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ICD-10 Impact Presentation
ICD-10 is a comprehensive healthcare coding system introduced by the WHO in 1993 to replace the outdated ICD-9, essential for accurately documenting modern medical diagnoses and procedures. The transition to ICD-10 involves significant changes to healthcare IT systems, staff education, and business processes, with a deadline for compliance set for October 1, 2014, where non-compliance can lead to claim denials. This transition presents challenges, including an increase in codes, the need for dual coding, and potential disruptions to cash flow and revenue cycles.
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ICD-10 Impact Presentation
- 2. What is ICD-10?! u ICD-10 is a healthcare coding system implemented by the World Health Organization (WHO) in 1993 to replace ICD-9, a now-outdated system for coding. u ICD-10 is used in most countries, except the United States. u ICD-10 is a far more robust coding system, needed to accurately describe health diagnoses and procedures with the level of detail needed in modern medicine. • Healthcare organizations are required by October 1, 2014, to convert from ICD-9 coding to ICD-10 in documenting diagnoses and procedures. • Non-compliance will result in non- payment of claims.
- 3. " Why the Changeto ICD-10?" ! u Measures the quality and safety of care u Ensures more accurate claims payments u Improves operational and strategic planning u Monitors resource utilization u Improves performance: clinical, financial and administrative u Improves research and clinical trials u Reduces healthcare fraud and abuse u Tracks public health and risks u Enables the adoption of beneficial new technologies u Maximizes investment in IT ICD-10 provides improved data to support 21st century healthcare.
- 4. Conversion to ICD-10will impact systems and processes across your organization. Examples: § IT systems changes § Staff education and training § Business process and documentation changes § Changes in super-bills, charges § Increased documentation costs § Cash flow disruptions § Reporting changes PAYORS HOSPITAL DEPARTMENTS IT VENDORS & 3RD PARTY SERVICE PROVIDERS Why Should You Care?! Technology People Processes
- 5. Most staff willbe affected by, disrupted by, and/or need education on ICD-10.! u Senior Management u Physicians / Nurses / Clinicians u Health information management u IT staff and data analysts u Quality management staff u Patient access and registration staff u Finance and administrative staff u Clinical department managers u Allied health care professionals ARE YOU READY FOR THIS?!
- 6. It goes beyondadding specificity to patient charts or learning a new set of codes for billing. It’s a lengthy, complex, and revolutionary transition It requires a focused, converted effort across all areas of business operations Most staff will be affected or disrupted by the code set Education and training is required Diagnosis & Procedure Codes are the foundation of healthcare. The transition to ICD-10 diagnosis and procedure codes is the most profound change our industry has ever faced. ICD-9-CM (Diagnosis) 5 characters = 14,000 codes ICD-9-CM (Procedure) 5 characters = 4,000 codes ICD-10-CM (Diagnosis) 7 characters = 68,000 codes ICD-10-PCS (In patient) 7 characters = 72,000 codes ICD-10 is More Than it Seems!
- 7. u In ICD-10, it’snot just two more characters. It’s a completely new construct that defines what each character or group of characters represents in assigning a diagnosis. u An almost 5-fold increase in the number of diagnosis codes to choose from. u An almost 20-fold increase in the number of procedure codes to choose from. u ICD-9 codes exists in numerous locations in the organization. What Makes This Coding System " So Challenging?! It is estimated that the average size hospital may have 50 - 75 IT systems or more, in which ICD-9 codes reside.
- 8. Key Differences: ProcedureCodes! Sources: WEDI ICD-‐10 White Paper, 2000; ICD-‐10-‐CM and ICD-‐10-‐PCS Update, Thirteenth NaAonal HIPAA Summit, September 2006; AHIMA Web site. Feature! ICD-9-CM Volume 3! ICD-10-PCS! Code Set! ICD-9-CM Volume III ICD-‐10-‐PCS (Procedural ClassificaAon System) Structure! Minimum of 3 digits, max of 4 digits Decimal point after the 2nd digit Min/max 7 digits, no decimal point Numeric Alphanumeric Limited Multiaxial structure Multiaxial structure, each code character has the same meaning within the specific procedure section and across procedure sections, where possible Sample Codes! 47.01, Laparoscopic appendectomy 0DTJ4ZZ, Laparoscopic appendectomy Format! X X X X. 1 2 3 4 5 6 7 Body system or site of the procedure Specific code with relation to site, purpose, technique or diagnosis Section Body System Root Operation Body Part Approach Device Qualifier
- 9. Key Differences: DiagnosisCodes! Sources: WEDI ICD-‐10 White Paper, 2000; ICD-‐10-‐CM and ICD-‐10-‐PCS Update, Thirteenth NaAonal HIPAA Summit, September 2006; AHIMA Web site. Feature! ICD-9-CM Volume 3! ICD-10-PCS! Code Set! ICD-9-CM Volume I & II ICD-‐10-‐CM (Clinical ModificaAon) Structure! Minimum of 3 digits, max of 5 Decimal point after the 2nd digit Minimum of 3 digits, max of 7 Decimal point after the 3rd digit Numeric, except for supplementary codes – V codes & E codes Alphanumeric, with codes using alpha lead character Structure of injuries designated by would type Structure of injuries designated by body part (location) No laterality (left vs. right) Laterality (left vs. right) Sample Codes! 733.01, Senile osteoporosis M80.011a. Postmenopausal osteoporosis with current pathological fracture, right shoulder, initial encounter for fracture Format! X X X X. X X X X X X Category Significant axis, such as anatomical site Category X Etiology or disease manifestation Subclassification . X Ecology Extension: visit encounter or sequelae for injuries and external causes
- 11. Administration u Compliance u Risk Management u Vendor Partners u TradingPartners u Relationship and Contracts u Contingency Planning u Finance (fiscal well being) Providers u Documentation Requirements u Training u Modification of Order Sets, Protocols u Provider Profiling Changes u Pay for Performance Protocols ICD-10 Will Impact!
- 12. Medical Management u Disease Management u UtilizationReview Processes u Pre-cert/Referral u Preventive Care Programs u Profiling u Quality Measurement u State Reporting u Managed Care Reporting Care Delivery u Medical Policy Management u Clinical Protocols u Orders u Clinical System Triggers u Documentation Requirements u Pharmacy Triggers u Utilization Review u Compliance and Reporting ICD-10 Will Impact!
- 13. Systems u Interfaces u EDI u Data Collection Field Delimiters u DataWarehouse Schemas u Triggers (clinical systems) u Customer Support / Help Desk u Testing Revenue u ABN Modifications u Medical Necessity Edits u All Coding (encoding, abstracting, billing) u System Logic Edits u National and Local Coverage Criteria ICD-10 Will Impact!
- 15. ICD-10 Requires SystemsChanges! u Multiple system upgrades will be needed. u New systems may have to be purchased to replace non-compliant systems. u Upgraded and replaced systems must go through testing cycles. u Interfaces will need to be created or updated. u Existing IT staff may need to be augmented. u New collaboration with payers to adapt to their upgraded systems. u The medical record will require a greater level of specificity in documentation.
- 16. Impact of ICD-10on Systems! Pharmacy DocumentaAon Orders and Protocols Financial Payments CMS DRG Grouper Provider Pricing Membership & Provider Portals Provider EffecAveness and PredicAve Modeling Profiling Claims Submission Billing Demographics & Payments Provider ContracAng Actuarial & AnalyAcal Systems Disease Management Case Alerts Compliance AbstracAng Encoding ABN Systems RegistraAon Scheduling UR / Precert EDI Claims HIM Systems Patient RegistrationProvider Contracting Delivery of Care
- 17. ICD-10 Requires Process Changes! u Business process analysis of contracts, coverage, and documentation u AdapAng to new vendor compliant IT systems (related to screen changes, new tables, etc.) u Processes related to new systems or tools used to support ICD-‐10 conversion u Processes related to record coding (e.g. Computer Assisted Coding) u Need for temporary “dual coding” (ICD-‐9 & ICD-‐10) u New or updated workflows, reports, forms, and policies and procedures Process Culture People Change Management Technology
- 18. Initial Patient Pointof Entry Payment for Services! Patient Access Services HIM Services Revenue Cycle Services IS Services ICD-10 Impact! Clinical/Patient Services • Pre-Registration • Patient Registration • Appointment Scheduling • Financial Counseling • Document Review • Forms Audit • Coding - Auditing • OE Clinical Procedures • Physician/Clinician Clinical Documentation • Case Management • Charge Processing • Forms & Reports Use • CDM Maintenance • Charge Processing • Claims Production • Payment Processing • Resubmit/Appeals • Contract Mgmt • A/R Follow up • Vendor Systems • Interfaces • Data Extract Files • Reports Impact of ICD-10 On" Business Processes! ý= Minimal or none ý= Medium ý= High ý ý ý ý ý
- 19. u Coders must learnnew, more difficult codes, and handle substantially increased queries. u Physicians must be trained to adopt new codes and documentation. u Clinicians must be trained, and ensure clinical documentation enhancement, with procedures reflecting increased ICD-10 detail. u Information technology staff, already burdened with Meaningful Use / EHR initiatives must take on more, highly specialized work. u Financial management and administrative staff must learn new codes and deal with reduced revenue cycle productivity. u Management must address shortages of required, specialized skills to manage and conduct implementation. Impact of ICD-10 on Workforce" Almost all areas of the organization will experience disruption. Training will be key – and will require a major enterprise-wide effort.
- 21. § UpdaAng of medical coding, billing, claims processing and A/R management § Reconfiguring eligibility and uAlizaAon management § UpdaAng of protocols for medical necessity, policy checks and related § Planning for Increased costs related to ICD-‐10 changes § OpportuniAes to leverage the stronger capabiliAes of ICD-‐10 should be idenAfied to § achieve process opAmizaAon § more accurately reflect services provided § offset higher business costs § miAgate new financial risks § make be_er strategic business decisions ICD-10 Requires Changes in Revenue Cycle Management! CMS and industry leaders predict dire consequences to healthcare operations and revenue if ICD-10 is not implemented properly.
- 22. Impact of ICD-10On" Revenue Cycle! ý= Minimal or none ý= Medium ý= High! Encounter Charge Capture Coding Medical Record Documentation Financial Counseling Scheduling/ Registration Certification Contract Management Claims Submission 3rd Party Follow-Up Rejection Processing Payment Posting Appeals Encounter Charge Capture Coding Utilization Review
- 23. Potential Impact ofICD-10 " On Finances! Decrease in cash flow and loss of revenue Slowdown in payments for up to two years Increase in claims errors and returns Increase in denial rates Initial increase in costs (training & implementation) Mitigation of financial risks must be planned and executed
- 25. Areas for AssessmentConsideration! Revenue Cycle Systems Admin Systems Interfaces Data Extract Files Clinical Systemsa • Registration • Patient Management • Coding System/ HIM • Professional Billing • Patient Accounts Data Extract Files • Decision Support System • Data Warehouse • Business Intelligence System • Emergency Department • Laboratory • Pharmacy • Radiology • Surgical Services • ADT • Charges • Coding Abstract • Internal Systems • External Systems • Professional Fee Billing • Reports • Forms Don’t Delay – Get Started…!
- 26. ! Free One-Day Assessmentto! …with a! u Define scope of work u Identify project and approximate deadlines u Identify education needs u Define areas of concern If interested, let us know and one of our ! ICD-10 experts will be in touch!
- 27. Phoenix Health Systemshas the expertise you need.! With over 20 years of healthcare IT experience, Phoenix is passionate about supporting exceptional healthcare. We support hospitals to solve critical challenges like ICD-10 conversion, Meaningful Use, IT strategic planning and more. Vendor-independent, we bring objective, highly experienced senior level IT leaders and project managers to every client engagement. To learn more about how Phoenix can help your organization, contact us.