ICD-10 Transition & Impact (Billing/Coding/Front Desk/Clinicians)

Transcription

1 Partnering with CHCs to Help Achieve Their Mission Priority Management Group presents ICD-10 Transition & Impact (Billing/Coding/Front Desk/Clinicians) Priority Management Group, Inc. 700 School Street Pawtucket, RI P: F: Agenda Organizing the Implementation Planning, Awareness and Assessment. Why Change is Necessary Key Obstacles to Change What is a project plan? Organizing & Process before implementation Overall Project team and other teams Impact Analysis Key Highlights of ICD-10 Final Rule Information technology ICD-9 vs ICD-10 Impacts on Documentation Crosswalks Coding Scenarios How to Mitigate Risk Q&A Resources 1

2 Speakers: Julia M Gilbert, MBA, CPC, CPC-H Julia Gilbert is Managing Director of PMG Consulting and has nearly two decades of experience within the healthcare revenue cycle industry and leads PMGC s ICD-10 Transition and Training Services and Revenue Cycle Service offerings. Her strong skill set includes business management/analytics, project management, coding/billing optimization, contract negotiations and leadership. Tasked with improving revenue, Julia excels at evaluating and optimizing the chargemaster, coding tables within practice management systems, and related audits seeking to enhance efficiency and accuracy of documentation, coding, and billing. Having led large scale EMR implementation, Julia thrives at engaging physician leaders in the process of maximizing reimbursement. Author of The Electronic Medical Record from a Clinical/Patient Perspective published in HFMA/Mass Media, June The coding guidelines, interpretations, and recommendations set forth as part of this training session are presented as a guide only. Attendees understand and recognize that actual coding decisions are the sole liability and responsibility of the provider(s) and respective billing staff. Priority Management Group, Inc. does not accept any liability or responsibility in this regard. 2. The presentation today includes discussion about a particular commercial product/service and the presenter has significant financial interest/relationship with the organization that provides this product/service. 2

3 Good Medicine Outdated ICD-9 (30+ years) Structure is running out of capacity for updates Accurate and complete reporting Better tracking of disease and response Reduce coding errors More accurately represent service provided Quality measurement Impact on future reimbursement Resistance to change Challenge of updating skills Challenge of learning a new system Waiting too long to begin implementation Impact the health center s livelihood Impact the health center s financial stability Challenge of updating skills Time to begin the huge undertaking in now. 3

4 A project plan is a document that outlines the purpose, structure and implementation of the project. Vision, scope, objectives what we have to achieve Stakeholders, roles, responsibilities who will take part in it Resource, financial, quality plans- how to undertake it First step in a successful implementation is to create an overall project team or steering committee High-level stakeholders to provide guidance on the overall strategic direction of ICD-10 transition Managers and Directors who are involved in the business objectives At least One Physician An Administrator or Manager Coders Billers Other Key Staff Work independently and periodically report to strategic ream and get help from executive level when needed 4

5 Review the ICD-10 Final Rule Obtain Senior Management Support Complete preliminary analysis of system impact Prepare project plan Identify the senior manager project supporter Establish senior management s role Obtain support from all providers Identify all areas that will be impacted clinical areas, systems, documentation, etc Establish a regular schedule to report progress to senior management Coordinate with the 5010 team. Steering Committee or Project Team Project Lead ICD-10-CM expert Practice Administrator/Manager Physicians/Providers Billing Coding Front Desk IT Compliance Non-Provider Clinical Staff 5

6 Educational Committee or Team Project Lead ICD-10-CM expert Practice Administrator/Manager Physicians Champion Billing Manager Coding Manager IT Manager Compliance Officer Non-Provider Clinical Champion Communication Committee or Team For large health centers or facilities. In smaller health centers this may be the Administrator/Operations Director with a lead in Billing and Coding Project Lead Administrator Coding Manager Billing Manager IT Manager Billing 6

7 Cross-Functional Team Representative from each area of the health center to assess their area impacted Team Leader Department Lead Front Desk Staff Member Biller Coder Physician/Provider Non-Provider Clinician Partnering early Must ensure compliance with clearinghouses, vendors, business partners and others Structure a commitment to: Cooperation Shared goals Open Communication Rapid issue resolution A collaborative relationship to work 7

8 Overall Project team steering committee should assess impact to all business areas Readiness Survey high-level assessment distributed to all of the practice business areas High-level Business Area Assessment Tool Operational Impact degree of change for core processes Technology assess complexity and experience level Vendor/Internal confidence level with vendors and internal knowledge People how much training is required. System IT should review systems hardware and software Project Team focus on key areas Areas for documentation Improvement Current state Future state Budget planning Implementation timeline Systems affected EMR, PM Training providers, coders, billers, front desk, and others Crosswalk to ICD-10-CM specific to practice specialty IT and Vendors to coding specifications 8

9 Project Team focus on key areas Review and update coding tools and forms Vendors discuss timeline on software updates and costs Operational transition Assess Coders knowledge gap A&P, medical terminology Identify weaknesses additional education needed Identify communication methods to keep all staff informed of the ongoing work Physicians Documentation laterality and specifity Coding Training Clinical Documentation & Forms Patient coverage: policies Superbills ABNs Prior Authorizations Referrals Finance / Managers Policies & Procedures Vendor & Payor contracts Budgets Training Plan Reporting Grant Writers UDS Reporting Nurses/MA Documentation Increase specificity Forms orders revised Prior Authorizations Front Desk HIPAA Systems Labs Documentation Reporting Billing Payor Policies & Procedures Code Sets Coding Code Sets Clinical A&P knowledge Concurrent use of ICD-9 & ICD-10 9

10 Areas affected by ICD-10 Begin with Clinical Area Next Business Area System Impact The goal is to determine which areas and systems will be impacted and require change Each business area has a project team Use of survey tools to capture information on each business area in the health center Systems and how they work Workflows Information management (data, extracts, reports, etc.) Link to other business area(s) in health center Link to external entities 10

11 A business plan is a formal document outlining the business reason for ICD-10 Implementation Explains what systems or processes will be impacted and describing high-level recommendations for the best solution Describes business problem Possible solutions Risks and benefits of each option Solution recommended for compliance Communicate objectives Provide information to create the business requirements Target specific obstacles Costs of a proposed solution Determine risk associated with the approved project Contingency planning- alternatives Make better decisions by reviewing all options 11

12 Issue: Superbills may not be a viable solution for ICD-10-CM. Number of diagnosis codes are too large. Possible alternatives: 1. Continue with paper superbills by removing the listing of diagnosis codes and including an area for providers to write out diagnosis descriptions/codes 2. Utilize electronic encounter forms/an EMR Risk of each option: 1. Providers may not give enough information to accurately code 2. The health center is not able to finance an EMR Administration can then decide the best course of action to move forward. Used properly this document should be reviewed regularly and gaged throughout the project to ensure the solution still meets the health center needs and the project is in line with the changing environments. Developed in the discovery phase. Each business area completes a business plan Business area project teams task includes completing a business plan for their area Share initial draft with steering committee documenting feedback in the business plan Strategic committee to share summary of completed plans to administration. Once the business plan is reviewed, the business area (cross-functional ) project teams will have a good understanding of the key factors involved with implementing ICD-10. Review business plan throughout project to verify the solution is still viable with the overall implementation. 12

13 Utilize flow charts to track progress and issues with timelines Function Team Member Areas Impacted Communication Target Date Completion Date Implementation Plan Communication Plan Administrator /Operational Director Billing Manager All Workgroup TBD TBD ALL s TBD TBD Impact Analysis Director of IT All Workgroup TBD TBD Crossfunctional Analysis Clinical Director Budget CFO Finance/ Admin All TBD TBD TBD Spreadsheets TBD TBD Once the initial assessment is complete, the findings are presented to senior management Goal of presentation Outline of key concepts Why ICD-10-CM is necessary Areas impacted High-level financial impact Timeline with key projects for October 1, 2014 compliance 13

14 Good Communication Follow-through Effective Cross-Functional Team Team Leader needs to be a cheerleader for the team Knowledgeable in their area Work well together Clear project plan Teambuilding sessions Discovery phase will help understand challenges ahead and take about 3 months to complete Readiness surveys High-level impact assessments Operational Technology Vendor People Business plans 14

15 A. Claims for all services provided on or after October 1, 2014, must use ICD-10 diagnosis... Claims that do not use ICD-10 diagnosis cannot be processed. ( Making the transition to ICD-10 is NOT optional. ICD-10-CM and ICD-10-PCS coding systems will replace ICD-9-CM effective October 1, 2014 ICD-10-CM diagnosis codes all settings ICD-10-PCS procedure codes- hospital inpatient settings CPT and HCPCS coding system remains for outpatient reporting for procedures and services General acute care impatient reimbursement for Medicare based on MS-DRGs using ICD-10 classification system not ICD-9 15

16 The anticipated benefits of transition to ICD-10 Increase level of detail to handle advancements in medicine and technology Appropriate reimbursement Improve data quality for clinical and financial decision making Support value based purchasing Facilitate quality reporting ICD-10-CM code set is maintained by the National Center for Health Statistics (NCHS) of the Centers for Disease Control and Prevention (CDC) for use in the United States. It is based on ICD-10 developed by the World Health Organization (WHO) and is used internationally. ICD-10-PCS code set was developed by 3M HIS for CMS and is maintained by CMS. Mapping files for conversion of ICD-9-CM & ICD-10-CM and ICD-10-PCS codes and vice versa were created and available on the CMS website. 16

17 ICD-9-CM Volume 3 procedure codes ICD-10-PCS procedure Codes 3-4 numbers in length Seven (7) alpha-numeric characters in length Approximately 3,000 codes Based upon outdated technology Limited space for adding new codes Lacks detail Lacks laterality Generic Terms for body parts Lacks description of methodology and approach for procedures Limits DRG assignment Lacks precision to adequately define procedures Approximately 87,000 available codes Reflects current usage of medical terminology and devices Flexible for adding new codes Very specific Has laterality Detailed description for body parts Provides detailed descriptions of methodology and approach for procedures Allows DRG definitions for recognition of new technologies and devices Precisely defines procedures with detail regarding body part, approach, any device used, and qualifying information. ICD-9-CM Diagnosis Codes ICD-10-CM Diagnosis Codes 3-5 characters in length 3-7 Characters in length Approximately 14,000 codes First digit may be alpha (E or V) or numeric. Digits 2-5 are numeric Limited space for adding new codes Lacks detail Lacks laterality Difficult to analyze data due to non-specific codes Codes are non-specific and do not adequately define diagnoses needed for medical research Does not support interoperability because it is not used in other countries Approximately 79,000 codes Digit 1 is alpha; digit 2-7 are alpha or numeric Flexible for adding new codes Very specific Has laterality Specificity improves coding accuracy and depth of data for analysis Detail improves the accuracy of data used in medical research Supports interoperability and the exchange of health care data between other countries and the United States 17

18 Software updates May rest with software vendors but health centers must perform ongoing monitoring Ask for details on their plan no later than 1st quarter of 2014 Testing Integration all combine parts working together Regression retests the program to ensure no faults Performance test compliance of a system End-to-End full life cycle of a claim from receipt to payment to data storage 3-6 months of simultaneous use of both ICD-9 and ICD-10 Created by National Center for Health Statistics(NCHS),CMS, AHIMA, AHA and 3M Health Information Systems. Attempt to convert coding between ICD-9 and ICD-10 NCHS and CMS will maintain for at least 3 years beyond Oct. 1, 2014 Use as a guideline to convert diagnosis and procedure data for historical and transferring of information. 18

19 Two-way translation dictionaries where diagnosis and procedure codes can be translated to and from ICD-9-CM and ICD-10-CM/PCS 2 mappings for diagnosis: Forward mapping ICD-9-CM to ICD-10-CM Backward mapping ICD-10-CM to ICD-9-CM 2 mappings for procedures Forward mapping ICD-9-CM to ICD-10-PCS Backward mapping ICD-10-PCS to ICD-9-CM ICD-9-CM Code ICD-10-CM Mappings Problem Diabetes mellitus, type II Non-insulin dependent, neurological complications, controlled E11.40 Type 2 diabetes mellitus with diabetic neuropathy, unspecified Correct mapping E11.49 Type 2 diabetes mellitus with other diabetic neurological complication For neurological not neuropathy Note: An unspecified code in ICD-9-CM will map to an unspecified code in ICD-10- CM and will not show if there are more specific codes. In ICD-10-CM there are better choices available for many clinical conditions then we have in ICD-9-CM 19

20 Developed by CMS - health care industry request for standard reimbursement crosswalk Temporary for mapping ICD-10-CM/PCS codes submitted on or after Oct. 1, 2014 CMS used the GEMS as a starting point by selecting the best ICD-9-CM code that maps to each ICD-10 code. ICD-9 vs. ICD-10 20

21 ICD-10 differs from ICD-9 in a number of respects overall content is similar ICD-10 has alphanumeric categories rather than numeric categories Some chapters have been rearranged Some titles have changed Conditions have been regrouped ICD-10 has almost twice as many categories as ICD-9 Minor changes have been made in coding rules for mortality ICD-10 consists of: Tabular lists containing cause-of-death titles and codes(volume 1) Inclusion and exclusion terms for cause-of-death titles (Volume 1) Alphabetical index to diseases and nature of injury External causes of injury Table of drugs and chemicals (Volume 3) Description, guidelines, and coding rules (Volume 2) Note: Become familiar with chapter specific guidelines to know when the 7 th character is needed. 21

22 Chapter ICD-9-CM ICD-10-CM 1 Infectious and Parasitic Diseases Certain Infectious and Parasitic Diseases 2 Neoplasms Neoplasms 3 Endocrine, Nutritional and Metabolic Diseases, and Immunity Disorders 4 Diseases of the Blood and Blood-Forming Organs Disease of the Blood and Blood-Forming Organs and Certain Disorders involving Immune Mechanism Endocrine, Nutritional and Metabolic Diseases 5 Mental Disorders Mental, Behavioral and Neurodevelopmental disorders 6 Diseases of the Nervous System and Sense Organs Diseases of the Nervous System 7 Diseases of the Circulatory System Diseases of the Eye and Adnexa 8 Diseases of the Respiratory System Diseases of the Ear and Mastoid Process 9 Disease of the Digestive System Diseases of the Circulatory System 10 Diseases of the Genitourinary System Diseases of the Respiratory System 11 Complication of Pregnancy, Childbirth, and the Puerperium Diseases of the Digestive System 12 Disease of the Skin and Subcutaneous Tissue Diseases of the Skin and Subcutaneous Tissue Chapter ICD-9-CM ICD-10-CM 13 Diseases of the Musculoskeletal System and Connective Tissue Diseases of the Musculoskeletal System and Connective Tissue 14 Congenital Anomalies Diseases of the Genitourinary System 15 Certain Conditions Originating in the Perinatal Period 16 Symptoms, Signs, and Ill-Defined Conditions Pregnancy, Childbirth and the Puerperium Certain Conditions Originating in the Newborn (Perinatal) Period 17 Injury and Poisoning Congenital Malformations, Deformations and Chromosomal Abnormalities 18 N/A Symptoms, Signs and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified 19 N/A Injury, Poisoning and Certain Other Consequences of External Causes 20 N/A External Causes of Morbidity 21 N/A Factors Influencing Health Status and Contact with Health Services Supplementary Classification Supplementary Classification Classification of Factors Influencing Health Status and Contact with Health Services (V codes) Classification of External Causes of Injury and Poisoning (E codes) N/A N/A 22

23 ICD-9 Hypertension ICD-10 Hypertension I10 Coincidence? Acute MI timeline decreased from 8 weeks to 4 weeks. DM Classifies uncontrolled as DM with hyperglycemia and combination codes now reflect complications. Musculoskeletal and other conditions reflect laterality (left vs. right), specific digits and visit encounter (initial, subsequent or sequela. 23

24 Obstetric conditions include specificity regarding trimester and fetus affected (malposition, etc). 1 st trimester: less than 14 weeks 2 nd trimester: 14 weeks to less than 28 3 rd trimester: 28 weeks until delivery UDS indicator Newborn codes suspected to be affected by maternal conditions do not have to be confirmed to use. Alzheimer s disease reflects early or late onset Respiratory diseases expanded to include conditions such as recurrent, manifestations and due to specifications (rhinovirus, streptococcus, etc) Asthma definitions mild intermittent, mild persistent, moderate persistent and severe persistent UDS Indicator for persistent asthma and pharmacological plan 24

25 Digestive disorders greatly expanded Crohn s disease specifies the site and complication. Dermatitis is now categorized as allergic or irritant and substance should be specified. Much greater use of code first underlying condition. External causes, activities and locations greatly expanded. Nicotine dependence that identifies tobacco products and induced disorders greatly expanded use. Must document cessation efforts. UDS Indicator 25

26 Coding scenarios This 36-year-old woman is 26 weeks pregnant and being seen for gestational diabetes without other problems. Other current conditions in the mother, complicating pregnancy, abnormal glucose tolerance

27 This 36-year-old woman is 26 weeks pregnant and being seen for gestational diabetes without other problems. Gestational diabetes mellitus in pregnancy Diet-controlled O Insulin-controlled O Unspecified control O Twin sister of the 36-year-old woman, 26 weeks pregnant with gestational hypertension. Transient hypertension of pregnancy, antepartum care

28 Twin sister of the 36-year-old woman, 26 weeks pregnant with gestational hypertension. Gestational hypertension without significant proteinuria, 2 nd trimester O13.2 Female with type II diabetes mellitus with a diabetic ulcer on left heel. Diabetes with other specified manifestations, type II, not specified as uncontrolled Use additional code to identify manifestation Ulcer of heel and midfoot, other than pressure No specificity about extent of breakdown or laterality. 28

29 Female with type II diabetes mellitus with a diabetic ulcer on left heel. Type 2 diabetes mellitus with foot ulcer E Use additional code to identify site of ulcer Non-pressure chronic ulcer of left heel, limited to breakdown of skin L with fat layer exposed L with necrosis of muscle L with necrosis of bone L Note: In ICD10, uncontrolled would be with hyperglycemia. As always, add additional code for insulin use. Anemia due to end-stage renal disease. Anemia in chronic kidney disease Assign an additional code from category 585 to indicated the stage of chronic kidney disease End stage renal disease Note: Manifestation is coded first, underlying disease second. 29

30 Anemia due to end-stage renal disease. End stage renal disease N18.6 Use additional code to identify dialysis status Anemia in chronic kidney disease D63.1 Code FIRST underlying chronic kidney disease Note: The order is switched in ICD10 to reflect the underlying disease process first. Patient has coronary artery disease with angina with no previous history of CABG. Coronary atherosclerosis of native coronary artery Angina, NOS

31 Patient has coronary artery disease with angina with no previous history of CABG. Atherosclerotic heart disease of native coronary artery with unstable angina pectoris I angina pectoris with spasm I other forms of angina pectoris I unspecified angina pectoris I extrinsic asthma intrinsic asthma asthma with COPD exercise induced asthma cough variant asthma asthma, unspecified 0 unspecified 1 with status asthmaticus 2 with acute exacerbation 31

32 Uncomplicated, with acute exacerbation, or with status asthmaticus Severity Frequency of daytime symptoms Mild Intermittent Mild Persistent Less than or equal to 2 days per week More than 2 times per week Moderate Persistent Severe Persistent Daily, may restrict physical activity Throughout the day; frequent severe attacks limiting ability to breathe CC: 5 year old presents to the office today with a cut on leg. HPI: Patient fell into window and has wound from glass. Current medication being used to treat:polysporin.happened Monday night. Seemed like a puncture. Still spotting blood, slight raised area. Do not think there is any glass in there. Seemed to be one solid piece that cut him. Has been mildly fussy for a few days. No other symptoms. ROS: No swelling or tenderness. No fever, no ear pulling, no cold symptoms SH: Lives with both parents ALLERGIES: No known allergies. Allergies have been reviewed with child s family and no changes reported. PE: Normal, well nourished, well hydrated. Eyes: general/bilateral. External eye: no hyperemia of the conjunctiva. Ears:general/bilateral. External auditory canal: normal, not bulging, no retraction of tympanic membrane. Intact. Nose: No rhinorrhea. Pharynx/Oropharnyx: normal. Neck: normal. Lungs: normal. Respiratory movements were normal, CV: normal. Heart rate and rhythm normal. No murmurs heard. Skin: 1 cm wound, left thigh +ecchymosis, no discharge, +tenderness. Turgor normal. Musculoskeletal system/general bilateral: normal. A/P: Wound, left thigh, overall looks good w/o signs of infections 32

33 ICD-10-CM Code S71.102A W19.XXXA ICD-10 Code Description Unspecified open wound, left thigh, initial encounter Fall (accidental) ICD-10-CM offers very specific code choices for wounds. The choices include: site of wound, laceration, puncture, open wound, with or without foreign body, laterality. In the HPI portion of this note the provider indicates that it seemed like a puncture ; however that was not specified in the final diagnosis. Also, in the exam portion of the note the provider indicates a laceration of left thigh. Since there are three specific types of wounds in this section of the ICD-10-CM coding book, the provider will need to be asked for the selection of the most appropriate diagnosis code in this case, and education should be provided on the specifics of the ICD-10-CM coding for this condition. Managing Reluctance to Change Provider (& other) apathy Flat salary, no incentive Employed vs. owner Coding reluctance before ICD-10 Already burdened (perception vs. reality) Too few doctors Too many demands Allocation of Scarce Resources Capital/Money Time Human Capital Rearranged Priorities Provider Shortages Too few coders (nationally never mind affordability) Revenue loss if production truly inhibited 33

34 Acceptance Commitment from Top-Down Identify Internal and External Resources Define impacted areas/staff Create defined multi-year plan Allocate Budget for plan Work the plan Train (All resources) Test, test, test (IT, EDI, staff) Communicate 5010 has happened ICD-10 transition needs to start now using a phased approach with timelines Budget planning needs to begin Understanding the differences between ICD-9 and ICD-10 is key Major impact on documentation Plan to mitigate risk to health center 34

35 Asthma severity chart: R-3_pocket_guide.pdf CMS ICD-10 Planning by CMS/AHIMA (MLN) port.pdf actices508.pdf ICD-10 Overview by CMS (MLN) 6.pdf 10OverviewPowerPoint.pdf 35

36 AHA ICD-10 Info erview.shtml AHIMA ICD-10 Info AAPC ICD-10 Info issues and concerns: