smooth transition. Test and report documentation and billing for accuracy. 27

28 ICD-10 The Impact on the Central Business Office Review all super bill s and charge tickets for ICD-10 accuracy Review compliance strategies in the CBO Review any AR charge editing software Determine the coder s responsibilities in the CBO Training for staff that will process charges 28

29 ICD-10 The Impact on the Central Business Office Claims Validation and Processing New edits based on new payer proprietary rules. On going builds of new edits increasing as payers refine adjudication criteria Changes as coding conventions for modifiers, injury codes, V codes, etc. may be replaced with more granular ICD 10-CM coding Claims edits must be flexible and able to be customized 29

30 Revenue Process Registration & Scheduling Point of Service Cash Collections Charge Capture & Entry Procedure & Diagnosis Coding Client Management 3 rd Party Payer Follow Up Patient Billing & Collections Medical Necessity & Authorization Call Center Insurance Eligibility Verification Patient Identity & Address Verification Claim Submission Payer Contract Management & Credentialing Reporting & Analysis Denials & Appeals Management Payment Posting Every part of the revenue cycle process will be affected with the ICD-10 transition.

31 Process Flow by Department Patient Access Hospital Documentation of Services Billing Receivables Management Customer Service Scheduling Care Delivery Charge Master Claims Editor Payment Posting Customer Inquiries Pre- Registration Case Management Transcription Bill Reconciliation Secondary Billing Issue Resolution Eligibility & Verification Utilization Management Coding/ CDMP Claims Submission Follow-Up Financial Counseling Discharge Planning Charge Capture Contractual Adjustments Appeals/ Denial Mgmt Registration Patient Discharge Late Charges Patient Statements Bad Debt/ Write-Offs/ Legal Collections Feedback 31

32 Top Reasons for Expected Decrease in Revenue Reason % Incomplete physician documentation 47% Payers will not be ready in time 15% Coding staff mistakes 12% Shift in DRGs (Diagnosis Related Groups) 11% Delays in submission of bills 7% Technology won t be ready in time 4% Other 4% Source: Health Leaders Survey 32

33 Closed Loop Denial Prevention Denied Claim/New Policy Closed Loop Denial Prevention New Rule Built Rule fires for all employees every time 33

34 Polling Question #4 Do you expect your revenue cycle to be negatively impacted by ICD- 10? (Select one) 1. Yes 2. No 3. Somewhat 4. Unsure 34

35 ICD-10: Overall Financial Impact Clinical Staff Who Issue Financial Impact Process of locating and entering ICD-10 information for outside labs, outside procedures, referrals or authorizations will take longer Clinical staff will not be able to process requests or set appointments as quickly, slowing the revenue for ancillary and referral sources Coders Training required to learn new ICD-10 coding structure Cost of training and time away from office (approximately hours of training, costing $2, and more) Coder Learning curve of ICD-10 coding Slow down of approximately 20% in coding productivity; coding less with fewer charges being billed on a daily basis; slow down in revenue 35

36 ICD-10: Overall Financial Impact Biller Provider Payer Issue Added time to work rejections and denials immediately following implementation date as carriers adjust to new coding structure also Will take longer to ensure progress note is specific enough for proper coding Testing of all Payers will all individual systems Financial Impact More time is taken to work claims as billers learn and adjust to carrier requirements; fewer claims being corrected and resubmitted on a daily basis; slow down in revenue Longer time spent doing documentation, resulting in fewer patients being seen during a normal office day; reducing the amount of revenue normally generated Some are expecting a 30% reduction in paid claims. Some are expecting a delay of days in delayed response times -What does this remind you of? 36

37 Coding Productivity ICD-9-CM (2013) Start ICD-10 (2014) ICD-10 ( ) Inpatient 4.62 min 2.15 min 3.75 min Day Surgery min 3.82 min 8.53 min Emergency min 6.49 min 8.83 min Source: AHIMA October 2014 newsletter Key Take-Away: You need to know the impact to your coders but you also need to get down to the impact by specialty. Make sure your coding team can share reports that highlight this info or work with an outside consultant who can walk you through this data. 37

38 Clinical Documentation Improvement Clinicians will need to improve documentation so diagnoses and procedures can be coded to the highest level of specificity. There are other reasons why clinical documentation improvement (CDI) is needed. "The medical record is the most important source of information within a healthcare organization. It is used not only for providing patient care but also for assessing the effectiveness and quality of that care, as well as for billing and reimbursement, research and to set healthcare policies as needed." 38

39 Clinical Documentation Improvement This breaks down to two major motivations for CDI: Patient care: Complete and accurate medical records are needed to ensure the patient gets the right treatment. Cash flow: Medical claims are rejected and down-coded because there is not enough documentation to support a diagnosis. 39

40 5 Key Steps to Improving Clinical Documentation 1. Assess documentation for ICD-10 readiness 2. Analyze the impact on claims 3. Implement early clinician education 4. Establish a concurrent documentation review program 5. Streamline clinical documentation workflow Key Take-Away: Documentation is key to success. All webinar attendees will receive the complete article on the Five Steps to Improve Clinical Documentation following this webinar. 40

41 Clinical Documentation Reminders In general, you will need to include details such as laterality and origin. For specific conditions, requirements will vary; some examples for common conditions in family medicine include: Asthma: intermittent, mild persistent, moderate persistent, severe persistent Fractures: Gustilo classification, type of fracture Seizures: General or focal, what type, intractability Pregnancy: Which trimester Poisoning or toxic effect: Which substance Ulcers: Which stage 41

42 Polling Question #5 As a healthcare leader, where is your main focus over the next eight months as you prepare for the transition to ICD-10 on October 1, 2015? (Select Two) 1. Hiring certified coders 2. Training existing coders 3. Selecting outsourcing vendor for coding services 4. Testing in ICD Educating physicians 6. Clinical documentation audits 7. Compliance planning 8. Technology upgrades 9. Payer readiness 10. Revenue implications 11. Staff productivity implication 42

43 The Effect On Specialties 43

44 Specialty-specific Impact Radiology Anesthesiology Emergency Department Pathology Clinical Laboratory Preparation and planning is key to the success of the implementation Sufficient education is a must Understand the limitations of working with the systems (ICD-9 and ICD-10) in tandem Learn from the experience of others 44

45 Specialty-specific Impact Radiology Referring Physician Plan Radiologists and their practice managers must work with referring physicians so they provide detailed medical necessity to translate into ICD- 10-CM based diagnoses. 1. Develop a plan to contact your high volume referring physicians and begin to work extensively with them to prepare for ICD-10-CM. 2. Referring physicians must supply radiologists with specific, detailed orders Failure of referring physicians to supply this information may cause delayed or lost reimbursement to the radiologist. 45

46 Specialty-specific Impact Radiology Example: Hip fracture, neck of femur, closed ICD-9-CM code: Fracture of neck of femur; unspecified part of neck of femur, closed ICD-10-CM code: S72.009A Fracture of unspecified part of neck of unspecified femur, initial encounter for closed fracture When coding fractures, the A in the ICD-10-CM code is the indicator of the episode of care with A meaning it is the initial encounter. With ICD-10-CM, it will also be necessary for the radiologist to document the encounter type. Current coding does not necessitate the inclusion of that information. 46

47 Specialty-specific Impact Anesthesiology The increased level of specificity and clinical detail Laterality Fracture Type Episode of care (Initial, Subsequent, Sequela) Definite need to capture information about the patient s condition that had not been previously documented 47

48 Specialty-specific Impact Emergency Department The Emergency Department is a pivotal role of a hospital s profitability. According to statistics from the California Healthcare Foundation, an Emergency Department generates approximately 20%-25% of a hospitals net profits, and is the source of almost half of all inpatient admissions. It will be important for the Emergency Department to have the ability to capture complete information without disrupting the workflow or patient care. For patients admitted to the hospital through the Emergency Department, coding professionals will need clinical documentation that clearly states possible & probably diagnoses rather than listing acute symptoms. Templates will require revisions. 48

49 Specialty-specific Impact Pathology There are a wide range of diagnoses that cause referring physicians to order laboratory tests. How well you document specificity for ICD-10-CM will determine whether or not you get paid. Capturing new information about the patient s condition and more detailed diagnosis information from referring physician orders will be a particular challenge as it is for the radiologist. 49

50 Specialty-specific Impact Clinical Laboratory Labs continue to be completely dependent on ordering physicians to provide accurate diagnosis codes on test orders a unique but not new dilemma Claims for lab tests must contain valid and specific diagnosis codes that explain the reason the tests were performed Labs already spend a tremendous amount of time working with physicians on the use of ICD-9-CM codes for limited coverage tests, and to this day still have a fairly high percentage of diagnoses that are not coded at the highest level of specificity. (AACC American Association for Clinical Chemistry) 50

51 Memorable Codes 51

52 Memorable Codes* W61.42, Struck by turkey, or W61.43, Pecked by turkey; S91.232, Puncture wound without foreign body of left great toe with damage to nail; R46.0, Very low level of personal hygiene; T71.233, Asphyxiation due to being trapped in a (discarded) refrigerator, assault; Y92.65, Oil rig as the place of occurrence of the external cause; T43.612, Poisoning by caffeine, intentional self-harm; and V04.09, Pedestrian on snow skis injured in collision with heavy transport vehicle or bus in nontraffic accident W5921XA Bitten or struck by a turtle-initial encounter * 52

53 Resources American Academy of Professional Coders: American Health Information Management Association: American Medical Association: Centers for Medicare & Medicaid Services: 53

54 Questions Contact Us at

55 Thank you 55