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  • 1. Click space bar to continue
  • 2. Dear Staff: Thank you for taking the time to complete this mandatory learning module on the ICD-10 transition. This general overview is just that – A general overview. It is not intended to give you extensive knowledge, nor do we expect you to be subject matter experts. It is meant to be a tool to assist you with a basic understanding of the upcoming changes and the challenges the transition will present. We hope you find this information helpful. Enjoy! This overview should take about ½ hour to complete, including the short quiz at the end. Click space bar to continue
  • 3. • General Overview of ICD-10, not comprehensive • Provide understanding that Status Quo is Unsustainable Click space bar to continue
  • 4. Click space bar to continue
  • 5. • The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) • System used by physicians and other health care providers to classify and code all diagnoses, symptoms and procedures recorded in conjunction with hospital care in the United States. Click space bar to continue
  • 6. • ICD-9 is over 30 years old • Outdated terms • Limited in the number of new codes • Limited data about patient’s medical conditions and hospital procedures • Last industrialized nation to adopt ICD-10 Click space bar to continue
  • 7. • ICD-10 is NOT just a coding project or IT upgrade. It has to be a well thought out strategic initiative utilizing time, money and resources. • Decrease in physician productivity. • Decrease in revenue cycle efficiency. • 1-Day Conversion: All will change on 10/1/14. • Cash flow is very much at risk: No uniformity of medical necessity across payers. Click space bar to continue
  • 8. ICD-10 Productivity Impact • Issues with improper and returned claims may account for an estimated $329 million in productivity losses in 2015.1 • For physician practices, ICD-10 implementation will cost an estimated $28,500 per physician.2 1. “Cost of ICD-10 Conversion: Medium Group Practice (10 Physicians)” Health Data Management Magazine, August 1, 2010, http://www.healthdatamanagement.com/issues /18_9/health-care-technology-news-icd-10-cost-40914-1.html 2. Clark, “ICD-10 Cost, Timing Concerns Explain AMA Vote” 2011. Click space bar to continue
  • 9. The Benefits of Transition: • Alignment of the US with coding systems worldwide • Improved ability to track and respond to international public health trends • Greater coding accuracy and specificity • Higher quality information for measuring healthcare service quality, safety, and efficiency • Improved efficiencies and lower costs • Recognition of advances in medicine and technology • Space to accommodate future expansion Click space bar to continue
  • 10.  The IDC-10 Final Rule was published on January 16, 2009 which identified the timeline for ICD-10-CM. Original implementation was scheduled for October 2013 but a one year delay was approved. Implementation is now scheduled for October 1, 2014. The United States is the last developed country to migrate to ICD-10. However, we are a multi-payer system using it for reimbursement, unlike other countries, which complicates our transition. Click space bar to continue
  • 11. Who? This transition will have a major impact on anyone who uses health care information that contains a diagnosis and/or inpatient procedure code, including: • Hospitals • Health care practitioners and institutions • Health insurers and other third-party payers • Electronic-transaction clearinghouses • Hardware and software manufacturers and vendors • Billing and practice-management service providers • Health care administrative and oversight agencies • Public and private health care research institutions Before ICD-10
  • 12. After ICD-10 Implementation Click space bar to continue
  • 13. We continue to monitor the MVA and worker’s comp insurances. Although not required to transition, some will.....some may not. We will provide more information as it becomes available. This will necessitate ability to dual code. Click space bar to continue
  • 14. Enterprise-Wide Impact: • Information Systems: • Broad range of impacted systems • Coordinated testing of all impacted systems • Reporting • Training • Coding • Drop in productivity • the keying of a combination of alpha and numeric keys will slow down even the most experienced coders • Talent Shortage • Physicians • Documentation Specificity • Increase in documentation time, coding questions Click space bar to continue
  • 15. • Finance: • Increase in A/R days • Impact to cash flow • Revenue Cycle: • Increase in denials, inquiries, and claims adjustments • Payer contract renegotiations • New authorization processes Click space bar to continue
  • 16. Impact on the Revenue Cycle:  ICD-9 evolved over time  ICD-10 is a massive one day “earthquake” that will disrupt this equilibrium  “Aftershocks” of changes to reimbursement for 3, 6, 12 months of rapid change will occur Click space bar to continue
  • 17. • Patient access functions will have a greater impact than many realize, education and training around authorization and medical necessity will be important! • Due to an increase in code volume, more procedures will require authorization. • ICD-10 codes are required on requests, prior to 10/1/14, for dates of service after 10/1/14. Patient Access – Referral , Scheduling, Pre-Certs/Authorizations Click space bar to continue
  • 18. Revenue Cycle: Service Delivery Added complexity in the authorization process will require increased involvement from clinical resources for retro or extended authorizations.  Physician documentation will need to ensure that medical necessity, appropriateness of care and proper authorization is obtainable.  Payers will focus more heavily on clinical documentation during the appeals process, therefore staff will need to be more involved in the denials management process. Centers of Medicare and Medicaid Services (CMS) predicts claims error rates will reach a high of 6 – 10% in comparison with the average 3% error rate with ICD-9 Click space bar to continue
  • 19. Physician Documentation • Insufficient documentation to support the specificity required for the new ICD-10-CM code sets will be one of the largest problems after the October 1, 2014 implementation. • If an office is fully prepared for ICD-10-CM, but clinical documentation has not improved, accurate coding and proper payment will not be feasible. It has been widely noted that a small % of today’s documentation is actually ready for the transition from ICD- 9 to ICD-10 coding. Click space bar to continue
  • 20. Revenue Cycle: Physician Documentation • Coders can’t code • Greater increase in physician queries impacting physician productivity • Increased A/R days due to slowed claims If documentation does not meet requirements…… Click space bar to continue
  • 21. What Can We Expect? Adverse short-term impact on practice revenue stream : The transition between coding systems might slow down the practice’s revenue stream. The following may occur as a result of the ICD-10 transition: • Payers may not be ready to make the transition, which can result in slowed processing and payment of claims and more denials. Payers may examine claims more carefully to identify potential duplicate billings and/or payments for service dates before and after October 1, 2014. For example, the same claim submitted once under the ICD-9 coding system and again under ICD-10. Click space bar to continue
  • 22. • Payers may make more requests for medical records to substantiate specific claims. • Expect that staff will need to follow-up with payers more often about claim payment delays, denials, referrals, and other administrative activities that may affect claim payment during and after the transition period. Expect higher call volumes to report and resolve claim/authorization rejections due to incorrect coding. • Expect the need to emphasize to physicians and other clinicians the critical importance of proper clinical documentation, and periodically audit sample records for completeness, accuracy, and consistency with related claims. Click space bar to continue
  • 23. Need for Modification of Front-End Procedures: Prior Authorizations/Certifications: Prior authorization has come to the forefront partly due to the cost savings it can bring to the payers and its ability to approve procedures based on medical necessities. Providers, on the other hand, are burdened by the undue pressure placed on them due to the high number of services that must be authorized before they are performed. On the other side of the health care spectrum, patients are also frustrated due to the delay caused in the turnaround of the authorizations from the payers. The next slide includes a few areas provider organizations should carefully consider as they move forward with their ICD-10 implementation programs. Click space bar to continue
  • 24. Diagnosis code submission Diagnosis codes play a key role in the approval of prior auth requests. With ICD-10 implementation, these new codes have increased significantly and present a challenge to the provider who must use the correct codes for prior auth requests. Procedure code submission Submitted ICD-10 codes need to match the procedure codes requested to ensure timely approval of authorizations. Incorrect mapping might lead to denials and non-payment. New Procedures Providers will have to train their employees, including auth requestors, on the new procedures (i.e., C-section), which might require prior authorizations. Since these are common procedures and do not require previous authorization, it becomes a bottle neck for the staff to handle the huge volume of auth. submissions. Authorization Delays Due to the existing manual process, information provided in the forms is not sufficient for payers to make a quick decision. Because of this, the payers end up calling the providers for additional information to approve the request. Patient Care Due to payers requesting additional services for prior auths, delays caused in approving the requests due to the existing manual process and the introduction of additional codes with ICD-10 have put excessive pressure on the providers to supply the required patient care in time. Click space bar to continue
  • 25. ICD-10 Codes Your Almost Done! Just a couple more slides! Click space bar to continue
  • 26. Major Differences Between ICD-9 and ICD-10 Codes: ICD-9-CM ICD-10-CM 13,600 Codes 69,000 Codes Code book contains 17 Chapters Code book contains 21 Chapters Consists of 3 to 5 characters Consists of 3 to 7 characters 1st character is alpha or numeric 1st character is always alpha Only utilizes letters E and V Utilizes all letters (except U) Second, third, fourth, and fifth characters are always numeric Second character is always numeric Third, fourth, fifth, sixth and seventh characters can be alpha or numeric Shorter code descriptions because of lack of specificity and abbreviated code titles Longer code descriptions because of greater clinical detail and specificity and full code titles Click space bar to continue
  • 27. 2 93 8 Numeric or Alpha (every letter except U) Numeric Category ICD-9 Alpha (every letter except U) Numeric Category Category, anatomic site, severity ICD-10 (must be 3 – 7 Characters) H 6 5 1 1 6 Added code extensions (7th character) for Obstetrics, injuries, and External causes of injury 2 93 8 Numeric or Alpha (E or V) Category, anatomic site, severity Click space bar to continue
  • 28. T 1 6 1 X X A For Example: The initial visit for a foreign body in the right ear T16 identifies that this “foreign body in ear” 1 identifies that this is the Right Ear The letter “X” always serves as a placeholder when a code contains fewer than six characters and a seventh character applies. The “X” also allows for future expansion of the codes. “A” identifies that this is the initial encounter Click space bar to continue
  • 29. Click space bar to continue
  • 30. ASamplePagefromICD-10CodingBook Click space bar to continue
  • 31. The GEM files were created in an attempt to convert coding between ICD-9 and ICD-10 and is a joint compilation between the National Center for Health Statistics (NCHS) and the Centers for Medicare and Medicaid Services (CMS). This effort created a national “translation dictionary” to ensure consistency in national data. The files were designed to give all sectors (Health Plans, Providers, Medical Researchers and Medical Software Vendors) using coded data, a tool to convert and test systems, link data in long term clinical studies, develop application- specific mappings and analyze data collected during the transition period and beyond. There are a few ICD-9 and ICD-10 codes whose translation (via GEM) is very straightforward and easy to match one with another. These are referred to as “one-to-one” (1:1) match. The one-to-one match does not necessarily mean the two codes are identical, it simply means there is only one alternative. ICD-9-CM ICD-10-CM 783.21 Loss of Weight R63.4 Abnormal Weight Loss For Example: Click space bar to continue
  • 32. The GEM files were created in an attempt to convert coding between ICD-9 and ICD-10 and is a joint compilation between the National Center for Health Statistics (NCHS) and the Centers for Medicare and Medicaid Services (CMS). This effort created a national “translation dictionary” to ensure consistency in national data. The files were designed to give all sectors (Health Plans, Providers, Medical Researchers and Medical Software Vendors) using coded data, a tool to convert and test systems, link data in long term clinical studies, develop application- specific mappings and analyze data collected during the transition period and beyond. There are a few ICD-9 and ICD-10 codes whose translation (via GEM) is very straightforward and easy to match one with another. These are referred to as “one-to-one” (1:1) match. The one-to-one match does not necessarily mean the two codes are identical, it simply means there is only one alternative. ICD-9-CM ICD-10-CM 783.21 Loss of Weight R63.4 Abnormal Weight Loss For Example:
  • 33. General Overview: Quiz Time! 1. All entities must transition to ICD-10 prior to 10/1/2014. A. True B. False 2. The United States will be the first country to adopt ICD-10? A. True B. False 3. IDC-10 is aimed at improving healthcare by tracking general conditions. A. True B. False 4. The first digit of an ICD-10 Codes is : A. Always numeric B. Always a letter C. Either a number or a letter 5. What are the benefits of ICD-10? A. Greater specificity in diagnoses B. Provides ability to compare data efficiently, effectively worldwide C. Ability to reflect current medical conditions and procedures D. All of the above 6. Which of the following statement is true? A. Every code is ICD-10 will consists of 7 characters B. ICD-10 codes will consist of 3-7 alpha/numeric characters C. Every code in ICD-10 will consist of 7 alpha/numeric characters D. Every code in ICD-10 ends with a numeric character
  • 34. 7. The Transition will have an impact on: A. Hospitals B. Health Insurers and other third-party payers C. Hardware and software manufacturers and vendors D. Billing and practice management services providers E. All of the above - Anyone who used healthcare information that contains a diagnosis and /or inpatient procedure code. 8. ICD-10 preparedness is most important for: A. Coders B. Physicians C. Front-end personnel D. A and B E. All of the above 9. If the ICD-10 transition is implemented properly in a practice, providers do not need to be concerned about delays, denials, or a decrease in revenue? A. True B. False 10. A patient was seen in clinic of 9/30/14 but the claim will not be submitted until 10/4/14. Which code set will be used. A. ICD-9 B. ICD-10 C. Both 11. Practices can decrease the delays expected with the transition by requesting authorizations for surgeries booked after 10/1/14 while ICD-9 is still in effect. A. True B. False