Impact of ICD-10-CM on Your Practice

Transcription

1 Impact of ICD-10-CM on Your Practice From Apprehension to Comprehension Presented by Kelley Lipsey

2 Today s Goal Brief overview of recent ICD-10-CM webinar series for providers Discuss ICD-10s impact on your organization Consider your organizations readiness for ICD-10

3 ICD-10-CM for Providers Evaluation and Management (E/M) Documentation Bread and butter of primary care Average primary care physician loses approximately $36k/year in patient generated revenue due to under coding. Audits that show over-coding is normally just under documenting by the provider While FQHC reimbursement isn t directly effected by the level of E/M code, the data is used to determine the national PPS rate(s). Details supporting the assigned ICD-10-CM code must be included in the E/M documentation.

4 ICD-10-CM for Providers Evaluation and Management Documentation ICD-9 vs ICD-10 Fracture of one or more phalanges of the foot CATEGORY = Closed Fracture of Foot and Toe, except Ankle Etiology, Anatomic Site, Severity 5 = Lesser Toe(s) 3 = Distal Phalanx 4 = Nondisplaced, Right 7th Character Extension Initial encounter for Closed Fx

5 ICD-10-CM for Providers Evaluation and Management Documentation ICD-9 vs ICD-10 Common Primary Care and Behavioral Health ICD-9 codes and their ICD-10 counterparts ICD-9 ICD Diabetes mellitus w/o complications, type II E11.9 Type II DM without complications ssssssssstype II or unspecified type, not stated as sssssssssuncontrolled DM w/ ophthalmic manefestations, E11.31 Type II Diabetic retinopathy with *diabetic retinopathy, and macular degeneration Macular degeneration Essential hypertension I10 Essential (primary) hypertension

6 ICD-10-CM for Providers Evaluation and Management Documentation ICD-9 vs ICD-10 Common Primary Care and Behavioral Health ICD-9 codes and their ICD-10 counterparts Impact of ICD-10-CM on provider documentation Uncommon specificities Episode of care (Initial, Subsequent, Sequela) T38.3X6A Poisoning: Insulin-Underdosing, Initial Encounter Trimester Z34.01 Encounter for supervision of normal first pregnancy-first trimester Severity (mild, severe, etc.) F31.31 Bipolar disorder, current episode depressed, mild

7 Apprehensive? From 14k codes to 70k codes Only 5% of ICD-9 codes have an exact match in ICD-10 Some ICD-9 codes now translate to over 2000 ICD-10 code options New combination codes for some conditions with common manifestations/complications/symptoms E Type 2 DM w/moderate nonproliferative diabetic retinopathy with macular edema I13.2 Hypertensive heart and CKD with heart failure and stage 5 CKD, or ESRD Most EMRs will not provide an algorithmic method for choosing the correct ICD-10 code Unspecified codes in ICD-10 will cause claims to deny much more often than ICD-9 unspecified codes H65.90 Unspecified nonsuppurative otitis media, unspecified ear Provider documentation must support assigned diagnosis codes, or risk non-compliance and/or payer recoupment after audits

8 Good News! Many codes Finite set of concepts 50% of ICD-10-CM codes are in the musculoskeletal section 36% of codes are different only in that they address laterality (right, left, bilateral) H65.05 Acute serous otitis media, recurrent, left ear Many codes are repetitive with regard to other concepts Anatomical Site Episode of care Trimester/Fetus Etiology/Manifestation Acuity Most new concepts are already being documented by providers

9 Focus of Documentation Disease type Disease acuity Disease stage Site specificity Laterality Missing combination code detail Changes in timeframes associated with familiar codes

10 Ready or not, here it comes! It s mandatory! It WILL impact your organization Systems Administration Patient and Work Flow Revenue Cycle Process Cash Flow Compliance Preparation is key

11 Dangerous Assumptions My EHR vendor has it under control My billing department has been trained Providers don t really need ICD-10 education Payments for services rendered are not effected by diagnosis code(s)

12 Operational Considerations How do you choose a diagnosis code in your EHR now? Are there current diagnostic coding challenges? For whom? What are current work-arounds? Will that process change with the implementation of ICD-10 Will the choice be algorithmically based Will providers have to search by key words (and what about coding conventions and guidelines?)? Don t try to teach your providers to be coders Build all code choices for a condition into your EHR system Include pertinent conventions/guidelines where applicable

13 Financial Considerations Preparation Phase Cost of System setup/update Time for system setup Specialty specific picklists/superbills Cost of staff training (including providers) Value of outside assistance Transition Phase Value of outside assistance Post Implementation Phase Physician time Claim Delays Billing errors/rejections Pre-Payment Audits Claim Denials Prior Authorizations/Referrals Auditing/Compliance (Fraud & Abuse)

14 Control Disruption of Revenue Determine your practice s most frequently coded conditions ( conditions, not codes ) From last 12 months (to capture any seasonal changes) Determine ICD-10 codes related to those top conditions to gain a better understanding of key concepts For ICD-10-CM coding accuracy For documentation support and compliance Can your EHR system be modified to capture the necessary documentation elements to support the code specificity of your most common conditions Make the necessary updates/edits to your system to capture the most specific ICD-10 code for the condition(s) being treated Current ICD-10-CM Code Set updates (vendor or practice responsibility?) Additional and/or Updated Picklists or Superbills Consider the value of additional coding software resources

15 Control Disruption of Revenue Test ALL systems involved in documentation, coding or billing (any area or process that utilizes an ICD code) Internal testing Claims (electronic and paper) Order/requisition forms Referral forms Paper prescriptions Electronic Lab orders/results (through systems interface) External testing Billing Service Clearinghouse Payers (authorizations/pre-certs, referrals, direct billing, etc.) Data repositories/registries Provide any necessary coding resources

16 Other Considerations Strategies for better alignment with providers, coders/billers, vendors, and other outside partners to ensure that this migration is a successful joint effort, as opposed to an adversarial one Impact to measures of physician quality, efficiency and appropriateness, as well as healthcare outcomes.

17 Preparation Recap Determine the most commonly treated conditions in your practice over the last 12 months Identify all applicable ICD-10-CM code options for those conditions Use that information to Create updates and changes to your Practice Management, EHR, and Billing systems to allow for complete and accurate coding and documentation, as well as a functional and efficient revenue cycle processes Develop customized, specialty specific ICD-10 training for appropriate administrative, clinical and professional staff Test all systems and processes prior to October 1 st Create common patient scenarios and walk through the entire revenue cycle process to test each process and system necessary Consider the value of outside assistance

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