Page 0March 26-27, 2014
Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues
American Health Lawyers Asso...
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Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues
• What is ICD‐10 and why is ...
Page 2March 26-27, 2014
Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues
What is ICD‐10 and why is it...
Page 3March 26-27, 2014
Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues
There’s A Code For That!
Sou...
Page 4March 26-27, 2014
Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues
What Are ICD Codes?
• The In...
Page 5March 26-27, 2014
Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues
• Replaces ICD-9 – Not a rev...
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Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues
There is no relationship bet...
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Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues
What’s ICD-10-CM?
ICD-10-CM
...
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Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues
What’s ICD-10-PCS?
ICD-10-PC...
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Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues
How Big Could It Be?
ICD-9-C...
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Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues
Key ICD-10-CM Changes
• Alp...
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Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues
ICD-10 vs. ICD-9
Issue ICD-...
Page 12March 26-27, 2014
Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues
ICD-10 Code Comparison
Toba...
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Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues
What are the benefits of IC...
Page 14March 26-27, 2014
Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues
What can we learn from othe...
Page 15March 26-27, 2014
Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues
There’s A Code For That!
So...
Page 16March 26-27, 2014
Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues
What is the current regulat...
Page 17March 26-27, 2014
Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues
When is it official?
Januar...
Page 18March 26-27, 2014
Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues
National Coverage Determina...
Page 19March 26-27, 2014
Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues
Local Coverage Determinatio...
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Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues
Industry Readiness Survey
•...
Page 21March 26-27, 2014
Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues
Fact or Fiction
ICD-10-CM-b...
Page 22March 26-27, 2014
Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues
What do I need to do to get...
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Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues
What do I need to know to g...
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Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues
Once I get this claim out o...
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Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues
DRG Assignment
• CMS did no...
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Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues
ICD-10 Impact
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Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues
Scope of ICD-10 Impact
• Al...
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Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues
ICD-10 Industry Impact
Hosp...
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Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues
Clinical
Documentation
• Ac...
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Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues
ICD-10 Organizational Impac...
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Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues
Estimated Financial Impact:...
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Provider Impact
• Value-bas...
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Payers, Health Plans
Impact...
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Compliance Impact
• A huge ...
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Coder Impact
• Need to know...
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Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues
ICD-10 Potential Financial ...
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Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues
Expected Denial Reasons
Min...
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Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues
There’s A Code For That!
So...
Page 39March 26-27, 2014
Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues
Readiness and Implementatio...
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Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues
Strategy
Convene Implementa...
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Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues
Assessment
Organizational r...
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Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues
Implementation Process
Proc...
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Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues
Roles
Role Task
Administrat...
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Vendor Readiness
• Identify...
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Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues
Vendor Readiness
Our billin...
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Payer Readiness
• As with v...
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Code Analysis
Review top 20...
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Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues
ICD-10 Impact on Physician ...
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Budget
• Cost of training/d...
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Budget
How much emergency c...
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Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues
Implementation Issues
Train...
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Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues
Training
Coding and Billing...
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Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues
Training
Clinicians
• Physi...
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Tiered Training Structure
Page 55March 26-27, 2014
Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues
ICD-10 & EHR
• Analyze EHR ...
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• Plan for dual ICD-9 and 1...
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Priority List
Create an ICD...
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ICD-10 is not just a coder’...
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The future?
WHO is currentl...
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Key Resources
• ICD-10 Prop...
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There’s A Code For That!
So...
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Questions?
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Contact Information
Denise ...
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ICD-10 Transition Presentation: What Health Lawyers Need to Know

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PYA Consulting Principal Denise Hall, along with co-presenter Julie Chicoine, recently updated health lawyers about ICD-10 transition readiness at the American Health Lawyers Association Institute on Medicare and Medicaid Payment Issues, held March 26-27, 2014.

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  • This is the code for ‘struck by pig’: W55.42
  • So we have more codes… what does that mean to me and my hospital????
  • This is the code for ‘driver of SUV injured in collision with fixed or stationary object in traffic accident’: V47.51
  • WHO IS IMPACTED
  • These are the codes for ‘falling on escalator’: W10.0xxA, ‘bit by sea lion’: W56.11xA, and ‘alcohol intoxication’: F10.12
  • This is the code for ‘fire aboard spaceship’: V95.44
  • ICD-10 Transition Presentation: What Health Lawyers Need to Know

    1. 1. Page 0March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues American Health Lawyers Association Institute on Medicare and Medicaid Payment Issues March 26-27, 2014 ICD-10 Transition Update: What Health Lawyers Need to Know
    2. 2. Page 1March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues • What is ICD‐10 and why is it important to the healthcare community? • What is the current regulatory status of ICD‐10? • Organizational Impact – Operational and Finance • Readiness and Implementation Strategies Learning Objectives
    3. 3. Page 2March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues What is ICD‐10 and why is it important to the healthcare community?
    4. 4. Page 3March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues There’s A Code For That! Source: http://www.youtube.com/watch?v=GWJQSmqRLRk
    5. 5. Page 4March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues What Are ICD Codes? • The International Classification of Disease (ICD) codes are the international classifications for all diseases and many other health problems for purposes of health management, including: – Analysis of the general health of population groups – Monitoring of the incidence and prevalence of diseases – Monitoring other health problems in relation to other variables such as the characteristics and circumstances of the individuals affected, reimbursement, resource allocation, and quality http://www.who.int/classifications/icd/en/ • ICD codes are now recorded on many types of health records and are key components in reimbursement, quality and utilization review, and other data management activities.
    6. 6. Page 5March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues • Replaces ICD-9 – Not a revised version of ICD-9 • ICD-10 represents a complete change from one coding system to a new one structured in an entirely new way • Like all medical coding systems, it provides a way to condense textual clinical information into “codes” that can be used for billing and other data-based applications What is ICD-10?
    7. 7. Page 6March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues There is no relationship between the two code sets – they have completely different structures and uses. ICD-10 Is Really Two Different Code Sets ICD-10-CM • International Classification of Diseases, 10th Revision, Clinical Modification ICD-10-PCS • International Classification of Diseases, 10th Revision, Procedure Coding System
    8. 8. Page 7March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues What’s ICD-10-CM? ICD-10-CM • Diagnosis Coding System – Used to report the patient‟s condition (i.e., what‟s wrong with the patient) • Direct replacement for ICD-9-CM Volumes 1 & 2 • Will be used in all settings – hospital inpatient, hospital outpatient, physician office, etc. • Like ICD-9-CM, developed and maintained by the World Health Organization (WHO) and the National Center for Health Statistics within the Centers for Disease Control
    9. 9. Page 8March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues What’s ICD-10-PCS? ICD-10-PCS • Procedure Coding System – Used to report surgical procedures performed • Direct replacement for ICD-9-CM Volume 3 • Only used in a hospital inpatient setting (and only for reporting facility services) • Like ICD-9-CM Volume 3, ICD-10-PCS was developed and is maintained by CMS
    10. 10. Page 9March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues How Big Could It Be? ICD-9-CM Diagnosis: 14,000 Procedures: 4,000 ICD-10-CM & ICD-10-PCS Diagnosis: 68,000 Procedures: 87,000
    11. 11. Page 10March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues Key ICD-10-CM Changes • Alphanumeric codes • Expanded injury codes – grouped by anatomic site not injury type • Laterality (right vs. left) • Obstetric codes include trimester • Diabetes codes differentiate between I, II, drug, chemical induced diabetes, or due to an underlying condition (chemotherapy) • Intraoperative and postoperative complications • Visits – initial or subsequent
    12. 12. Page 11March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues ICD-10 vs. ICD-9 Issue ICD-9-CM ICD-10-CM Volume of codes Approximately 13,600 Approximately 69,000 Composition of codes Mostly numeric, with E and V codes alphanumeric. Valid codes of three, four, or five digits. All codes are alphanumeric, beginning with a letter and with a mix of numbers and letters thereafter. Valid codes may have three, four, five, six or seven digits. Duplication of code sets Currently, only ICD-9-CM codes are required. No mapping is necessary. For a period of up to two years, systems will need to access both ICD-9-CM codes and ICD-10-CM codes as the country transitions from ICD-9-CM to ICD-10-CM. Mapping will be necessary so that equivalent codes can be found for issues of disease tracking, medical necessity edits and outcomes studies. Source: http://www.aapc.com/icd-10/faq.aspx#why
    13. 13. Page 12March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues ICD-10 Code Comparison Tobacco Abuse ICD-9-CM: 1 Code ICD-10-CM: 5 Codes Diabetes Mellitus ICD-9-CM: 10 Codes ICD-10-CM: 318 Codes Fracture of Radius ICD-9-CM: 33 Codes ICD-10-CM: 1,818 Codes
    14. 14. Page 13March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues What are the benefits of ICD-10? The new, up-to-date classification system will provide much better data needed to: • Measure the quality, safety, and efficacy of care • Improve quality reporting and scoring • Reduce the need for attachments to explain the patient’s condition • Design payment systems and process claims for reimbursement • Conduct research, epidemiological studies, and clinical trials • Set health policy • Support operational and strategic planning • Design healthcare delivery systems • Monitor resource utilization • Improve clinical, financial, and administrative performance • Prevent and detect healthcare fraud and abuse • Track public health and risks
    15. 15. Page 14March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues What can we learn from other countries’ implementation? • Planning and preparation are the keys to success – Start now to allow time to understand the impact and come up with solutions • Education and training are all important – Prepare for productivity loss and longer turn around times • Collaborate with others – Share information and experiences to learn what works and what to avoid
    16. 16. Page 15March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues There’s A Code For That! Source: http://www.youtube.com/watch?v=j_mD8yDZD7M
    17. 17. Page 16March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues What is the current regulatory status of ICD‐10?
    18. 18. Page 17March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues When is it official? January 1, 2010 • Payers and providers should begin internal testing of Version 5010 standards for electronic claims December 31, 2010 • Internal testing of Version 5010 must be complete to achieve Level I Version 5010 compliance • Providers should form ICD-10 sponsorship team January 1, 2011 • Payers and providers should begin external testing of Version 5010 for electronic claims • CMS begins accepting Version 5010 claims • Version 4010 claims continue to be accepted December 31, 2011 • External testing of Version 5010 for electronic claims must be complete to achieve Level II Version 5010 compliance January 1, 2012 • All electronic claims must use Version 5010 • Version 4010 claims are no longer accepted October 1, 2014 • Claims for services provided on or after this date must use ICD- 10 codes for medical diagnosis and inpatient procedures • CPT codes will continue to be used for outpatient services Per the Department of Health and Human Services, the compliance date for implementation of ICD-10-CM and ICD-10-PCS is October 1, 2014.
    19. 19. Page 18March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues National Coverage Determinations (NCDs) • CMS is responsible for converting approximately 330 NCDs • Not all are appropriate for translation – Edits based on HCPCS – Older obsolete technology or considered outdated CMS has determined which NCD should be translated and is in the process of completing system changes for those NCDs http://www.cms.gov/outreach-and-education/medicare-learningnetworkmln/mlnmattersarticles/downloads/MM7818.pdf
    20. 20. Page 19March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues Local Coverage Determinations (LCDs) • According to CMS, LCDs are made by the individual Medicare Auditing Contractor (MAC – i.e. CAHABA) • Contractors shall publish all ICD-10 LCDs and ICD-10 associated articles on the Medicare Coverage Database (MCD) no later than April 10, 2014 http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8348.pdf
    21. 21. Page 20March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues Industry Readiness Survey • The Workgroup for Electronic Data Interchange (WEDI), the leading authority on the use of Health IT to improve the exchange of healthcare information, announced submission of the latest ICD-10 industry readiness survey results to the Centers for Medicare & Medicaid Services (CMS). • Some key results from the survey include: – All industry segments appear to have made some progress since February 2013, but have not gained sufficient ground to remove concern over meeting the October 1, 2014 compliance deadline. – About three-fifths of health plans have completed their impact assessment- and another one- fifth are nearly complete. This shows moderate progress since the February 2013 survey where approximately one-half had completed their assessment. – The number of providers that responded „unknown‟ to when they would complete their impact assessment, business changes, and begin external testing is down significantly from the February 2013 survey; responses indicate the majority will not complete these steps until 2014. – About three-fifths of vendors indicate they are already doing, or plan to begin customer review and beta testing by the end of this year. This is down slightly from the two-thirds indicated in the February 2013 survey. Sources: http://www.wedi.org/docs/comment-letters/2013-wedi-icd-10-survey-results-letter.pdf?sfvrsn=0 http://www.wedi.org/news/press-releases/2013/04/11/wedi-provides-vital-icd-10-industry-readiness-survey-results-to-cms
    22. 22. Page 21March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues Fact or Fiction ICD-10-CM-based super bills will be too long or too complex to be of much use Fiction (sort of) • Practices may continue to create super bills that contain the most common diagnosis codes used in their practice. ICD-10-CM-based super bills will not necessarily be longer or more complex than ICD-9-CM-based super bills. Neither currently-used super bills nor ICD-10-CM-based super bills provide all possible code options for many conditions. • The super bill conversion process includes: – Conducting a review that includes removing rarely used codes – Cross walking common codes from ICD-9-CM to ICD-10-CM, which can be accomplished by looking up codes in the ICD-10-CM code book or using the General Equivalence Mappings (GEM) – Vendors electronic superbill and posting scrubber that assist physicians in the transition to ICD-10 Source: http://www.whiteplume.com/learn-more/icd-10
    23. 23. Page 22March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues What do I need to do to get the claim out the door? • Medicare will begin accepting a revised 1500 (version 02/12) on January 6, 2014 – Allows for reporting of ICD-10 codes – Use as many as 12 codes in the diagnosis field (the current limit is four) – Qualifiers to identify the following providers role (on item 17) • Ordering, Referring, Supervising • Starting April 1, 2014, Medicare will accept only the revised version of the form – The revised form will give providers the ability to indicate whether they are using ICD-9 or ICD-10 diagnosis codes
    24. 24. Page 23March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues What do I need to know to get the claim out the door? • Reporting ICD-10 diagnosis codes • Claims Submission of diagnosis codes – ICD-9 codes no longer accepted on claims with date of service after October 1, 2014 – ICD-10 codes will not be recognized/accepted on claims before October 1, 2014 – Claims cannot contain both ICD-9 and ICD-10 codes--will be returned as “Unprocessable” • Date span requirements – Outpatient claims-split claim form and use from date – Inpatient claims-use only through date/discharge date for ICD-10 code submission
    25. 25. Page 24March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues Once I get this claim out of the door, am I going to get paid? • The Department of Health and Humans Services (HHS) anticipates that the percent of returned claims following the ICD-10 implementation could be more than double of what we have seen in the past with ICD-9 updates.
    26. 26. Page 25March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues DRG Assignment • CMS did not address the impact of ICD-10 on DRG assignment in the ICD-10 Final Rule • However, CMS and 3M have used the GEMs to convert the MS-DRG definitions from ICD-9-CM to ICD-10 • CMS and 3M found that the GEMs were 95% to >99% effective in converting the MS-DRGs to ICD-10
    27. 27. Page 26March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues ICD-10 Impact
    28. 28. Page 27March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues Scope of ICD-10 Impact • All HIPAA-covered providers and entities – Includes, payers, health plans, DME, pharmacy, vendors • Other Code Sets – No impact » Current Procedural Terminology (CPT) Codes » Healthcare Common Procedure Codes (HCPCS)
    29. 29. Page 28March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues ICD-10 Industry Impact Hospitals Pharmacy Research Vendors Payers/ Health Plans Physicians Home Health Laboratory Business Associates
    30. 30. Page 29March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues Clinical Documentation • Accurate diagnosis • Improved quality of care Quality • Pay-for-performance • Public Reporting Financial • Utilization management • Cost containment ICD-10 Transitional Impact
    31. 31. Page 30March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues ICD-10 Organizational Impact • Physician Documentation • Physician Integration • Physician Performance • Staffing Effectiveness • Revenue Impact Assessment • Process Flow & Improvement • Decision Support Impact • Documentation Analysis • ICD-10 Education & Training • Coding Production Impact Physician Office Post Acute Services • Scheduling, ED & Access Areas • DNFB, Coding, CDI • Case Management • Billing, Reimbursement Health Information Management ICD-10 Revenue Process Physician Operational Planning Information Technology • IT Systems • Capability, Communication • Functionality • Vendor Preparedness
    32. 32. Page 31March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues Estimated Financial Impact: Revenue Cycle AR (Days Increase) Write-Off (potential $ lost) Incremental Staff ($) AR (Days Increase) Write-Off (potential $ lost) Incremental Staff ($) AR (Days Increase) Write-Off (potential $ lost) Incremental Staff ($) Staffing Impact (incremental) 95,545$ 47,773$ 23,886$ Medical Necessity / Denials 5.2 585,715$ 2.6 292,857$ 1.3 146,429$ Coding 3.2 1.6 1.6 Staffing Impact (incremental) 121,415$ 60,708$ 30,354$ Staffing Prep 60,000$ (creating/testing billing edits) Billing Rejections / Denials 10.4 1,171,429$ 5.2 585,715$ 2.6 292,857$ Patient Access Patient Financial Services Health Information Mgt. TOTALS 18.9 5.5 439,286$ 54,240$1,757,144$ 276,961$ 9.4 878,572$ 108,480$ FY2016 Revenue Cycle Metrics Revenue Cycle Metrics Revenue Cycle Metrics FY2014 FY2015 Notes: See Key Assumptions for information on assumptions underlying these estimates. Figures may not add to Totals due to rounding.
    33. 33. Page 32March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues Provider Impact • Value-based compensation • Increased documentation time – up to 15% • May affect patient volume • Quality Measures/P4P – need to be determined based on ICD-10 codes • Difficult to measure impact of change – is it because of code set or because of changes in underlying practice? 32
    34. 34. Page 33March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues Payers, Health Plans Impact: • Coverage determinations • Payment determinations • Medical review policies • Actuarial projections • Quality measurements
    35. 35. Page 34March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues Compliance Impact • A huge potential for double billing exists if two systems (ICD-9 and ICD-10) remain in use during the transition period: – This scenario could potentially create unintentional billing compliance risks. – The shortage of experienced coding professionals also poses a risk since medical coders nearing retirement age may elect to retire rather than learn a new system. • Additionally, the General Equivalency Mappings (GEMS) do not provide a definitive map from ICD-9 to ICD-10 with only 5% mapping accurately 1:1 with ICD-10 codes – Because ICD-9 codes could map into multiple ICD-10 codes, this risk rises even more.
    36. 36. Page 35March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues Coder Impact • Need to know anatomy and physiology • Need to know new code sets • Decreased productivity – ICD-10 Watch: Some studies suggest a 50% drop in coding productivity • Industry demand for more coding professionals!
    37. 37. Page 36March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues ICD-10 Potential Financial Impact • According to CMS, Estimated Organizational Cost by Bed Size Bed Size Cost 400 + $1.5 Million – $5 Million 100 – 400 $500,000 – $1.5 Million < 100 $100,000 – $250,000 Decrease in Cash Flow / Loss of Revenue • Industry experts from CMS and AHIMA estimate the following: – Denial rates will increase by 100% to 200% – Accounts receivable days will be extended by 20% to 40% – Healthcare organizations will be hindered with payment declines for more than 2 years after the implementation Date of October 1, 2014 – Claims-error rates will increase from 6% to 10% (The average current rate is close to 3%)
    38. 38. Page 37March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues Expected Denial Reasons Minich-Pourshadi, Karen. “ICD-10 Puts Revenue at Risk.” HealthLeaders Media Intelligence (July 2011), p. 22.
    39. 39. Page 38March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues There’s A Code For That! Source: http://www.youtube.com/watch?v=yKYwr31s4bk
    40. 40. Page 39March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues Readiness and Implementation Strategies
    41. 41. Page 40March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues Strategy Convene Implementation Taskforce Multi-disciplinary • Clinical, IT, HIM, Finan ce, Compliance, Com munications, Payer/Ma naged Care Contracting, Operation s Key stake holders • Identify who is impacted and what needs to be done • Establish timeline and designate leaders Designate Physician Champion
    42. 42. Page 41March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues Assessment Organizational readiness • Map a patient‟s encounter and look at every piece in the organization touched by ICD-9 • Affected Areas Financial/HIM/IT • Billing systems, DRG grouper, claims software, medical record abstracting, encoding software, case mix systems Clinical • Patient care protocols, medical necessity, laboratory and pharmacy systems, utilization, quality and case management Patients • Patient registration and scheduling systems, advance beneficiary notice, preauthorization
    43. 43. Page 42March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues Implementation Process Processes Reports Work Flow Information Systems and Software All Forms of Documentation Analysis of all Departments
    44. 44. Page 43March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues Roles Role Task Administrators Confirm capabilities, provide training, review processes IT Staff Confirm integration in system and documentation Providers Outpatient: Document in support of ICD-10 code selected Inpatient: CM and PCS codes will have to be supported Billers Understand how to look up codes, understand how to query physicians, pull new LCDs Coders Understand ICD-10 guidelines and how to properly select ICD-10 codes base on documentation
    45. 45. Page 44March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues Vendor Readiness • Identify vendors affected by ICD-10 (billing companies, medical transcription, home health, DME – start with your Business Associate Agreements) − What system changes/upgrades are needed? − What costs are involved? Are they included in existing vendor agreements? − What customer support (implementation, testing, training) will the vendor be offering?
    46. 46. Page 45March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues Vendor Readiness Our billing software vendor indicates they will be ready for these transitions. What can I do in the meantime, besides train for ICD-10 coding? • Ask your billing software vendor for a detailed schedule of deliverables and begin preparing to test implementation of the modified software at your location. • Be sure to verify the following: – The vendor is addressing the ICD-10 upgrades – The number and schedule of planned ICD-10 software releases – Their ICD-10 conversion plan accommodates your clearinghouse testing schedule – Any related costs to your organization – Customer support and training they will provide
    47. 47. Page 46March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues Payer Readiness • As with vendors – establish dedicated contact • Evaluate payer readiness – What‟s their implementation plan/timeline? – Are they implementing new rules for claims submission or re-submission? – Will contract terms for coverage and billing change? Will they require the provider to report the code with the highest specificity? – Will their payment and reimbursement schedules change? – Will the claims appeal process change? • Add language to current contracts to require ICD-10 compliance • Share your plans for ICD-10 changes with them • Establish regular meetings, compare implementation plans, review and update contracts as necessary • Medicare and Medicaid - Are they on track? When will they be ready for end-to-end testing? What are their contingency plans?
    48. 48. Page 47March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues Code Analysis Review top 20-50 diagnosis codes • Evaluate documentation currently in the notes • Crosswalk them to ICD-10 • Review new codes for additional required codes, additional code descriptions and “code also” requirements • Identify areas where additional documentation will be required
    49. 49. Page 48March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues ICD-10 Impact on Physician Work Flow • Will the EMR allow the physician to enter a descriptive diagnosis rather than a specific diagnosis code? • Is the physician prepared for the dramatic increase in diagnosis codes now displayed on the drop-down list? • How will the physician‟s workflow change when more time is needed to assign the appropriate diagnosis code? • Can the EMR support a workflow that sends patient encounters to coders for review and assignment of the most specific diagnosis code based on the physician‟s documentation?
    50. 50. Page 49March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues Budget • Cost of training/decreased staff productivity • Cost of hardware/software upgrades • Forms redesign • Testing costs/Consulting services • Vendor readiness – external testing • Temporary maintenance of dual systems • Cash reserves for denials increase, payment delays, decreased productivity Determine financial impact, budget, resources, cash reserve needed for ICD-10 migration
    51. 51. Page 50March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues Budget How much emergency cash should providers keep in case of cash flow disruption? • Review what happened to your organization with HIPAA 5010, this would be a good baseline; with the transition of ICD-10 there will be delays in reimbursement. • Vendors and clearinghouses have been working hard, but we will not know the true effects until Oct. 1, 2014. • It is recommended that you have up to several months' cash reserves or access to cash through a loan or line of credit to avoid potential headaches. • The amount of reserves you need to set aside will be impacted by the preparation work you do for ICD-10. • Will need to cover at a minimum practice operation expenses for three to six months: – Medical supplies – Payroll – Rent
    52. 52. Page 51March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues Implementation Issues Training • Will be required for various users • Will require coder retraining – Coding rules and conventions are similar, but not exactly the same • Some short-term loss of productivity is expected during the learning curve • Will require changes in data retrieval/analysis • Will require changes to data systems
    53. 53. Page 52March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues Training Coding and Billing Staff • Assess training needs and develop a plan – Professional coding staff – ICD-10-CM – Determine who will train staff and how this will be accomplished – Factor in time away from work, consider post-testing and ongoing support – Make ICD-10 proficiency part of your coding staff‟s performance goals » ICD-9-CM to ICD-10-CM Dual Coding • Assign staff members to be the “ICD-10 Experts” looking at the impact from the billing to the clinical side
    54. 54. Page 53March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues Training Clinicians • Physicians – focus on codes germane to their practice • Review clinical documentation improvement efforts and develop new strategies • Incorporate documentation improvement as component to compliance training • Ancillary staff – identify needs and level of training needed, nursing, financial services, quality, utilization, ancillary departments… Information Technology • Training to ensure that codes are accurately cross-walked in organization‟s IT systems
    55. 55. Page 54March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues Tiered Training Structure
    56. 56. Page 55March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues ICD-10 & EHR • Analyze EHR for functionality and compliance • Review templates, interfaces, default documentation, and level of detail • Can the system accommodate the data format changes for ICD-10? • What is the EHR vendor‟s timeline for the transition? When will their upgrades be available for installation? Make sure that installation of upgrades is far enough in advance to facilitate early testing. • Will there be additional costs for the upgrade? Will multiple upgrades be required? Is there a waiting list? • Is the EHR vendor training its staff on ICD-10 system upgrades? • Can they ensure that the right components are in place to select the more specific code? • Will they have specialty specific codes? • Will ICD-9 still be available for use and comparison? • Does the system allow for dual coding?
    57. 57. Page 56March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues • Plan for dual ICD-9 and 10 codes for a brief period to address services rendered before October 1, but discharged after October 1 • Monitor physician documentation to ensure ICD-10 compliance • Monitor impact on claim-processing activity, claim denials, and rejections • Audit coder productivity and accuracy • Monitor patient satisfaction • Post-transition Review – What‟s working? – What needs fixing? • Schedule 30-day post-conversion claims assessment ICD-10 Go Live, The Day After…
    58. 58. Page 57March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues Priority List Create an ICD-10 impact awareness throughout the organization Ensure your foundational IS structure is actively preparing for the transition Define your change approach to ensure you have defined the proper structure and sponsorship Develop projections of operational needs, including staffing and internal educational training Identify specific documentation gaps to determine focused educational needs Calculate potential impact on financial results
    59. 59. Page 58March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues ICD-10 is not just a coder’s issue! This transformation entails foundational changes to ALL HIPAA-covered entities and providers • In a nutshell, here are some key points to keep in mind going forward: Senior management‟s involvement is critical to successful implementation! • Risks of late or no implementation must be understood Problems should be expected! • Develop action plans to manage them • Have a back-up plan Establish a budget. Develop a timeline and follow it!
    60. 60. Page 59March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues The future? WHO is currently working on ICD-11 • They will build upon ICD-10 • The first draft was made available online in July 2011 for review • The final draft is expected to be submitted to WHO's World Health Assembly for official endorsement by 2017
    61. 61. Page 60March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues Key Resources • ICD-10 Proposed and Final Rules – http://edocket.access.gpo.gov/2008/pdf/E8-19298.pdf – http://edocket.access.gpo.gov/2009/pdf/E9-743.pdf • CMS Website on ICD-10 – https://www.cms.gov/ICD10/ • CDC Website on Classification of Diseases – http://www.cdc.gov/nchs/icd.htm • CMS ICD-10-CM Quick Reference Guide – https://www.cms.gov/ICD10/11b14_2012_ICD10CM_and_GEMs.a sp#TopOfPage
    62. 62. Page 61March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues There’s A Code For That! Source: http://www.youtube.com/watch?v=IVhyUsGTxiE
    63. 63. Page 62March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues Questions?
    64. 64. Page 63March 26-27, 2014 Prepared for AHLA – Institute on Medicare and Medicaid Payment Issues Contact Information Denise Hall, RN, BSN Principal Pershing Yoakley & Associates, P.C. 678-441-0645 dhall@pyapc.com www.pyapc.com Julie Chicoine, Esq., RN, CPC, CPCO Wexner Medical Center at The Ohio State University 614-293-2007 julie.chicoine@osumc.edu www.medicalcenter.osu.edu Thank you for allowing us to share our thoughts and expertise with you.

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