ICD-10 Preparation for Non- Coders in the Revenue Cycle

Transcription

1 ICD-10 Preparation for Non- Coders in the Revenue Cycle September 24, 2015 Arkansas HFMA Revenue Cycle Seminar Susan Wallace, MEd, RHIA, CCS, CCDS, CDIP, FAHIMA Program Objectives Explain the impact of the ICD-10 code set to hospital operations. List examples of new features and requirements to assure reporting accuracy. Demonstrate an increased understanding of the impact of ICD-10 changes on their role within the healthcare facility

2 Howis coded data used? Public Report Cards Research Epidemiology Outcomes Statistical Analysis Financial and Strategic Planning Evaluation of Quality of Care Communication to Support Patient s Treatment Insurance Coverage Determination Reimbursement 3 Payment for Inpatient Stays Physician Documentation: Pneumonia Diagnoses & Procedures Coded Codes on Claim Submitted MS-DRG 179Pneumonia without CC / MCC 2

3 Coding and Documentation Is The Key To: Payment NCHS / WHO HAC Coded Data VBP Public Reports Quality Reports Hospital Wide Readmission Hospital Compare 7/1/11 6/30/14 3

4 Risk-Standardized Mortality Rates Medicare Hospital Quality Chartbook(Sept 14) 7 Hospital Value-Based Purchasing Domain Weights 100% 80% 10% Coded Claims Data / Risk Adjustment Affects All Domains Except Experience 20% 25% 60% 40% 30% 25% 40% 20% 0% 25% 25% 25% 25% 25% 25% FY16 FY17 FY18 Experience Efficiency Outcomes Process Clinical Care Safety 8 4

5 Hospital Value-Based Purchasing Baseline vs Performance Periods Program Year Baseline Period Performance Period FY17 FY18 FY19 FY20 FY21 9 What is changing? 5

6 Whenis it changing? Inpatient Discharges as of 10/1/15 Outpatient dates of service 10/1/15 See billing instructions for claims spanning implementation date Why is it changing? ICD-9 Insufficient detail Insufficient room for expansion Provide greater clinical detail and specificity in describing diagnoses and procedures Lack of current terminology / technology (1979) Updated to be consistent with current clinical practice Worldwide morbidity reporting 6

7 Who Remembers 1979? 1979 Trivia Age 65+ AvgLOS OB AvgLOS 10.8 days only 3.7 days % Pts w/ >1 diagnosis 48% Top volume IP Procedures (exclude delivery) Biopsy Digestive system endoscopy D&C 7

8 Prevalence of ICD countries use for morbidity; 11 use for reimbursement / case mix Created by WHO (World Health Organization) in 1994 Canada Began adopting in 2001 Over a 5-year implementatio n Only use diagnosis codes Use for statistical purposes, not billing Netherlands Adopted in 2013 United Kingdom Adopted in 1995 Germany Adopted in 1998 Use ICD-10- AM for morbidity Implementatio n took 3 years Russia Adopted in 1999 China Adopted in 2002 Brazil Adopted in 1998 Australia Adopted in 1998 Implementation took 2 years South Africa Adopted in 1996 Countries who have adopted ICD-10 ICD-10 Benefits CMS MLN Matters SE 1239 Measure quality, safety, and efficacy of care Reduce need for attachments to explain patient s condition Design payment systems and process claims for reimbursement Conduct research, epidemiological studies, and clinical trials Set health policy 8

9 How is it changing? Diagnoses Procedures 14,567 ICD-9-CM 69,823 ICD-10-CM 3,882 ICD-9-CM 71,974 ICD-10-PCS Biggest Changes ICD CM Category Injury / Poisoning External causes of morbidity / mortality Musculoskeletal System / Connective Tissue Pregnancy, Childbirth, Puerperium 9

10 Reasons for Change Added codes for laterality (1/3 of changes) Right, left, bilateral Added codes for episode of care for select conditions (25%) Initial vs subsequent episode or sequela (late effect) Distinguish between acute and chronic conditions Payer Options Accept ICD- 10 Codes Map back to ICD-9 equivalent Accept ICD- 10 Codes based on increased ICD- 10 specificity Require ICD-9 Codes per current methodology Apply based on ICD-9 methodology CMS ICD-10 MS-DRG /NCD/ LCD policies Non-HIPAA entities 10

11 ICD-10 Impact to Future Inpatient Reimbursement After CMS has gathered sufficient coded ICD-10-CM/PCS datato make adjustments based on the increased specificity of the ICD-10-CM/PCS codes, CMS would propose updates to the ICD-10-CM/PCS version of the MS-DRGs. CMS Unspecified Codes May Result In Payers questioning unspecified diagnosis codes Delays in prior approval: Laboratory and imaging tests Referrals Elective surgeries More claim rejections and appeals 11

12 CMS / AMA Agreement Posted July 5-6, 2015 While diagnosis coding to the correct level of specificity is the goal for all claims, for 12 months after ICD-10 implementation, Medicare review contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule. However, a valid ICD-10 code will be required on all claims starting on October 1, CMS / AMA Agreement Q&A Published July 27, 2015 Guidance only applies to Medicare fee-for-service claims from physician or other practitioner claims billed under the Medicare Fee-for-Service Part B physician fee schedule. the recent Guidance does not change the coding specificity required by the NCDs and LCDs. submitters will know that it was rejected because it was not a valid code versus a denial for lack of specificity required for a NCD or LCD or other claim edit. the audit and quality program flexibilities only pertain to post payment reviews

13 ICD-10-CM Diagnosis Code Structure Category Subcategory Extension Letter Number Number Letter Number Letter Number Letter Number Letter Number Letter Expanded Field Lengths for Codes and Descriptions Alphanumeric ICD-10-CM Diagnoses (69,823) 3 to 7 Characters Decimal after 3 rd Character I50.9 HIPAA required for all health claim diagnoses ICD-10-PCS Procedures (71,974) 7 Characters, No Decimal Letters I and O not used HIPAA required for inpatient procedures Will hospital use for internal reporting of outpatient procedures?

14 New Features: More Info in Code K57.21 Diverticulitis of large intestine with perforation and abscess with bleeding E Type 2 diabetes mellitus with severe nonproliferativediabetic retinopathy with macular edema I Atherosclerotic heart disease of native coronary artery with unstable angina pectoris Coding Example- ICD CM: Increased Length of Code Descriptions S72.461A Displaced supracondylar fracture with intracondylarextension of lower end of right femur, initial encounter, closed fracture S72.391H Other fracture of shaft of right femur, subsequent encounter for open fracture type I or II with delayed healing 14

15 ICD PCS Procedure Codes Only for Hospital IP Claims 0 L B 5 0 Z Z Section Body System Root Operation Body Part Approach Device Qualifier ICD PCS Illustrations 0FB03ZX -Excision of liver, percutaneous approach, diagnostic 0DQ10ZZ- Repair, upper esophagus, open approach

16 GEMs Uses Translation of data for: Tracking quality Recording morbidity / mortality Calculating reimbursement Converting ICD-9 based application to ICD-10 NOT substitute for assigning ICD-10 codes Free CMS Resources

17 Good Resource 33 ICD-10 Reimbursement Mappings Identify best matching ICD-9-CM code that can be used for reimbursement purposes for each ICD-10 code. All ICD-10-CM/PCS codes are in the ICD-10 Reimbursement Mappings ; however, all ICD-9-CM codes are not included. Consists of two crosswalks: ICD-10-CM to ICD-9-CM for diagnosis codes; and ICD-10-PCS to ICD-9-CM for procedure codes. CMS is not using the ICD-10 Reimbursement Mappings for any purpose. We are converting our systems and applications to accepticd-10-cm/pcs codes directly

18 Planning for the Transition Will report request forms require revision? What happens when requestor is unfamiliar with ICD-10 codesets? How will requests that span 10/1/15 (such as 2015 calendar year requests) be handled? Jan-Sept per ICD-9 and Oct-Dec per ICD-10? Use GEMS to translate? 35 DRG-Based Reports ICD-10 codes occasionally map to different DRG than ICD-9 counterpart! Should any DRG-based report include a parenthetical notation that notes the ICD-10 implementation date? i.e. calendar year DRG report requests Will Case-Mix Index (CMI) reports flag the transition date?

19 What is reportable? Whose documentation is used for coding? Any physicianinvolved in the care and treatment of the patient, including documentation by consultants, anesthesiologists, as long as there is nothing conflicting from the attending physician. NOT diagnostic test results, i.e. pathology or radiology reports, echocardiogram, rhythm strips, etc. Nurse practitioners and physician assistants if they are considered legally accountable for establishing a diagnosis. 37 ICD CM Outpatient Coding Guideline J. Code all documented conditions that coexist at time of visit and require or affect patient care treatment or management. Do not report conditions previously treated that no longer exist. History codes may be used if the historical condition or family history has an impact on current care or influences treatment. 19

20 Medical Necessity National Coverage Determinations (NCD) Local Coverage Determinations (LCD) List of CPT codes and corresponding diagnosis codes that establishes medical necessity for the procedure NCDs and LCDs for ICD-10 have been published to the appropriate websites Local Coverage Determinations MLN Matters MM8348 All ICD-10 LCDs and associated ICD-10 articles will be published on the Medicare Coverage Database (MCD) no later than April 10, All LCDs and Articles will receive a new LCD/Article ID number. i.e., LCD ID 1234 might become LCD ID

21 New for ICD CM Combination codes for atherosclerotic heart disease with angina pectoris. NOT necessary to use additional code for angina CAD CAD w/ Angina Angina Angina Options I20.1, Angina pectoris with documented spasm I20.8, Other forms of angina pectoris I20.9, Unspecified angina pectoris I25.11, Atherosclerotic heart disease of native coronary artery with angina pectoris 21

22 Cardiac Rehab Programs Medicare Coverage with these Conditions: Acute MI within past 12 months; or Coronary artery bypass surgery; or Current stable angina pectoris; or Heart valve repair or replacement; or PTCA or coronary stenting; or Heart or heart-lung transplant; or Stable, chronic heart failure NCD ALERT Cardiac Rehab Programs Angina decubitus I Prinzmetal angina I20.1 Other and unspecified angina pectoris I20.8 Other and unspecified angina pectoris I20.9 NCD ALERT Other forms of angina pectoris Angina pectoris with documented spasm Other forms of angina pectoris Angina pectoris, unspecified

23 Cardiac Rehab Programs NCD ALERT What about Combination Codes for Coronary Artery Disease with Stable Angina?? I25.1XX I25.7XX Errors? Edits? ASK A CODER 115 pages of ICD-10-CM diagnosis coding guidelines 15 pages of ICD-10-PCS procedure coding guidelines 123,336 new codes!

24 CMS Claims Processing Instructions Issued Billing and Payment FAQs MLN Matters SE1325 Institutional Services Split Claims Billing Instructions for Medicare FFS Claims that Span the ICD-10 Implementation Date MLN Matters SE1408 Medicare FFS Claims Processing Guidance for Implementing ICD-10 MLN Matters SE1410 Special Instructions for ICD-10 Coding on Home Health Episodes that Span October 1, CMS Billing FAQ OP Date of Service / IP Discharge 9/30/15 10/1/15 ICD-9-CM DxONLY ICD-9 / CPT Procedures ICD-10-CM Dx ONLY ICD-10-PCS / CPT Procedures Otherwise Returned / Rejected 24

25 OP Encounter Spans 10/1/15 Services prior to 10/1/15: bill separately with ICD-9 Keep all charges within same LIDOS Line item date of service Do NOT split single item services whose timeframes cross midnight 9/30/15. Use from date ED = date patient enters ED OBS = date observation care begins OP Encounter Spans 10/1/15 Emergency Department Arrives ED 1900, discharged 0100 LIDOS = 9/30/15 ICD-9 codes 1 st claim 10/1/15 charges ICD-10 codes, 2 nd claim No services actually provided 10/1/15? Only 1 claim ICD-9 codes 25

26 OP Encounter Spans 10/1/15 OP Observation Admit to OBS 1400, discharged 0800 LIDOS = 9/28-29/15 ICD-9 codes, 1 st claim 10/1/15 charges ICD-10 codes, 2 nd claim Encounter Spans 10/1/15 Admit within 3 Day Payment Window OP Surgery 1400, admitted as IP 1000, with discharge 0800 Since all outpatient services (with a few exceptions) are required to be bundled on the inpatient bill if rendered within three days of admission, the claim must be billed with ICD-10 for those bundled outpatient services 26

27 IP Encounter Spans 10/1/15 Admitted as IP 9/28/15 Discharged Home 10/2/15 All billed based on 10/2/15 discharge ICD-10 codes Post-Implementation Activity Tracking initial ICD-10 charts coded Determine volume per each service type Coding Claim Remit 27

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