Implementing ICD-10 and the New Administrative Simplification Standards: A Step by Step Guide for Medical Groups Robert M. Tennant Senior Policy Advisor MGMA Government Affairs rtennant@mgma.org Step One: Understanding the What and the Why of ICD-10 Rule Development Timeline 1996 HIPAA includes ICD-10 placeholder 2003 NCVHS hearings 2005 Congressional hearing (HR 4157) 2008 NPRM January 16, 2009-Final rule October 1, 2013 Original compliance date for implementation of ICD-10-CM and ICD-10-PCS. October 1, 2014 Revised compliance date for implementation of ICD-10-CM and ICD-10-PCS. No grace period and/or extension per CMS! 1
The ICD-10 Challenge ICD-10 is the biggest change in healthcare in over 20 yrs The most significant overhaul of the medical coding system since the advent of computers Implementing ICD-10 will impact every system, process and transaction that contains or uses a diagnosis code Major changes of ICD-10 include: Codes use alphanumeric characters Combination of diagnosis/symptom codes Laterality Expanded potential digits Why Replace ICD-9-CM? Proponents argue that: Almost 30 years old (outdated, obsolete codes) Rapidly running out of space (more so in PCS than CM) Evolving healthcare data needs Comparison with international data is hindered Increased sensitivity when refining grouping and reimbursement methodologies Enhanced ability to conduct public health surveillance Decreased need to include supporting documentation with claims Misconceptions About ICD-10 Implementation Only a back office and coder issue Only an IT issue My PM and CH vendors will take care of this for me The compliance date now Oct 2014 there is no rush ICD-10 will have little impact on my business processes There won t be any impact on productivity or revenue If I ignore it it might just go away 2
ICD-9-CM vs. ICD-10-CM ICD-9-CM 3-5 digits or characters 1st character is numeric or alpha (E or V codes) 2 nd 5 th characters are numeric Decimal placed after the first 3 characters 17 Chapters and V & E codes are supplemental ~13,000 codes ICD-10-CM 3-7 digits or characters 1 st character is alpha (all letters used except U ) 2 nd 7 th characters can be alpha or numeric Decimal placed after the first 3 characters 21 Chapters and V & E codes are not supplemental ~69,000 codes Crosswalks Mapping codes between ICD-9-CM and ICD-10-CM CMS General Equivalence Mapping (GEM)-not a 1 to 1 crosswalk from ICD-9-CM to ICD-10-CM Mappings will be used to: Convert and test systems and analyze data before and after Link data in long-term clinical studies Develop application-specific mappings Analyze data collected during transition period and beyond ICD-10: Still in Flux? Of all the HIPAA/HITECH/ACA administrative provisions, ICD-10 is the only one where ROI for medical groups is unproven Provider organizations have consistently raised concerns to CMS regarding cost, timing, alternatives, lack of resources, too much going on Clinical staff will need to be engaged, trained Clearinghouses cannot solve all claim issues Why was the 2013 date moved? Will Congress act? 3
Step Two: Determine the Potential Impact of ICD-10 Critical Impact Area: Changes to Software EHR / decision support / other clinical systems Practice management systems Billing systems Encoding software Medical record abstraction systems Scheduling and registration systems Accounting systems Quality management systems Test ordering systems Impact on Practices Statistics / research / historical benchmarking (Longitudinal data captured in ICD-9-CM) Trend analysis / Utilization management Disease management HEDIS Reimbursement and contracting Fee schedules / contracts Proprietary health plan payment policies could require time of service access to plan information 4
Impact Areas Redesign of superbills (one AAFP test converted a one page superbill into 11 pages when moving to ICD-10 Form Changes (CMS 1500, UB 92, X12 837, 270) Workflow-data capture, data usage (claims) Increase needed in system storage capacity Impact Areas Need for greater coder understanding of anatomy and physiology by staff Transition period Potential for billing delays due to coding backlogs (internal/external) Dual use of ICD-9 and ICD-10 (WC?) Rejected claims (how can the required data be identified post visit?) 14 Determining the Potential Impact Action plan: Create internal ICD-10 Team (sr management, medical staff, billing/coding, information systems, reporting) Create a spreadsheet/other way of tracking steps/issues Identify the impact areas Prioritize in terms of potential impact to staff, workflow and revenue (consider rating by impact: high, medium, low) Identify internal and external contacts Assign internal staff for specific duties 5
Step Three: Build Internal Awareness and Create an Implementation Timeline Building Internal Awareness Expect push back, especially from physicians (AMA HOD votes) Explain new timing from CMS Originally Oct. 1, 2013, now compliance will be Oct.1, 2014 Explain consequences of inaction! Potential of higher cost and/or disruption of claims revenue cycle Potential of not identifying adequate coding support Building Awareness /Establish a Timeline Action plan: Educate practice staff on the reality and impact of ICD-10 Consider peer to peer communication Create a reasonable timeline, include action steps and assign staff Collect tools and resources Include regular updates at staff meetings, internal communications Network with your colleagues to identify and solve problems 6
Step Four: Conduct an Internal Systems Assessment Conduct an Impact Assessment Your internal analysis should review: Practice infrastructure Computer systems (core systems, key business area applications, non-essential) All workflow processes that utilize codes Information management (data, extracts, reports, etc) Linkages to other business areas and external entities Documentation issues Code assignment processes Impact Assessment Questions Action plan: ask the critical questions Which vendor applications do we use for these codes? How are ICD-10 codes currently used in each information system? What is the current character length specification? How are the codes entered are they manually entered or pulled in from another system? Do we have or do we need to have the ability to maintain and utilize both ICD-9 and ICD-10 data? Will we have the ability to implement an internal testing process? Do we need outside help? 7
Step Five: Create an ICD-10 Budget Estimated costs to move to ICD-10 There are many estimates of the initial and ongoing costs to moving to ICD-10. Rand Study (2002) Conversion $425M to $1.15B $5M to $40M a year in lost productivity BCBSA (2002) Conversion $5.5B to $13.5B $150M to $380M a year in lost productivity Both estimates presented to NCVHS MGMA, AMA, 9 other organizations, commissioned a new study, released in 2008 MGMA Estimated Costs to move to ICD-10 Typical Small Practice (3) Typical Medium Practice (10) Typical Large Practice (100) Education $2,405 $4,745 $46,280 Process Analysis $6,900 $12,000 $48,000 Changes to Superbills $2,985 $9,950 $99,500 IT Costs $7,500 $15,000 $100,000 Increased Documentation $44,000 $178,500 $1,785,000 Cash Flow Disruption $19,500 $65,000 $650,000 Total $83,290 $285,195 $2,728,780 8
Cost to upgrade or replace PM/EHR for a 10 FTE Practice = $201,690 Approximately how much will it cost, or did it cost, to upgrade or replace your Practice Management System? Average cost per FTE physician: $10,190 Approximately how much will it cost, or did it cost, to upgrade or replace your EHR? Average cost per FTE physician: $9,979 Additional Areas of Potential Cost Project cost (time NOT spent doing other productive activities) Documentation review (additional person to review? Mapping cost (consultant needed?) Additional staff (temporary or contract) or overtime during learning curve Revenue Impacts of specificity Denials Additional documentation production Loss of productivity rebills, rejections, EOB work, medical necessity rejections/follow up, coder slow down Developing a Comprehensive Budget Action plan: budget for the following: Assessment costs IT infrastructure (software/hardware) Contract revisions (legal) Super bill or other code assignment process Staff time and clinician productivity losses Consulting services Cash flow disruptions and contingencies (line of credit, $ reserves, postponing of capital projects 9
Step Six: Understand the Impact on Clinical Documentation Impact of ICD-10-CM on Medical Record Documentation Detailed medical record documentation is required if coders are to code to the highest degree of specificity Non-specific unspecified codes are available to use when detailed documentation is unavailable, but be careful! It is true that a more detailed documentation will result in a more accurate clinical picture and better data but Expect a 15% increase in documentation time (per AAPC) Impact of ICD-10-CM on Medical Record Documentation Documentation issues to consider: Documentation of Additional Symptoms or Conditions Associated and/or Related Conditions Cause of Injury Dominant vs. Non-dominant Side Remember that coders can only code what they see in writing, in front of them (especially critical if you utilize offsite coders) Consider workflow implications (post visit) 10
Internal Coding Action Steps Action plan: Evaluate the extent of code changes specific to your specialty Review documentation to assure that it is adequate to support new coding systems Decide what is best approach for code assignment Superbills /book/computer program/app Consider testing options: Use old claims and attempt to assign ICD-10 codes Dual code 31 Step Seven: Clinical and Administrative Staff Training Staff Training-General Plan Implement ICD-10 education for impacted staff Begin by identifying education needs: Who requires training What (type (yp and level) training How should they be trained Key issue when should each group be trained? Too early will require re-training, too late it may be difficult to get a slot recommended timing: 6-9 months before for coders, 3-6 months ahead for physicians 11
Training Action Steps Action plan: Wide variety of training opportunities and materials available through professional associations, online courses, webinars, and onsite training If you have a small practice, think about teaming up with other local providers. You might be able to: Train one staff person from the practice, who can in turn train other staff members Hire one trainer for multiple practices Have a super user who can assist multiple clinicians or even practices Step Eight: External System Impact Assessment and Testing Work with your Key Vendors Software action plan questions: Vendor readiness Vendor timeline for installation / testing Modules or interfaces Will YOUR version of the software be upgraded? Will you require any hardware upgrades? Are they offering any training? Expected cost 12
Work with your Key Vendors Clearinghouse action plan questions: What ICD-10 services will you provide? Is my submission format appropriate? What will be the cost of the service? When can you accept test claims? Can you run a report of my denied/pended claims? Can you run a report identifying my use of unspecified ICD-19-CM codes Are you offering any training opportunities? Health Plan Questions Action plan, talk to your clearinghouses / plans and ask: When will your upgrades to your systems to accommodate the ICD-10 codes be completed? How can you help me in this transition? What will be the impact of Medicare NOT testing? When can I send claims and other transactions with ICD- 10 codes to you so you can test that they will be accepted? Will you be utilizing the CMS ICD-10 GEMs/crosswalks? When will you let us know coverage/payment changes? Will you provide me a list of the data content changes I need? Step Nine: Ongoing Review and Maintenance 13
Outstanding Issues Readiness level of vendors, payers, others If 4010, NPI and 5010 are any indication. What will workers comp do with ICD-10? Resource allocation to manage all requirements: 5010/ICD-10 Quality reporting programs Admin simplification Meaningful use Outstanding Issues Industry cross-walks What will the payers do? Plan payment policies: granularity requirements What will the payers require? How will reimbursement be changed? Could it lead to o Current payment: $100 o Under ICD-10-CM: Unspecified code = $50 Granular code = $100 From BCBSNC: Some impediments to timely reimbursement will be the use of ICD-9 codes after 10/1/2013, the use of truncated codes, and the use of Not Otherwise Specified codes where specificity is available. Ongoing Issues and Maintenance Action plan: Watch for any announcements of/changes to: Compliance dates, federal plan payment/documentation policies Commercial plan payment/documentation policies Vendor announcements Be watchful of variances in clinician productivity Some staff may require additional training and/or monitoring Keep on top the readiness level of your external readiness Identify any issues/roadblocks as early in the process as possible Evaluate issues and assign resolution to staff 14
Section 1104 of the ACA Chicken and Egg Issue Solved In 2006 practices spent an average of $68,274 per physician per year (roughly $31 billion) interacting with health plans (Health Affairs, Casalino et al., 2009). Previously-each stakeholder blamed the others for why providers didn t have administrative functionality Providers didn t want multiple proprietary solutions Payers didn t want to offer solution that only small number of providers will adopt With no single approach, no market for vendors HIPAA/ACA/MU etc solves, at least in part, this issue ACA 1104 Wish List Required Operating Rules Eligibility verification and claim status (2013) EFT standards and operating rules (2014) Other HIPAA transactions (2016) Health Plan Identifier Claims attachments (2016) Plan certification and enforcement (2014) 15
Eligibility Operating Rules Previously, practices would: Pick up the phone and attempt to verify eligibility Log on a proprietary plan website Employ the submit claim and cross fingers technique Play chase the patient for the outstanding balances With new operating rules practices will receive: Health plan name and coverage dates Static financials (co-pay, co-insurance, base deductibles) Benefit-specific and base deductible for individual and family In/out of network variances Remaining deductible amounts ACA Section 1104 Action Steps Assess your current claims revenue cycle processes Does your current PM system leverage the HIPAA transactions? Which ones now, which ones does it have the capability to? Do you use manual processes for any of these transactions? What staff does what and how efficient are these processes? (Hint, just because your practice has been using them for a long time, doesn t make them efficient.) Do you pay a billing service or clearinghouse for transactions, if so, which transactions and how much? Review your options for increasing your level of automation: PM upgrade PM replacement Web-based vendor solutions ACCESS the AMA-MGMA Selecting a PMSS Toolkit Summary and Key Points 16
Summary Implementing ICD-10 is NOT just an IT project it impacts business processes and may impact other systems Keep on top of all industry developments Create internal change team and identify a clinical leader Create a multi-year upgrade and training budget Clinician documentation critical to prevent claim denials Implementation will be heavily dependent on when vendors have upgrades ready and when they can be installed Testing with trading partners is extremely important Look at the ROI with ACA Robert Tennant Senior Policy Advisor MGMA Government Affairs rtennant@mgma.org (202) 293-3450 Questions? Resources Admin Simp Mgma.com/adminsimplify CMS Admin Simp http://www.cms.gov/ MGMA ICD-10 Mgma.com/icd10 CMS ICD-10 Web Pages http://www.cms.gov/icd10/ http://www.cms.gov/transactioncodesetsstands/02 _TransactionsandCodeSetsRegulations.asp 17
Resources 52 CDC Web Page (General ICD-10 information) http://www.cdc.gov/nchs/about/major/dvs/icd10des.htm ICD-10-CM files, information and GEMs between ICD-10-CM and ICD- 9-CM http://www.cdc.gov/nchs/about/otheract/icd9/icd10cm.htm ICD-10 home page (WHO) http://www.who.int/whosis/icd10/index.html NCHS Basic ICD-10-CM information http://www.cdc.gov/nchs/about/otheract/icd9/abticd10.htm CMS ICD-10-PCS information http://www.cms.hhs.gov/icd10/02_icd-10-pcs.asp WEDI ICD-10 Implementation www.wedi.org Toolkit Appendix 18
New CMS-1500 Claim Form New Features to ICD-10-CM Combination codes for conditions and common symptoms or manifestations E10.21 Type 1 diabetes mellitus with diabetic nephropathy Combination codes for poisonings and external causes T42.4x5A Adverse effect of benzodiazepines, initial encounter Added laterality (left vs. right) M94.211 Chrondromalacia, right shoulder Added 7 th character extensions for episode of care S06.01xA Concussion with loss of consciousness of 30 minutes or less, initial encounter Expanded codes (injuries, diabetes, alcohol/substance abuse, postoperative complications F14.221 Cocaine dependence with intoxication delirium New to ICD-10-CM Injuries are grouped by anatomic site rather than by type of injury. Diseases of the sense organs (eyes & ears) have their own chapters, no longer part of Nervous System chapter. Inclusion of trimesters in obstetric codes (and elimination of 5 th digits it for episode of care) O99.013 Anemia complicating pregnancy, third trimester Change in timeframes specified in certain codes Acute myocardial infarction time period changed from 8 weeks to 4 weeks Full code titles for ALL codes (no reference back to common fourth and fifth digits). Post-op complications have been moved to procedure-specific body system chapters. 19
Combination Codes Examples I25.110 Atherosclerotic heart disease of native coronary artery with unstable angina pectoris E11.311 Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema K71.51 Toxic liver disease with chronic active hepatitis with ascites K50.012 Crohn s disease of small intestine with intestinal obstruction N41.01 Acute prostatitis with hematuria ICD-10-CM Specificity Examples S72.044G Nondisplaced fracture of base of neck of right femur, subsequent encounter for closed fracture with delayed healing I69.351 Sequelae of cerebral infarction, Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side Z48.21 Encounter for aftercare following heart transplant GEM Examples ICD 9 CM Code Diagnosis ICD 10 CM Code V20.2 Routine infant or child examination V04.81 Need for prophylactic vaccination and inoculation Z00.129 (Encounter for routine child exam without abnormal findings). Z00.121 (Encounter for routine child exam with abnormal findings). Use additional code(s) to identify abnormal findings. Z23 (Encounter for immunization). At this time in ICD 10 CM there is only one code for immunizations. 401.1 Hypertension, benign I10 (Essential [primary] hypertension). ICD 10 CM does not differentiate between hypertension that is controlled or uncontrolled, benign or malignant and there is only one code. 427.31 Atrial fibrillation I48.0 (Atrial fibrillation) I48.1 (Atrial flutter) 786.50 Chest pain, unspecified R07.0 (Chest pain, unspecified). ICD 10 CM expands upon chest pain symptoms and unspecified code may no longer be necessary. 465.9 URI J06.9 (Acute upper respiratory infection, unspecified) 724.2 Lumbago M54.5 (Low back pain) 466.0 Bronchitis, acute J20.0 (Acute bronchitis, unspecified). ICD 10 CM includes 10 choices for acute bronchitis. Copyright 729.5 2013. Medical Group Management Limb Association pain(mgma ). All rights reserved. M79.604 (Pain in right leg) 20
CAQH EFT Enrollment Solution Overview Web-based based data entry for provider EFT enrollment information. Alignment with CORE ERA / EFT Operating Rules for definition of the standard enrollment data set and supporting documents. Web-based access portal for health plan customers. Provider adoption campaigns / integration with UPD to electronically promote the CAQH EFT enrollment utility to UPD provider users. Provider support center. Voided check and other uploaded document processing. Pre-note transactions via ACH partners to validate bank account information. www.caqh.org 21