AHIMA Game of documentation - dance with the icd10 dragon

1. @DrNic1 #DrHITDell - Internal Use - Confidential Nick van Terheyden, MD (aka @drnic1) Chief Medical Officer Dell Health and Life Sciences Game of Documentation: Dance with the ICD-10 Dragon

2. @DrNic1 #DrHITDell - Internal Use - Confidential Spoiler alert This presentation may contain details from the Game of Thrones series and may spoil your enjoyment

3. @DrNic1 #DrHITDell - Internal Use - Confidential You too can tame the ICD-10 Dragon like Daenerys Targaryen

4. @DrNic1 #DrHITDell - Internal Use - Confidential Agenda • A quick recap • So it’s happening – really • Basic changes from ICD9 to ICD10 • What it means to you • The impact to patients • Tips on surviving • What’s next

6. @DrNic1 #DrHITDell - Internal Use - Confidential ICD-10 history ICD-10 adopted by the World Health Organization in 1990 United Kingdom: 1995 Australian Mods: 1998 Canadian: 2001 U.S. development began in 1994 • Multiple versions final implantation date October 1, 2014 • SGR Bill signed April 1, 2014 • Final implementation deadline October 1, 2015 ICD-11 not likely until 2017, earliest • 2 years for U.S. to consider, 2 year review, 2 year mandated wait • ICD-11-CM not before 2023 (with the same structure as ICD-10)

7. @DrNic1 #DrHITDell - Internal Use - Confidential Survey question Where are you on the continuum of preparing your office for ICD-10? A. We’re ready B. We have a plan and are on our way to being ready C. We might be ready because D. We’ve talked about it E. Uh, when do we have to start? F. No need to prepare... it will be delayed again

9. @DrNic1 #DrHITDell - Internal Use - Confidential Jon Snow Expect the unexpected It ain’t over till it’s over

10. @DrNic1 #DrHITDell - Internal Use - Confidential High level message • ICD-10 implementation will improve patient care • ICD-10 is not being imposed on physicians by the hospital • The hospital is collaborating to reduce impact on physicians by building knowledgeable infrastructure • Independent physicians need to focus now on their practice, specifically their systems and staff • Further education will be coming at the appropriate time for every specialty and subspecialty

12. @DrNic1 #DrHITDell - Internal Use - Confidential Should we really replace ICD-9? • ICD-9-CM is 35 years old – when it was put in use: • Margaret Thatcher, Ronald Reagan, and Mikhail Gorbachev were the leaders of that time and Russian Olympics were boycotted but the U.S. Won the Miracle on Ice • Rubik’s Cube was all the rage • John Lennon was shot dead • CNN went worldwide • Music: Celebration/ Another One Bites the Dust • SmallPox was declared eradicated • And doctors could still smoke in room with patients

13. @DrNic1 #DrHITDell - Internal Use - Confidential Should we really replace ICD-9? • Much of the terminology and classification of conditions are outdated and even obsolete • Increasingly demonstrates lack of specificity especially for EHR and population data tracking • Problematic for international comparison

14. @DrNic1 #DrHITDell - Internal Use - Confidential Intake Select chief complaint Enter vitals Review of symptoms Review past medical and social history Review medications and allergies Exam Review Intake Document patient exam Select diagnosis Enter orders Review quality measures Sign-off Review assessment and plan Sign off on orders Complete billing slip Generate letters Review charges Close the patient encounter Check-in Verify appointment, demographic, insurance information Collect patient payments Print billing slip Forms Check-out Schedule follow up appointments Collect outstanding balances Distribute patient education materials Enter charges The ICD-10 transition broadly affects the patient visit

15. @DrNic1 #DrHITDell - Internal Use - Confidential Coders Physicians The Coder / Physician dichotomy • ICD-9 is 35 years old with outdated terminology • Coders must learn current anatomy, pathophysiology, terminology, etc. • Coders must understand the entire ICD-10 system • Coders must think expansively of all possible code options • The burden on coders is tremendous • ICD-10 includes modern terminology • Physician practice has evolved even though the coding system was stagnant • Physicians need to learn what is applicable to their specialty • Physicians tend to be linear and hierarchical • The burden on physicians is manageable

16. @DrNic1 #DrHITDell - Internal Use - Confidential Some ICD-10 new features • Combination codes (etiology and manifestation) – Type 1 diabetes with diabetic nephropathy • Laterality – Left, right, bilateral, unspecified (4) • Episode of care – Initial (open, closed), subsequent (routine, delayed, nonunion, malunion), treatment of sequela • Trimesters for obstetrical care • Clinical changes – Time frames for acute myocardial infarctions

17. @DrNic1 #DrHITDell - Internal Use - Confidential Changes to the codes • Condensation of codes • Expansion of codes • Changes to terminology

18. @DrNic1 #DrHITDell - Internal Use - Confidential ICD-9-CM ICD-10-CM Acute Myocardial Infarction Acute Myocardial Infarction (30 codes) • Primary axis: Site involved (10) – Anterolateral, other anterior wall, inferior wall, inferoposterior wall, other inferior, other lateral, true posterior, subendocardial, other, unspecified • Secondary axis: episode of care (3) – initial, subsequent, unspecified Acute Myocardial Infarction (14 codes) • Axes of classification: Initial MI (9) • STEMI (8) (by site) –Anterior (3) » L main, L anterior descending, other coronary artery –Inferior (2) » Right coronary artery, other –Other (2) » Left circumflex, other sites –Unspecified (1) • NSTEMI (1) –Subsequent MI (5) • Anterior wall • Inferior wall • Non-STEMI • Other sites • Unspecified Subsequent AMI AMI occurring within 4 weeks of previous AMI, regardless of site

19. @DrNic1 #DrHITDell - Internal Use - Confidential Changes to terminology

20. @DrNic1 #DrHITDell - Internal Use - Confidential Asthma classification Asthma 14 codes Type/etiology/cause (12 types) • Extrinsic • Intrinsic • Chronic obstructive • Asthma, Unspecified – Severity (for above types) • Unspecified • With (acute) exacerbation • With status asthmaticus Other forms of asthma (2 types) • Exercise induced bronchospasm • Cough variant asthma Asthma 18 codes Severity / type • Mild intermittent (3) • Mild persistent (3) • Moderate persistent (3) • Severe persistent (3) – Presentation (for each above) • Uncomplicated • With acute exacerbation • With status asthmaticus Other and unspecified asthma • Unspecified (3) – With 3 presentations above • Other asthma (3) – Exercise induced bronchospasm – Cough variant asthma – Other asthma ICD-9-CM ICD-10-CM

22. @DrNic1 #DrHITDell - Internal Use - Confidential 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 additional documentation 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

23. @DrNic1 #DrHITDell - Internal Use - Confidential Why physicians are liking ICD-10 • Codes are more specific – They link etiology to disease (staph pneumonia) – They link manifestation to etiology (hypertensive heart disease) • They make more clinical sense – Injuries grouped by anatomical site rather than type of injury – Laterality has been added to relevant codes • They are up to date – Code titles reflect new technology & recent terminology – Codes have been added to describe postoperative or post-procedural conditions • ICD-10 is essential for clinical research and epidemiology

24. @DrNic1 #DrHITDell - Internal Use - Confidential 329 major small and large bowel procedure W MCC Rel wt Exp mort Exp LOS Exp cost Exp readmit Exp payment Secondary DX acute systolic failure 5.26 9.51% 13.59 $30,302 18.69% $34,716 330 major small and large bowel procedure W CC Rel wt Exp mort Exp LOS Exp cost Exp readmit Exp payment Secondary DX chronic systolic failure 2.57 0.73% 7.79 $16681 12.25% $16,962 *Exp outcome values based on specific population with proprietary analysis of severity may vary with different population and assessment methods for illustrative purposes only based on real data 331 major small and large bowel procedure WO CC/MCC Rel wt Exp mort Exp LOS Exp cost Exp readmit Exp payment Secondary DX CHF 1.64 0.13% 5.67 $12851 8.93% $10,824 Effect of accurate documentation on outcomes

25. @DrNic1 #DrHITDell - Internal Use - Confidential Philosophy • Physicians do not need to learn coding • Physicians need to work in a collaborative process to achieve accurate documentation on every patient • The process must increase efficiency • The documentation process should be “owned” by physicians

26. @DrNic1 #DrHITDell - Internal Use - Confidential Basic concepts Coding solutions, alone, cannot resolve the issue of inadequate physician documentation Physician leaders must be able to engage their colleagues in a proactive manner, establishing the appropriate motivation & sharing necessary knowledge to achieve success under Coding and Continuous Documentation Improvement Programs Inadequate physician documentation has been a challenge for accurate coding under ICD-9 If uncorrected, that challenge continues to increase

27. @DrNic1 #DrHITDell - Internal Use - Confidential Clinical documentation is everything

29. @DrNic1 #DrHITDell - Internal Use - Confidential “Feds to allow use of Medicare data to rate doctors” – USA Today 12/5/11 The federal government announced that Medicare will now allow use of its extensive medical claims database by employers, insurance companies and consumer groups to produce report cards on local doctors and hospitals. …By analyzing masses of billing records, experts can glean such critical information as how often a doctor has performed a particular procedure and get a general sense of problems such as preventable complications. Compiled in an easily understood format and released to the public, medical report cards could become a very powerful tool for promoting quality care and reducing waste… Announced by Marilyn Tavenner Acting Administrator of CMS

30. @DrNic1 #DrHITDell - Internal Use - Confidential

31. @DrNic1 #DrHITDell - Internal Use - Confidential MCOs ALSO measure MD Performance… UnitedH Physician Locator Website…

32. @DrNic1 #DrHITDell - Internal Use - Confidential MCOs ALSO measure MD Performance… UnitedH Physician Locator Website…

33. @DrNic1 #DrHITDell - Internal Use - Confidential UnitedH Physician Locator Website… • Quality and cost efficiency • Cost efficiency and not enough data to assess quality • Quality and not enough data to assess cost efficiency • Quality and did NOT meet cost efficiency • Did NOT meet quality and cost efficiency Members in health plans that offer tiered benefits may pay lower copays and coinsurance amounts for services provided by UnitedHealth Premium® Tier 1 physicians. UnitedHealth Premium® Tier 1 physicians have received the premium designation for quality and cost efficiency…

34. @DrNic1 #DrHITDell - Internal Use - Confidential “…We believe our networks will continue to exceed accessibility standards – right down to the county level," McElrath-Jones said. “…We have conducted outreach to area providers that will remain in network to confirm their capacity to take on additional patients."

35. @DrNic1 #DrHITDell - Internal Use - Confidential The risk to providers • The only way clinical performance is adjudicated is through billing data • If you do not get the billing data correct then your performance will be adjudicated incorrectly…

37. @DrNic1 #DrHITDell - Internal Use - Confidential Post implementation Review documentation and coding quality post- October 1, 2015 Provide team member, clinician, and physician education, as needed Conduct financial impact analysis Update risk and monitoring plan Support accounts receivable billing and collection backlog and activity, as needed

38. @DrNic1 #DrHITDell - Internal Use - Confidential Conduct 3, 5, 6, 9 and 12- month post- conversion optimization assessments Reassess/ update training for coding personnel Validate future state workflows Perform post- implementation project training and documentation audits Develop medical coding tests for Health System new hire screening Post implementation

39. @DrNic1 #DrHITDell - Internal Use - Confidential Risks • Education/documentation gaps • Productivity losses • Lack of resources • Changes in reimbursement – Limited immediate but as ICD10 data arrives at CMS they will likely refine MS-DRG – Not limited to this: patient care outcomes, quality of care, profiling providers, P4P, medical necessity • Expect audits to focus on clinical documentation to determine if it supports the specificity of ICD-10 codes • Unspecified = unpaid !

40. @DrNic1 #DrHITDell - Internal Use - Confidential International lessons • Australians love ICD-10 because not working with so many “dump” codes or unspecified • Coders were back to old output rates w/in 3 months • Education is key • Providers still adjusting billing because of what they are learning from their ICD-10 data • See ICD-10 as a “must do” and a benefit

42. @DrNic1 #DrHITDell - Internal Use - Confidential Value-based payment Two shifts 1. Increasing accountability for quality and total cost of care 2. Timeline: a) 30% of Medicare payments in alternative payment models (categories 3 & 4) by the end of 2016 b) 50% of Medicare payments in alternative payment models (categories 3 & 4) by the end of 2018 c) Overall, 85% of payments in categories 2 through 4 by 2016 and 90% by 2018

43. @DrNic1 #DrHITDell - Internal Use - Confidential Principles Education, particularly on clinical issues, must be peer-to-peer Physicians are interested in their specialty, not material unrelated to their practice Physicians will commit minimal time Physicians should learn the documentation principles and specific changes relevant to their specialty Physicians should never attempt to memorize ICD-10-CM codes – there are simply too many Specific examples should be utilized

45. @DrNic1 #DrHITDell - Internal Use - Confidential Nick van Terheyden, MD CMO, Dell Health and Life Sciences AboutMe http://about.me/obiwan Twitter http://twitter.com/drnic1 LinkedIn http://www.linkedin.com/in/nickvt Blog http://drnick.vanterheyden.com/ FaceBook http://www.facebook.com/drnic1 E-Mail DrNick@dell.com, drnic1@gmail.com Google Voice (301) 355-0877 Where you can find me

46. @DrNic1 #DrHITDell - Internal Use - Confidential Resources CMS ICD10 Website http://www.cms.gov/Medicare/Coding/ICD10/index.html ICD10 MS-DRG Conversion Project (GEMS) http://www.cms.gov/Medicare/Coding/ICD10/ICD-10-MS-DRG-Conversion-Project.html Updated ICD10 Implementation Information (MLN) http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network- MLN/MLNMattersArticles/Downloads/SE1239.pdf ICD10 Myths and Facts http://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD-10MythsandFacts.pdf Medicare Fee-For-Service Provider Resources http://www.cms.gov/Medicare/Coding/ICD10/Medicare-Fee-for-Service-Provider-Resources.html Provider Resources http://www.cms.gov/Medicare/Coding/ICD10/ProviderResources.html The Road to ICD10 www.RoadTo10.org