March 2013 How much physicians will engage in and support the implementation of ICD-10 has been a heated topic of water-cooler conversation for the past few years, as it has become common knowledge that many physicians consider learning the new coding system burdensome or impractical. Recent studies point to physicians as being the primary source of delay to ongoing ICD-10 implementation for reasons that may or may not make sense to those intimate with the healthcare coding and reimbursement industry. While implementing ICD-10 in physician practices will be costly, as it is not tied to any financial incentives, if not implemented correctly or in a timely manner it will cause delays in physician payment, directly impacting the practice s bottom line. This whitepaper will discuss the issues at stake as they relate to physicians and the implementation of ICD-10, and the risks associated with non-compliance. Inside Background: Issues at Stake 2 Risks 4 Getting Physicians to Listen 6 Example: Oncology 8 Clinical Documentation Improvement 10 Summary 11 Wolters Kluwer Can Help 12 Document & Policy Manager 12 Physician s Resource Center 12 ProVation MD 13 Because ICD-10 will allow physicians access to a level of clinical data specificity that ICD-9 could not come close to providing, resulting in better outcomes and better patient care, getting physicians educated so that proper testing can occur prior to final implementation should be a universal goal for every organization. This paper will also discuss creative ways to get physicians to listen and learn as well as the importance of a concise clinical documentation improvement program. While pairing physicians and ICD-10 into one thought may at first sound like an oxymoron, once you have read this whitepaper, you will understand that it is the only winning combination for successful ICD-10 implementation.
2 Background: Issues at Stake The primary role for physicians in ICD-10 implementation is that of a student: they should be focused on receiving the proper education related to accurate documentation in a timely way to assure that appropriate testing occurs prior to implementation. While the CPT/HCPCS codes, not diagnosis codes, will continue to drive reimbursement for outpatient services, including surgical services by physicians, it is still prudent for all physicians to clearly understand that in every instance, if the diagnosis code is invalid the physician will most likely not get paid. Physicians will need to incorporate ICD-10 CM diagnosis codes into their daily workflow and understand the specifics behind clinical documentation. They do not need to know how the surgical codes with ICD-10 PCS work, but they should clearly understand that incomplete documentation and inaccurate diagnosis coding will result in a delay in billing. This whitepaper will discuss the issues at stake as they relate to physicians and the implementation of ICD-10, and the risks associated with non-compliance. Because ICD-10 CM and PCS change every aspect of the game, it will require change management for successful implementation. It will affect every part of a healthcare organization; IT, HIM, billing, reimbursement and clinicians (physicians) just to start. But, of that group, physicians have the unique challenge to try and fit a new coding and reimbursement system into their daily clinical workflow a huge change in their world, which is focused on patient care. Unfortunately, most of the available change management information in the industry is written for hospital systems, not specific physician practices and practice management groups. Since implementation started in earnest in 2012, some physician practices have assigned a staff member to head up an ICD-10 task force. Many practices have worked hard to understand the clinical documentation program, but we have seen the majority of this on the hospital side. Unfortunately, it is a fact that many physician practices and practice management groups that are not affiliated with hospital systems have not even started the process at all. This is largely due to the fact that physicians are overwhelmed and looking to their health system to provide guidance. Much of this behavior can be attributed to the delay in the official implementation date from October 1, 2013 to October 1, 2014. Many physicians still question if this will be the final delayed deadline, causing some to waffle on implementation in 2014 and others to ponder whether ICD-10 is really going to happen at all.
3 Physicians that are part of a health system are smart to lean on their systems, but what about the non-affiliated? A study done by the AMA reported that the average physician practice that has adopted an EHR may spend up to 80 thousand dollars ($80K) to implement ICD-10 and those that have not adopted an EHR, up to two-hundred fifty thousand dollars ($250K) to implement ICD-10. While the cost associated with ICD-10 implementation is staggering, take a moment to consider what the numbers could be if practices ignored the implementation date for ICD-10 and faced lost or lingering revenue due to incomplete or inaccurate documentation. Some of the most recent polls reflect the issue at large: physician education is one of the biggest concerns related to ICD-10 to date. The snapshot below is a poll taken by ICD-10 Monitor on January 22, 2013. In relation to a Clinical Documentation Improvement Program (CDIP), what is your biggest concern related to I10? A. Creating a CDIP 11% B. Re-evaluating your CDIP 9% C. Staffing your CDIP 6% D. Educating your CDIP staff 12% E. Educating your Physicians 63% Response Ratio The following pages will focus on this major risk to implementation and take you through key steps toward mitigating that risk to ensure successful implementation. Specifically, this whitepaper will address the questions raised by many when planning physician engagement strategies for ICD-10 implementation: What are the risks associated with not getting physician buy-in? What will it take to get physicians to listen when there is the preconceived notion that ICD-10 may not be implemented? What are the key factors in a viable clinical documentation improvement program?
4 Risks Within a physician organization, as well as other provider organizations, the implementation of ICD-10 will impact many revenue cycle processes, clinical management systems, and reporting systems, ultimately placing added financial and operational risk on the organization. With no grace period, all HIPAA compliant entities will transition to ICD-10 on October 1, 2014. This unfunded mandate requires significant expense allocation by providers and payers alike, and the implications of a poor or failed implementation are significant, even beyond the staggering figures associated with implementation expenses. It is imperative that providers adequately plan, prepare and execute comprehensive implementation plans as October 1, 2014 will be here before you know it. While reimbursement to providers under the Medicare Outpatient Prospective Payment System and the Physician Fee Schedule are not directly impacted by the implementation of ICD-10 because reimbursement under those payment systems is CPT/ HCPCS procedure-based, there is still significant risk to those settings, as valid and complete diagnoses coding utilizing ICD-10 will be required for successful claim submission and adjudication. Furthermore, ICD- 10 will directly impact inpatient reimbursement due to an expected DRG Shift in which similar inpatient claims will be paid under a different DRG due to changes in grouping logic, specifically Complication and Comorbidity (CC) and Major CC designations. It is imperative that providers adequately plan, prepare and execute comprehensive implementation plans as October 1, 2014 will be here before you know it. Due to the greater specificity inherent to ICD-10 coding, clinical documentation to support detailed coding within the Medical Record (including physician orders) is a must. Incomplete documentation will cripple a provider or an organization s ability to appropriately and completely assign ICD-10 codes. As a result, providers could see impacts to their revenue cycle in several areas, including potential overall delays in reimbursement from the increase in completion time of individual revenue cycle processes. When ordering outpatient services, physicians play a huge role in providing diagnoses to support the ordered services at the highest level of specificity. Incomplete or insufficient diagnostic information at the point of ordering will potentially delay scheduling and registration processes, overall coding processes, increase the volume of queries to the ordering physician, increase overall billing cycle time, overall Accounts Receivable (A/R) Days, and potentially result in medical necessity questions and increased denials.
5 Likewise, inpatient documentation must be detailed and specific to support appropriate and complete ICD-10 codes assignment. Again, if clinical documentation is lacking and not enhanced through comprehensive Clinical Documentation Improvement (CDI) programs, accurate and complete code assignment may be in jeopardy. The downstream effects of inaccurate or incomplete clinical documentation are: inaccurate authorizations which can potentially jeopardize reimbursement; inconsistent coding between the physician and the hospital, potentially delaying claim adjudication failure to properly notify beneficiaries of potential noncoverage issues (ABN), resulting in non-payment; increases in physician queries to facilitate coding processes, delaying the billing cycle; inaccurate, incomplete or noncompliant ICD-10 code assignment, impacting reimbursement and increasing compliance risks; resulting failures in meeting medical necessity requirements, potentially jeopardizing reimbursement; inaccurate data used for Quality Reporting and Pay-for-Performance initiatives; increased A/R days as the ability to submit claims in a timely manner, claim acceptance and claim adjudication (e.g., payments and denials) will be at jeopardy; and increased patient dissatisfaction. Example: Claims with valid diagnosis and procedure coding, that pass medical necessity edits for both the physician (professional) and the hospital (technical), but the codes documented by the physician and hospital for the surgical procedure performed do not match. For Medicare, this can be detected via the Common Working File (CWF). A mismatch between the profession and technical codes can potentially delay payment to both parties. Example: Incomplete coding could raise questions of liability in the case of personal, auto, or workers compensation claims. So, it is clear that entities should ensure that processes are put in place to proactively and efficiently address clinical documentation issues in order to facilitate accurate and timely ICD-10 code assignment and compliance with the mandated change in code sets. Many physicians currently do not report external injury codes. The diagnosis code(s) drives this type of claim; therefore, without change and complete ICD-10 coding, the patient may receive a denial and claims adjudication will likely be slowed down.
6 Although the risks associated with clinical documentation are significant and can create a domino effect throughout an organization, additional aspects of implementation will contribute to overall organizational risk. The following aspects will further negatively impact the successful deployment and implementation of ICD-10 within your organization: inadequate training at varying levels within the organization; failure to address system readiness to process ICD-10 codes; failure to make administrative form, documentation, and policy updates; and, failure to assess and prepare for payer readiness These additional implementation obstacles can put reimbursement further at risk from suspended payments, delayed reimbursement or decreases in reimbursement, amongst others. They also undermine overall coding compliance, putting the organization at risk for increased audit activity. Furthermore, it cannot go without mention that failure to submit accurate Quality Reporting and Pay-for-Performance data will have a direct effect on your bottom line. Getting Physicians to Listen It is not too early to start educating your physicians on ICD-10. Use the next 18 months to create and execute a thoughtful training plan that is a path to a successful October 2014 implementation. Your training sessions do not have to be long, exhaustive, or have intensive material to review; rather start small and continually build upon your previous sessions. When training and educating physicians on ICD-10 make sure you are clear with what the training sessions will cover. Is it diagnosis coding or is it procedural coding? Are we discussing laterality today or is that next month? Avoid confusion by having and following a documented training plan it will keep all parties on track and allow for standardization of training to ensure nothing gets missed or inadvertently skipped over. Be as specific as possible and zero in on your subject matter so as not to confuse or overwhelm your physicians. Again, be prepared and organized so you won t waste the physician s time, or your own. Tailor your training plan and education as much as possible you may want to begin with a high-level, basic overview explaining ICD-10; how it is an improvement over ICD-9, the new structure, how it ties into other projects within your organization (meaningful use, Accountable Care Organizations, etc.) and when it will be implemented. For each of your different specialties, you will need to review the differences between ICD-9 CM and ICD-10 CM with the physicians. How you will train your Orthopedic physicians will be different from how you educate the Oncologists or Gastroenterologists.
7 Be sure to bring your ICD-10 search tools and codebooks to your educational sessions for physicians to reference so they can find what is meaningful to them. Physicians are multi-taskers by nature so if all you give them to do during your sessions is listen, they will have their personal electronic devices out and you will have lost their full attention. Take advantage of those devices and show them different applications they can download to assist them in the transition and to utilize in between your meeting times. For each of your different specialties, you will need to review the differences between ICD-9 CM and ICD-10 CM with the physicians. How you will train your Orthopedic physicians will be different from how you educate the Oncologists or Gastroenterologists. Review how the codes in their specialty have been improved upon, are more granular and consist of greater specificity. Explain how the new codes will support their patients stories accurately and completely. An example for many physicians would be Diabetes Mellitus, which will no longer be classified as controlled or uncontrolled. In ICD-10 CM, the codes are expanded to include the classification of the diabetes and the manifestation into six categories: Diabetes Mellitus due to underlying conditions, Drug or chemical induced Diabetes Mellitus, Type 1 Diabetes Mellitus, Type 2 Diabetes Mellitus, Other specified Diabetes Mellitus or Unspecified Diabetes Mellitus. Oncologists currently have 11 choices in ICD-9 CM for Malignant Neoplasm of the male/female breast; however, there will be 54 choices in ICD-10 CM. As you can see in the abbreviated excerpt below, the additional codes are related to laterality as well as specificity for either male or female breast with equal selections available for male in ICD-10 CM.
8 ICD -9 CM 174.0 = Nipple and areola (female) 175.0 = Nipple and areola (male) ICD-10 CM C50.0 =Malignant Neoplasm of nipple and areola C50.01 = Malignant Neoplasm of nipple and areola, female C50.011 = Malignant Neoplasm of nipple and areola, right female breast C50.012 = Malignant Neoplasm of nipple and areola, left female breast C50.019 = Malignant Neoplasm of nipple and areola, unspecified female breast C50.02 = Malignant Neoplasm of nipple and areola, male C50.021 = Malignant Neoplasm of nipple and areola, right male breast C50.022 = Malignant Neoplasm of nipple and areola, left male breast C50.029 = Malignant Neoplasm of nipple and areola, unspecified male breast 174.1 = Central Portion (no specific male code) C50.1 =Malignant Neoplasm of central portion of breast C50.11 = Malignant Neoplasm of central portion of breast, female C50.111 = Malignant Neoplasm of central portion of right female breast C50.112 = Malignant Neoplasm of central portion of left female breast C50.119 = Malignant Neoplasm of central portion of unspecified female breast C50.12 = Malignant Neoplasm of central portion of breast, male C50.121 = Malignant Neoplasm of central portion of right male breast C50.122 = Malignant Neoplasm of central portion of left male breast C50.129 = Malignant Neoplasm of central portion of unspecified male breast 174.2 = Upper-inner quadrant (no specific male code) C50.2 =Malignant Neoplasm of upper-inner quadrant of breast C50.21 = Malignant Neoplasm of upper-inner quadrant of breast, female C50.211 = Malignant Neoplasm of upper-inner quadrant of right female breast C50.212 = Malignant Neoplasm of upper-inner quadrant of left female breast C50.219 = Malignant Neoplasm of upper-inner quadrant of unspecified female breast C50.22 = Malignant Neoplasm of upper-inner quadrant of breast, male C50.221 = Malignant Neoplasm of upper-inner quadrant of right male breast C50.222 = Malignant Neoplasm of upper-inner quadrant of left male breast C50.229 = Malignant Neoplasm of upper-inner quadrant of unspecified male breast
9 The increase in codes can easily create anxiety, so make it simple for your physicians. Demonstrate to the physician that they should have no trouble documenting the location of the neoplasm as it is more than likely already available to them within the radiologist s report from the patients mammogram. Orthopedics will see a dramatic increase in codes, rising to roughly 1,800 in ICD- 10 CM, although most are related to specificity. Before you meet with your physicians, be prepared to break down and pinpoint the four key concepts necessary for accurate and efficient orthopedic coding in ICD-10: location, laterality, type of fracture and type of visit. Providing the additional information will not translate into mountains of extra work for them and is no more than what they should be providing for quality care purposes. As you can see below, the required information is eight additional words: ICD-9 CM ICD-10 CM 822.0 = Patella Fracture, closed S82.025A = Nondisplaced longitudinal fracture of left patella, initial encounter for closed fracture When you are reviewing documentation with physicians, include what they are doing correctly! No one wants to hear what they are doing wrong and how much extra work they will have to do. Trumpet their successes if they have been consistently documenting side or an underlying condition, highlight their triumph and let them know it is correct and to keep up the good work. Recognize what is already accurate within their notes, focus on what they don t have to change and then thoughtfully build in what needs to be updated. With 18 months until implementation day, you have the time to incorporate documentation improvement processes into their day-to-day workflow without creating an atmosphere of urgency that could potentially undermine your efforts and hard work. Take advantage of the extra time created by the year delay and do it right! There is a physician or two within your organization that loves a new challenge. Invite them to join the education team then leverage their skills, knowledge and talent to assist with building the training plan and other educational opportunities. Physician champions will help fine-tune your training strategy by conveying what will work for training, what will not, and why. They will be able to assist you in breaking down barriers and reaching those physicians who do not handle change well or think ICD-10 is only a coder issue.
10 Your champions will be able to articulate in physician terms why the change is happening and how it will affect the organization. Ask them to help illustrate the positives of ICD-10: the breadth, granularity and specificity of codes which will allow physicians to paint a clear picture, presenting a precise story of the patient s health. Insufficient documentation for accurate coding under ICD-10 will impact patient safety, patient outcomes, compliance and the revenue cycle. Educate and provide proper follow through on documentation requirements that allow for the accurate and efficient coding necessary so as not to cause significant impact on revenue. Physicians do not need to know the finite details of how the ICD-10 coding system works, but both the importance of complete and proper documentation and their role in producing it needs to be clearly understood. Coders must be able to translate clinical information from the physician s report into the new ICD-10 codes and incomplete documentation will result in queries back to physicians, increasing everyone s workload while delaying the billing process. Clinical Documentation Improvement Detailed clinical documentation has always been essential, and wide-scale adoption of electronic health records provides an opportunity to systematize the practice of accuracy, specificity and completeness. Specifically, appropriate diagnostic and procedure code assignment are essential for registration, authorization and certification processes, for proper claims submission, and to justify care provided in the event of a retrospective review. Furthermore, CMS is moving towards the adoption of electronic specifications for quality reporting, which will make it necessary to document compliance with key quality measures within your EHR. The effects of poor documentation within your EHR ripples out to produce payment delays, challenges with meeting quality reporting requirements, and increased risk of audit and review. The effects of poor documentation within your EHR ripples out to produce payment delays, challenges with meeting quality reporting requirements, and increased risk of audit and review. Since ICD-10 is the core vocabulary used to catalog the patient s state of health, it is also a key driver for coordination of care, and because ICD-10 is more detailed, it demands that clinical documentation be as specific as the descriptions within the code set. Because of the passage of E.H.R. Meaningful Use Incentives by Medicare, most clinical settings in the U.S. are currently deeply entrenched in the creation, revision and maintenance of electronic health record workflows including customizing encounter forms, pick lists and other types of documentation. Improving the workflow for ICD-10 isn t radically new work, it simply requires a refocusing of
11 these existing work efforts with an eye towards the future. Regardless, it is very time consuming and resource intensive work, so it is important to begin now and spread the workflow changes out over the next 18 months. While the ICD-10-CM code set does not go into effect until 2014, existing documentation templates can be revised today to prompt clinicians for increased specificity where necessary in the future. Essentially, the guidelines and code descriptions need to be codified into the documentation work flow to ensure all appropriate information is captured for both the claim and for patient care. Fortunately, this is often information that is within the narrative section of the medical record, and the work may involve moving the precise location for clinician documentation from a free text area to a pick list or encounter form section that is used for code capture and claims processing. In some clinical areas, however, be aware that an entirely different axis of classification or terminology is used. Summary While the physician s role in ICD-10 is crucial to every organization s bottom line, changing physician attitudes and behavior will be one of the greatest challenges in the implementation of ICD-10. To effectively educate physicians to transition from ICD-9 to ICD-10, be sure to craft educational strategies that play to physician strengths and weaknesses, yet clearly emphasize the risks of not moving forward. Additionally, help physicians understand that successful implementation is directly related to their documentation in the medical record. Taking the steps to create a solid clinical documentation improvement program, including a clear and concise physician education component will be the key to a thriving ICD-10 implementation program. You may find your biggest allies amongst your physicians if you can get them to understand the greatest benefit of ICD-10: ICD-10 will provide detailed data for analysis, resulting in better patient care and quality physician outcomes. Below we will discuss some of the Wolters Kluwer solutions that are available to help pave the way to your successful ICD-10 implementation.
12 Wolters Kluwer Can Help Wolters Kluwer understands the challenges that small and large physician practices face and has solutions to support your successful implementation of ICD-10. ComplyTrack Document & Policy Manager Part of your Clinical Documentation Improvement and Education Program will include revising and introducing new policy documents for staff members. Use the ComplyTrack Document & Policy Manager module to provide staff with an easyto-access location for policies and version tracking with a streamlined revision and approval process. It can even be integrated with links to primary source regulations within any of our research products. For your Medical Policy Documents, you can work concurrently in the ICD-10 Explorer and Document and Policy Manager to translate your policies from ICD-9 to ICD-10, and include links to automatically updated manuals, LCDs, and coding/ payment tools within your subscription. Physician s Resource Center The Physician Resource Center is a useful tool for any specialty providing your practice with the essential tools you need to stay compliant with Medicare and to ensure accurate and efficient coding and reimbursement. Whether you access the Physician Resource Center via your laptop, smart phone or ipad, empower staff throughout your organization to understand and keep up with regulatory, coding, coverage, payment, and quality reporting issues specific to their specialty or area. Each specialist can create customized stored searches for key terms relevant to their department or area of focus. Your team will have a coherent and simplified coding and reimbursement workflow with the Physician s Resource Center, including enhanced electronic ICD- 10-CM and ICD-10-PCS books to provide the context staff need to understand the coding system. Easy to use diagnosis and procedure code, drug, and ICD-10 explorer tools allow for quick key word search to find appropriate procedure and diagnosis codes, plus they all integrate to up-to-date local and national coverage determinations for medical necessity review. Physician Quality Reporting cross coding is included as well!
13 ProVation MD Software that automates the documentation and coding process can ease the transition to ICD-10 and shorten the learning curve for physicians. When considering an automated solution, you will want to look for one that will: Drive comprehensive documentation. Capture the high level of detail necessary for ICD-10. Guide the physicians through the process of documenting with enough specificity and granularity to ensure appropriate coding. You do not want something that could potentially lead your physicians. Review what options a system has available, are you allowed to skip any areas that aren t pertinent to your case? Is there an area to document side so that the note is as specific and as granular as it needs to be? A professional who is thoroughly educated in ICD-10 should be involved in the evaluation process from the beginning to ensure that the software is prompting for relevant questions. Assess to make sure a system will not require additional system configurations in the future and that the software can extract information from documentation in multiple sources used by different specialties or functional areas. This requires a clear understanding of data content standards and effective coordination and management of your organization s data requirements. The professional does not have to be a coder it can be an administrator, physician champion, HIM director or combinations of people depending on your organization s size, structure and budget. The efficiencies inherent in technological solutions to provide significant support are just one piece of an overall ICD-10 readiness strategy. A solid combination of both CDI strategies, including education and training of the physician and technology, is required for a smooth, successful transition to ICD-10. It is imperative that automated solutions do not replace educated and trained coders. You will still need them to review and audit the documentation. For instance, what if your provider added free or unstructured text? You will still need an educated coder to review the material for accuracy and to ensure the codes match the documentation before sending the claim out the door. This validation process for the coder can be facilitated by the use of ProVation Coding Plus (Coding Plus), the coder s one-step reference spot for HCPCS, CPT, ICD-9-CM, APC, MS-DRG, NCCI and much more. The efficiencies inherent in technological solutions to provide significant support are just one piece of an overall ICD-10 readiness strategy. A solid combination of both CDI strategies, including education and training of the physician and technology, is required for a smooth, successful transition to ICD-10.