Celebrating ICD-10: A New Tradition of Codes.

Transcription

1 Celebrating ICD-10: A New Tradition of Codes. Delayed. Now What? Stop training entirely? Continue training as originally planned? Alter the course of training? Important Dates January 16, 2009 February 16, 2012 April 24, 2012 October 1, 2013 October 1, 2014 March 31, 2014 October 1, 2015 What is ICD-10? International Classification of Diseases Implemented by World Health Organization in 1993 to replace outdated ICD-9 developed in the 1970 s ICD-10-CM includes U. S. clinical modifications ICD-10-PCS for procedural coding system will only be used in inpatient setting in the U.S. What Are Codes Used For? Calculation of payment Determination of coverage Compilation of statistics Assessment of quality Risk adjustment Patient outcomes Be Prepared Nearly every aspect of your agency will be impacted by the transition to ICD-10. Failure to be fully prepared may result in: Increased claims rejections & denials Increased delay in processing authorizations & payment of claims Improper claims payment Cash flow problems Compliance issues Decisions made on inaccurate data All Rights Reserved. Copy with permission only. 1

2 Cost of Transition CMS expected the home health industry to have an overall transition cost of $16.58 million dollars, based on the initial. (Even more now with the delay.) Agencies need to determine the impact on their budget in these areas: Cost of training/education Updating software/hardware Updating forms/printing Consulting costs Staff time/loss of productivity Temporary or contract staffing Data conversion Additional operational tools/resources Impact on Coding System Agency management/leadership Perfect time to review decision on who codes for you Clinical managers may need to modify clinical documentation, forms & processes as well as coding & OASIS tools. They may also be responsible for training & competency assessment. Billing managers need to consider claims processing system changes, rules for cases that ll span the implementation date, payer readiness & testing, and HHRG revisions. Health information managers may need to reformat agency reports, both clinical & financial, and create a structure to trend ICD-10 data. CFOs will need to budget for and monitor conversion costs software upgrades, training, forms and prepare for cash flow disruptions. Administrators need to consider staffing needs, productivity impacts, contingency planning (e.g., outsourcing) and transition point people. Intake process Nursing & administrative staff that process referrals from hospitals, physicians, etc., who will be facing their own implementation challenges, may have a problem getting precise documentation. Intake & referral forms may need to be modified. Billing/accounting process Staff responsible for prebilling audits, claims review, claims submission, collections, appeals and denials, insurance verification and authorizations will need to be prepared to handle denials, incorrectly submitted claims, RHHI issues, and cash flow issues, due to the expected increase in coding errors resulting in rejected claims. Medicare expects a spike in rejected claims 3-6 months following implementation of the new code set, peaking at 10% of all claims. All Rights Reserved. Copy with permission only. 2

3 Quality assurance process Nurses & other clinicians that perform QA, chart audits, quarterly reports, tracking & trending, OASIS & coding review & clinical compliance will find challenges with specificity of documentation in supporting diagnoses coded and tracking & trending related to a particular diagnosis e.g., tracking of CHF over 2 years. Documents & processes may require updating. Clinical case management process Nurses & therapists, especially those who are responsible for collecting OASIS data, will be required to produce more thorough, accurate, & detailed clinical documentation. In order to determine the significance of the impact these changes will have, a focused review and analysis of current documentation trends, policies & procedures, systems, training, and forms is warranted. IT systems Staff, or contracted staff, that provides IT support will be greatly impacted. Software systems will need to be managed, & additional training regarding software & processes will be needed. Software vendors Agency compliance for claims submission, documentation, and accurate coding hinges on the software being in compliance! Updating codes & upcoming OASIS changes will be required. Billing & clinical components will also be affected. Why Change? No room for expansion in ICD-9 Most industrialized countries have been using ICD-10 for 20+ years ICD-9 lacks specificity and detail for diagnoses reporting laterality combination codes sequelae ICD-9-CM has been in use since 1979, and no longer reflects advances in medical treatment All Rights Reserved. Copy with permission only. 3

4 Differences ICD-9 ICD-10 Number of Codes Approximately 15,000 Approximately 70,000 Composi on of Codes Mostly numeric but contains some V and E codes. Codes can be 3-5 characters All codes will contain both alpha and numeric codes Codes can be 3-7 characters Chapters Groupings By injury type By anatomical site Comparison ICD-9-CM (438.21) 3-5 characters 1st character is numeric or alpha 2nd 5th characters numeric At least 3 characters Decimal after 3rd character ICD-10-CM (I69.951) 3-7 characters 1st character is alpha 2nd character numeric 3rd 7th characters alpha or numeric Use of placeholder x Alpha characters are not case-sensitive Structural Differences ICD-9-CM ICD-10-CM COPD 496 J44.9 Primary DM E11 Insulin use V58.67 Z79.4 ASA OD (accidental) E850.3 T CHF NOS I50.9 Femur fx S72.009B Pressure ulcer of R heel, stage II & L Obstructed labor breech presentation 763.x O64.1xx ICD-10-CM Format x x x. x x x x CATEGORY ETIOLOGY, ANATOMIC SITE, SEVERITY EXTENSION All Rights Reserved. Copy with permission only. 4

5 Improvements Added info relevant to ambulatory and managed care Expanded injury codes, grouped by anatomical site (e.g. head, arm, leg), rather than by injury type (e.g. fracture, burn) Creation of combination dx/sx or manifestation codes to reduce the number of codes needed Certain diseases have been reclassified to a more appropriate chapter Addition of placeholder X for future expansion Addition of 6th & 7th characters to represent obstetrics, sequelae or visit encounter Added laterality V & E codes no longer supplemental Post-op complications grouped within a procedure or specific body system Diseases of the eyes & ears were separated from nervous system chapter & have their own chapters Laterality Specifi es right, left or bilateral If no bilateral code available and condition is bilateral, code separate codes for right and left If side not specifi ed, use code for unspecifi ed side L89.20 (PU of unspecified side) L89.21 (PU of R hip) L89.22 (PU of L hip) L89.4 (PU of contiguous site of back, buttocks) Laterality Example Example: L (PU of left upper back, stage 1) 4th digit (1) indicates site of PU 5th digit (2) indicates laterality 6th digit (1) indicates stage of PU Combination Codes A single code used to classify: 2 diagnoses a diagnosis with a manifestation a diagnosis with an associated complication If combination code lacks specificity for both conditions, an additional code should be used for the manifestation or complication Combination Code Example Type II Diabetes with Diabetic Cataract one code E11.36 indicates both DM & cataract All Rights Reserved. Copy with permission only. 5

6 Sequela Formally late effects Residual effect after the acute phase of an illness or injury is over Residual may be apparent early (new CVA), or it may occur years later from an old injury As in ICD-9, some late effects will require 2 codes: the cause of the sequela followed by the residual. Others will need only 1 code Sequela of CVA Category I69 refers to late effects of categories I60-I67 which are not coded in home health as they refer to acute cerebrovascular diseases I69 codes that refer to hemiplegia, hemiparesis or monoplegia should identify dominant or non-dominant side. If not identified, and a default code doesn t exist, code as follows: ambidextrous - use dominant left side affected - default is non-dominant right side affected - default is dominant Sequela of CVA Examples Late effects of CVA: I Hemiplegia and hemiparesis (right dominant side) following a cerebral infarct (only 1 code needed) I Disturbance of vision following a cerebral infarct and H53.8 blurred vision (2 codes needed) CVA or TIA without residuals coded as Z86.73 Fractures Aftercare codes will not be used for aftercare of traumatic fractures. For aftercare of a traumatic fracture, assign the acute fracture code with the appropriate 7th character which will indicate initial or subsequent encounter of care or late effect of fracture. Aftercare following fracture Example: S42.001D - Fracture of unspecified part of clavicle. 7th character "D" indicates that this is routine aftercare following the initial encounter for the traumatic fracture 7th Characters Chapter 19 codes will require 7th characters "S" section provides codes for injuries to single body regions "T" section covers injuries to unspecified body regions as well as poisonings and other causes 7th character identify initial encounter, subsequent encounter or sequela (late effect) A or B for fractures are only used while the pt is receiving active treatment (surgery or ER eval) D is used for fractures that are healing normally after initial encounter G, K or P are used for fractures with a complication after initial encounter S is used for fracture with any residuals/sequela (late effects) after healing has occurred All Rights Reserved. Copy with permission only. 6

7 Complications of Care Many guideline changes have occurred (see link on resources pg) Complications of codes within a specific body system are found within the body system chapter with codes specific to the organ or structures of that body system. Codes are designated as either intraoperative or post procedural. Code also the specific complication if applicable Other Guideline Changes Changes in time frames for some conditions. Example: Acute MI time changes from 8 weeks to 4 weeks Drug & Alcohol a single ICD-10 code will be used to identify not only the substance used but the disorder the substance has caused. Example: F psychoactive substance dependence w/delirium Alzheimer s codes expanded to reflect onset (early versus late) Example: G30.1 Alzheimer s disease with late onset Blindness & low vision guidelines say to code first the underlying condition Hypertension in ICD-10 HTN codes no longer classify benign, malignant or unspecified as a type Placeholder "X" X is used as a placeholder at certain codes to allow for future.expansion. For example, it will be used in poisonings, adverse effects and under dosing codes (T36-T50). Where a placeholder exists, the X must be used otherwise the code will be invalid. If a code requires a 7th character for episode or sequela etc., but there is no 6th character, an X must be used to fill in the empty 6th space. Where Do We Go From Here? Assemble your transition team Identify which staff members still need training Identify what level of training staff needs Assess what needs to be learned by staff members - Anatomy and physiology especially for non-clinician coders - Pharmacology - Medical terminology Obtain up-to-date manuals Encourage dual & practice coding Choose options for training - In-house training - Formal training - On-line courses Discuss budgeting and scheduling training (includes developing calendar) Make contact with vendors (OASIS, billing, etc.) Make contact with agency's own IT staff All Rights Reserved. Copy with permission only. 7

8 Budget Needs Staff Training Books and other resources Hardware/Software Training When do I start? CMS recommends 6-9 months prior to implementation Who needs to be trained? Depends on who does your training What about field clinicians that don t routinely code Clinicians versus non-clinician coders Consider Outsourcing Continual coverage Timely submissions and billing Eliminates the need for intense staff training Assured expertise Questions for Your Vendors Where is your organization in the transition process? Will you conduct external testing? What will we need to test with you? When will you be ready to accept test transactions from my practice? Will you be dual processing, and if so, when will you start? What will happen if something goes wrong? Who will be my primary contact at your organization for the ICD-10 transition? Can we set up regular check-in meetings to keep progress on track? Do you anticipate any changes in policies or delays in payments to result from the switch to ICD-10? Resources & Links Official ICD-10 Coding Guidelines available at The ICD-10-CM (2010 version) available at icd10cm.htm or at General Equivalence Mappings (GEMs) assist in converting data from ICD-9 to ICD-10, and other ICD-10 resources and training materials will be available through CMS at: All Rights Reserved. Copy with permission only. 8

9 ICD-10 To-Do List Project Planning Designate a team leader, someone to spearhead all projects. Gather information from useful resources (i.e., professional associations) to provide your agency with knowledge on how to prepare for the changes that will occur with the release of ICD-10. Research and review the ICD-10 code set to gain a better understanding of the upcoming changes. Create a project plan that will focus on main headers below. Impact Assessment Compile a contact list which includes a primary contact name, phone number and address for: All Vendors Billing Service Company Clearinghouse(s) Payers Contact everyone in your contact list to learn about their plans for the release and implementation of ICD-10. Compile a list of your agency s clinical and administrative electronic systems and various work process systems that utilize ICD-9 codes. Identify which of these processes will need modifying for ICD-10. Identify any and all work flow adjustments that will need to take place for a successful ICD-10 implementation. Identify which of your staff members work with ICD-9 and what their involvement and duties are regarding ICD-9. Implementation Contact your vendor to learn when installation updates will occur. Contact your billing service company to learn when system changes will be installed. Contact clearinghouse(s) to learn when testing can start. Contact various payers to learn when testing can start. Perform various tests: Internal External testing with your billing service company External testing with your clearinghouse(s) External testing with payers Training Who: Identify which staff members need ICD-10 education and which level of education will be needed for each staff member. What: Review the time and costs necessary for training. When: Find out when the training will occur in relation to ICD-10 implementation. Where: Determine training location. How: Determine which training method(s) will be suitable for your staff. Begin staff training 6-9 months prior to implementation. Conversion & Monitoring Purchase ICD-10 coding books. Use ICD-10 codes for all discharges and services occurring on or after October 1, Examine the ICD-10 code processing. Be aware of things like code rejections, reimbursement changes, etc. 9 All Rights Reserved. Copy with permission only.

10 Thanks for Attending! Feel free to contact us with any questions. Jennifer Warfield, BSN, HCS-D, COS-C Join the PPS Plus Conversation! 10