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1 Surviving the Conversion to ICD 10: A Glimpse of What s to Come Richard E. Moses, D.O., J.D Annual Scientific Meeting Pennsylvania Society of Gastroenterology Lancaster Marriott at Penn Square Lancaster, PA September 18 20, 2015 Speaker s Disclaimer Richard E. Moses, D.O., J.D. does not have any financial conflicts to disclose. This presentation is not meant to offer medical, legal, accounting, regulatory compliance, or reimbursement advice, and it is not intended to establish a standard of care. Please consult professionals in these areas if you have related concerns. The speaker is not promoting any service or product. 2 1

2 Educational Goals Understand and discuss the rationale for and resistance to changing to ICD 10 coding Develop a basic understanding of ICD 10 v. ICD 9 Understand the changes and importance of documentation with ICD 10 Discuss the necessary preparations for a practice to be ready for ICD 10 Review available resources for ICD 10 education 3 INTRODUCTION 4 2

3 INTRODUCTION Overview Fundamentals of ICD 10 Documentation Issues Preparing for ICD 10 Resources Summary & Conclusions 5 OVERVIEW 6 3

4 Healthcare Reform Healthcare Reform Goals Improve Access Universal Coverage Increase quality reporting to include outcomes PPACA March 23, 2010 Increase integration of care through partnerships of physician networks and hospitals Cost control and cost reduction What this means to Physicians. Over 70% of healthcare executives surveyed believed that physicians performed inappropriate procedures for monetary benefit Centers for Medicare and Medicaid Services (CMS) in 2011 reported physicians & clinical services spending reached $529.2 billion Congress is focused on reducing unnecessary medical costs Physician Compliance Network Precyse Solutions, LLC ICD Endorsed by World Health Assembly (diagnosis only) 1994 Release of full ICD 10 by World Health Organization (WHO) January 1, 1999 U.S. implemented for mortality Death certificates 2002 Published in 42 languages Implementation 138 countries for mortality 99 countries for morbidity 8 4

5 ICD 10: It s Here! "There are no more delays and the system will go live on Oct 1 st. Let's face it guys, we've already delayed it several times and it's time to move on. It's a standard in the rest of the world." Marilyn Tavenner past CMS Administrator Andy Slavi current CMS Administrator Previous Implementation Deadline: October 1, 2014 Current Implementation Deadline: October 1, Conference: Healthcare Information and Management Systems Society (HIMSS) 9 ICD 9 CM Problems 35 years old technology has changed Provides limited data about patients medical conditions & hospital inpatient procedures Numerous outdated medical terms Running out of numbers to assign for codes many categories are full Insufficient clinical specificity to describe severity & complexity of various conditions Ineffective for monitoring resources, measuring performance, & analyzing healthcare costs 10 5

6 ICD 9 CM Problems Not descriptive enough for modern day purposes Lacks accuracy for payment for services rendered Improve quality monitoring by facilitating evaluation of medical processes and outcomes Not flexible enough to quickly incorporate emerging technologies Not exact enough to precisely identify diagnoses and procedures Cannot compare data with rest of the world Not compatible with emerging EHR 11 ICD 10 v. ICD 9 ICD 9 14,567 diagnoses codes 3,878 procedure codes Lacks laterality Lacks severity parameters Groups injury by type of injury Limited in definitions, categories, and certain disease descriptions No room for new codes ICD 10 69,832 diagnoses codes 71,920 procedure codes Laterality (right/left) Severity parameters + combination codes Groups injury by anatomical site New definitions, restructures categories, reclassifies certain diseases Ability to add codes 12 6

7 Reasons for Changing to New ICD 10 Codes Design payment systems with emphasis on claims processing Measuring the safety, quality, & efficiency of medical care Monitoring utilization of resources Improving financial, clinical, & administrative performance Providing healthcare consumers with data re cost & outcome of various treatment options Recognizing & identifying abusive and/or fraudulent billing practices & trends 13 ICD 10 FUNDAMENTALS 14 7

8 Structure of ICD 10 Codes Codes are in chapters arranged by body system Chapter 11 Diseases of the Diges ve System (K00 K94) Codes indexed via alphabetical index by disease, injury, eponym, or reason for the encounter Codes must be assigned to the full number of characters available to be valid Valid codes must be 3 to 7 characters long 7 th character includes encounter information Initial v. subsequent encounter v. sequela Laterality included in many codes Combination codes 2015 Optum360 LLC 15 Summary of Major ICD 10 CM/PCS Changes Laterality Specific disease pathophysiology Combination codes Common clinical guidance scales 7 th character & timing of encounters (acute, subacute, chronic) Alpha characters are used Identification of trimesters Increased granularity of disease manifestations X placeholders EtOH & drug dependence effects of use Expansion of injury codes Post procedural disorders 2015 Optum360 LLC 16 8

9 DOCUMENTATION 17 Documentation Issues for Physicians Providers will be judged on documentation more critically with ICD 10 More detailed description of activities conducted during encounters Increase in clarification queries from coders Services must be coded to highest level of specificity Chronic conditions are important to establish resource utilization AND severity of illness Justifying treatment choice + supporting E/M levels = Medical necessity 18 9

10 More Documentation Issues The note must support the level of care & ICD 10 code Think E/M, SOAP notes, Medical School Each progress note must stand alone Do not refer to a diagnosis from a previous note, et cetera When diagnosing a patient s condition, be sure to evaluate each condition and not just list it 19 Foreign Body Esophagus: ICD 9 v. ICD _Gastro_Alpha 1e99b924.pdf 20 10

11 Documentation Components Laterality which side of the body Episode of care ini al, subsequent, or sequelae Location Acute or chronic Causes/etiology Co conditions 2015 Optum360 LLC 21 PREPARATION 22 11

12 CMS and AMA Announce Efforts to Help Providers Get Ready For ICD 10 Released July 6, 2015 Joint statement that they will work together in educating providers through webinars, on site training, educational articles, and national provider calls The use of ICD 10 should advance public health research and emergency response through detection of disease outbreaks and adverse drug events, as well as support innovative payment models that drive quality of care. releases/2015 Press releases items/ html 23 CMS Guidance July 7, 2015 le er sent to Medicare providers First 12 months after ICD 10 transition, Medicare review contractors will not delay practitioner claims based solely on specificity of ICD 10 code Practitioner must use code from correct family of codes Medicare quality data review contractors will not subject physicians to penalties under PQRS, VBM, or MU during primary source verification or auditing related to the additional specificity of the ICD 10 diagnosis code Practitioner must use code from correct family of codes CMS will establish a communication and collaboration center that will address ICD 10 transition issues 10.pdf 24 12

13 Proactive Recommendations Read & follow the CMS & AMA publications on ICD 10 transition Budget for ICD 10 implementation Contact your billing company regarding its readiness Educate your in house billing staff Familiarize yourself with the ICD 10 ombudsman s office and the process to submit questions and complaints Test your billing systems prior to the ICD 10 implementation date CMS recommends testing claims, eligibility verification, quality reporting, & other transactions & processes involving ICD 10 codes Kalogredis VJ. The Legal Intelligencer. August 4, ICD 10 Estimated Cost PRACTICE SIZE PREDICTED COST Small (10 or fewer physicians) $56,639 $226,105 Medium (11 25 physicians) $213,364 $824,735 Large (26 physicians or greater) $2,017,151 $8,018,364 In addition to software upgrades, total costs include the expense of training, practice assessments, testing, payment disruptions, and productivity loss for physicians. assn.org/ama/pub/news/news/2014/ icd10 cost estimates increased for most physicians.page 26 13

14 RESOURCES 27 Educational Resources: WHO ICD 10 Instruction Manual Available in 42 languages On Line Training Tool 10%20training/Start/index.html Download area makes all licensed materials available

15 Educational Resources: CMS CMS training: Provider Resources Internet Page at CMS.Gov Physician training Vendor information FAQs Medical Practice Tips Checklists and Implementation Guides 29 Educational Resources: Others General ICD 10 Information ICD 10 PCS Coding System and Training Manual ICD 10 CM Coding System AMA information releases and examples assn.org/ama1/pub/upload/mm/399/icd10 differences factsheet.pdf 30 15

16 And Then Non GI ICD 10 Codes Hurt at the opera Y92253 Stabbed while crouching Y93D1 Walked into a lamppost W2202XA Lamppost, subsequent encounter W2202XD Submersion due to falling or jumping from crushed water skis V9037XA Struck by a duck (W6162XA) Bitten by a duck (W6161XA) Struck by a turtle (W5922XA) Spacecraft crash injuring occupant V95.41 (not billable) Spacecraft fire injuring occupant, initial encounter V95.44XA 31 SUMMARY & CONCLUSIONS 32 16

17 Thank You Pennsylvania Society of Gastroenterology 2015 Annual Scientific Meeting Lancaster Marriott at Penn Square Lancaster, PA September 18 20,