An Orientation to ICD 10: A Provider and Payer Perspective

Transcription

1 An Orientation to ICD 10: A Provider and Payer Perspective Lee Ratliff, Baptist Health South Florida George Vancore, Florida Blue September 21, :30 a.m. 10:30 a.m. EST Dial Toll Free 1 (800) Conference Passcode #

2 An Orientation to ICD 10: A Provider and Payer Perspective Session Objectives: 1. To increase your understanding of the current state of ICD-10; recent regulatory decisions and industry perspectives. 2. Increase your awareness and understanding of the challenges that ICD-10 brings to Providers and Payers. 3. To provide you with tools, techniques, best practices and helpful hints that could be used as you begin your ICD-10 preparations. 2

3 An Orientation to ICD 10: Current State On February 2, 2012, the AMA sent a letter to DHHS requesting that they consider delaying the implementation of ICD-10: On February 16, 2012, the DHHS announced its intent to delay ICD-10: On March 15, 2012, CMS/WEDI issued a summary report on the most recent ICD-10 readiness survey: On April 9, 2012, DHHS announced a proposed rule that would delay the compliance date for ICD-10 from October 1, 2013 to October 1, 2014: chtype=1&numdays=3500&srchopt=0&srchdata=&keywordtype=all&chknewstype=1%2c+2%2c+3%2c+4%2c+5 &intpage=&showall=&pyear=&year=&desc=&cboorder=date On June 19, 2012, delegates at AMA's Annual Meeting adopted a policy to evaluate ICD-11 as an alternative to replace ICD-9. The AMA will conduct more research on this issue and will report back to the House of Delegates in UPDATE: On August 24, 2012, the OMB (Office of Management and Budget) approved the DHHS (Department of Health and Human Services) request to postpone the implementation of ICD-10 from October 1, 2013 to October 1,

4 An Orientation to ICD 10: A Regulatory View Fundamentals In January 2011, the DHHS announced the final rules for new medical diagnosis and procedure code sets (ICD-10) under HIPAA-AS. The successful implementation of the new electronic transaction standard (HIPAA 5010) is a pre-requisite to the implementation of ICD-10. ICD-10 is intended to improve clinical data reporting, improve patient care quality, enhance claim processing and promote increased interoperability across industry stakeholders. Significant impacts to provider billing and payment processing may be realized across the health care industry if stakeholders fail to collaborate, coordinate and communicate on their ICD-10 initiatives. 4

5 An Orientation to ICD 10: A Regulatory View Fundamentals The ICD-10 CM (Clinical Modifications) and ICD-10 PCS (Procedure Coding Structure) are the new medical diagnosis and procedure code sets under HIPAA-AS. These new code sets represent a fundamental overhaul to the current ICD-9 coding system. ICD codes are used to codify medical diagnoses and procedures, calculate and adjudicate coverage, compile medical statistics, assess quality of care and help manage clinical quality outcomes for patients. The current ICD-9 codes sets are outdated and do not reflect advances in medical technologies nor are they descriptive enough. 5

6 An Orientation to ICD-10 A Regulatory View Fundamentals As highlighted in the final rule, the new ICD-10 CM and PCS code sets are intended to: Provide greater flexibility to enable future capabilities. Provide more descriptive and robust categories for precise coding. Enable streamlined reimbursement processes. Provide richer medical data with higher degrees of details and quality for further analysis; help enrich clinical care profiles and patient outcomes. Maximize the value of clinical data and the business value of interoperability of e-health initiatives and the Electronic Health Record (EHR). 6

7 An Orientation to ICD 10: A Regulatory View What is Changing? ICD-10 CM is the new medical code sets under HIPAA-AS for diagnosis reporting and replaces ICD-9 CM in all U.S. health care settings. 7

8 The Challenges of ICD 10: A Regulatory View What is Changing? ICD-10 PCS identifies medical procedures for use in U.S. inpatient hospital settings only; does not replace CPT/HCPCS codes for outpatient services. 8

9 An Orientation to ICD-10: A Regulatory View What is Changing? In addition to structural and content changes to the code sets, there are several medical terminology changes that are also being implemented. A few examples follow: 9

10 An Orientation to ICD 10: A Regulatory View Implementation Date The implementation of ICD-10 is Service Date driven for outpatient services and Discharge Date driven for inpatient services!! So, how does this impact you? Do you need to co-exist between ICD-9 and ICD-10 after the mandated compliance date? What happens if a pre-authorization is issued under ICD-9 but the Service is not performed until after ICD-10 is implemented? The original compliance date was October 1, 2013; on August 24, 2012, the OMB and DHHS approved a delay of one year to October 1,

11 An Orientation to ICD 10: A Regulatory View Implementation Challenges 11

12 Baptist Health South Florida ICD-10: The Countdown is On Lee Ratliff Clinical Business Technology Consultant September 21,

13 Baptist Health South Florida TOPICS About Baptist RFP Process Systems Education & Training Coding Review Budget Awareness \ Governance Testing and Dual Coding Plans 13

14 Baptist Health South Florida ABOUT BAPTIST HEALTH SOUTH FLORIDA 14

15 Baptist Health South Florida Scope of Services: Baptist Hospital of Miami South Miami Hospital Doctors Hospital Homestead Hospital West Kendall Baptist Hospital Mariners Hospital (Critical Access) Baptist Outpatient Services Medical Arts Surgery Centers Physician Practices 15

16 Baptist Health South Florida 16

17 Baptist Health South Florida RFP 17

18 RFP Process RFP - SUMMARY Objective BHSF seeks an experienced company to provide ICD-10 & 5010 consulting services for enterprise-wide impact assessment, implementation planning, and implementation services. Scope Business Process Assessment, Gap Analysis, and Mitigation Plan Health Plan Payer, Vendor, and System Readiness Training Program Development Testing Processes ICD10 Data Mapping and Analysis (translation challenges) Financial Impact Analysis 5010 Transition Impact Goals Achieve compliance with published federal regulations regarding HIPAA standard transactions and code sets including ICD10 & 5010 requirements. Develop Project Plan (Schedule) Develop Enterprise Budget 18

19 RFP Process RFP DECISION MAKING TEAM HIM Management IT Data Warehouse Patient Financial Services Management IT Corporate Business Systems PFS Billing Managed Care PFS Government Collections Physician Representative Revenue Pricing Integrity Financial Planning 19

20 RFP Process RFP - TIMELINE 01/31/11 RFP Released 02/21/11 Responses Due 03/07/11 Semi- Finalists Selected 03/21/11 Oral Presentations Completed 03/28/11 Final Vendor Selected Scheduled Meetings 3/03/11 9a-11a Determine RFP Semi-Finalists 3/17/11 9a-1p Oral Presentations 3/24/11 9a-11a Final Decision Making Meeting 20

21 RFP Process RFP - VENDORS Challenges Sources Limited Gartner information on ICD10\5010 consulting services vendors Lack of historical experience with ICD10\5010 services in the United States WEDI ICD10 Workgroup Resources Magazine Articles ICD10WATCH.COM Google 18 vendors identified reviewed 21

22 RFP Process RFP SELECTION CRITERIA Company Vendor s profile strength and stability; Previous experience with this type of project; History of delivering to like sized accounts; References. Personnel Size of workforce; Availability of resources; Skill level; Training and Experience of staff. Service Offering Ability to provide a complete solution for ICD10\5010 services within scope of RFP; Ability to meet requirements in the Business Requirements Consulting Services list. Business Offering Price; Invoicing; Risk acceptance. 22

23 Baptist Health South Florida PROCESS 23

24 Overview of ICD-10 Process Phase 1 July December 2011 Identification of business impact areas ICD-10 impact assessment kick-off and educational session with key stakeholders People, Process & System Assessment Education & Training (Staffing) needs assessment Coding and documentation assessment Communication Plan/Awareness Campaign Vendor/Payer Readiness Assessments ICD-10 reimbursement and coding risk/impact analysis Road Map to ICD-10 Readiness Refinement of ICD-10 Budget Phase 2 Jan Sept 2013 Education and training program System remediation/upgrades Testing, design and management Design & implement dualprocessing environment/mapping & translation strategy Clinical documentation improvement program Contingency Planning Phase 3 Oct End-state measurement and documentation Implement review and improve process Customer coaching Implement compliance program 24

25 Baptist Health South Florida SYSTEMS STATUS 25

26 System and Vendor Readiness Objectives Determine Vendor Remediation Plans & Timeline Version release information (timeline, hardware/software requirements, associated cost and work effort) Features & functionality, including support for dualprocessing/parallel environment Testing & training plans Determine Payer Remediation Plans & Timeline (surveys being conducted by BHSF) System remediation plans Impacts to contracts and medical policy (mapping & translation) Support for dual-processing/parallel environment Testing plans and timelines Surveys ( and/or phone) Interviews 26

27 System and Vendor Readiness System \ Vendor Surveys Consultant provided surveys required to be completed by vendors. Surveys ( and/or phone) Consultant worked with IT system owners (CBTCs) to communicate with vendors. Interviews Consultant gathered responses and documented in Report of Findings and Recommendations (Vendor\System Dashboard) 27

28 System and Vendor Readiness 66 The Number of Applications/Databases that Produce, Process and/or Store Diagnosis Information 28

29 System and Vendor Readiness Off Track primarily related to: Awaiting vendor ICD10 details Vendor with uncertain ICD10 plan NOTE: Have identified selected vendors to resurvey or follow up to validate, confirm ICD10 Plan At Risk primarily related to: Unknown ICD10 version and upgrade plan 29

30 System and Vendor Readiness No. Vendor Application Category Application/Module Description Application Use ICD-10 Status (Risk) ICD-10 Compliance Version Release Date Release Method Support for both ICD-9 and ICD-10 versions Version Prerequisite for Release/ Upgrade? Hardware Prerequisites? 1 Acute 2 Other EMR, Periop, IP Pharm Coding and Compliance 3 Ambulatory HIE 4 Acute Discharge Instructions Q4, 2011/Q1, 2012 Upgrade Yes No TBD TBD Q4, 2011/Q1, 2012 Upgrade Yes No TBD 5 Ambulatory OP clinicals and PM v11.0 Q2, 2012 Upgrade Yes No No 6 Acute Perinatal 7 Ancillary 8 Acute 9 Other 10 Other 11 Other 12 Other 13 Other 14 Ancillary 15 Ancillary Renal Transplant Coding and Compliance Coding and Compliance Claims Auditing Mgmt Dashboard Chargemaster Mgmt ABN Management Case Mgmt and Denials FU Home Care (clinicals and billing) TBD TBD Code Load Yes TBD TBD TBD TBD TBD TBD TBD TBD Available now Upgrade Yes No No Yes, but not dualmapped payer readiness based on By 1/1/2012 Upgrade No No Documents vendor and Yes, but not dualmapped By 1/1/2012 Upgrade No No Yes, if mandated TBD TBD Hosted No No by CMS and payers will be provided with final deliverables. TBD Q3, 2011 IF Mod Overlay Yes v7.2 or higher No TBD TBD Upgrade Yes TBD TBD 16 Other Clearinghouse TBD TBD Hosted Yes TBD TBD 17 Other Dictation/Transcrip 18 Other Dictation/ Transcription information collected during vendor/payer readiness surveys. All readiness plans/materials provided by vendors TBD TBD Upgrade Yes TBD TBD 19 Other Clinical Data Mgm TBD TBD TBD TBD TBD TBD 30

31 System and Vendor Readiness Example (Information Technology) outlines major system remediation/upgrade/testing effort. 31

32 Baptist Health South Florida EDUCATION AND TRAINING 32

33 Education and Training 63 The Number of Workflows and Processes that Use Codified Diagnosis Information 33

34 Education and Training 19,790 The Projected Number of Education & Training Hours Required Across Baptist Health South Florida 34

35 Education and Training Learner Categories Education Levels Coders Level 1: Overview Providers, Nurses, CDI Specialists Level 2: Job Impact/Knowledge- Based IT and BI/DS, Managed Care, Revenue Cycle Identify Train Maintain Level 3: On-the- Job/Skill Transfer 35

36 IT and BI/DS, Managed Care, Nursing, Revenue Cycle Business Impact Areas Awareness Campaign Level 1: Leverage Baptist Health Impact of ICD-10 Overview Clinical (web-based) University; content to be Impact of ICD-10 Overview Revenue Cycle (web-based) purchased and existing Impact of ICD-10 Overview IT/Reporting (web-based) platform leveraged to deliver Level 2: and track completion Impact to Nursing Documentation (web-based) Coding for Non-Coders Financial Coding for Non-Coders Clinical Clinical Documentation Improvement for ICD-10 (Body System) (web-based) Level 3: Practice Environment Quarter Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Level 1 Level 2 Education and Training Level 3 36

37 Education and Training Providers & Clinical Documentation Management Physician Awareness Campaigns Level 1: Impact of ICD-10 Overview Clinical (web-based) Level 2: Clinical Documentation Improvement for ICD-10 (Body System/Specialty Specific) (web-based) Supplemental Specialty-Specific/Physician Champion Onsite Training Employed Physician Office Coder Training (onsite) Level 3: Ongoing Physician Feedback via CDMP Utilize ICD-10 Reimbursement Analytics and CDMP reports to focus on Top DRGs, High Risk Diagnoses/Procedures Quarter Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Level 1 Level 2 Level 3 * Awareness * Documentation Tools * Workflow Redesign Clinical Documentation Management Program 37

38 Level 1: Education and Training Coders A&P, Medical Terminology, Pharmacology/Pathophysiology; ICD-10-CM Overview: Deciphering the Code/ICD-10-PCS Overview: Deciphering the Code ICD-10-CM/PCS Fundamentals of GEMs Level 2: AHIMA Coder Proficiency Assessments; Foundation A&P Focus Online Courses Approved AHIMA ICD-10 Trainers to deliver education to coders Level 3: Leverage CAC/3M HDM for Dual-Coding and Practice Environment ICD-10-CM/PCS audit process post ICD-10 (October December 2014) Quarter Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Level 1 Level 2 CAC Audit Level Hours/Coder 38

39 Education and Training Web-based Education Modules Characterized by body system Specialty specific Leverage Baptist Health University Multiple Delivery Platforms Dedicated Physician Educator Instructor-led On-site via classroom, department meetings, other platforms One-on-One Education Leverage CDMP - Clinical Documentation Management Program 39

40 Baptist Health South Florida Coder Productivity Coding Career Ladder Program 40

41 Coder Productivity Mitigation Plan Issues that impact coder productivity Dual Screens Computer-Assisted-Coding Coder Career Ladder (in process) Hire Additional Coders Increase Volume of Outsourced Accounts and Vendors Maximize ICD-10 Education & Training Opportunities Potential to leverage PFS Coders Critical Success Factor: Productivity Streamline Quality Limit Learning Curve Enable dual-processing environment Type Based on Current BHSF Productivity Standard and 8 hour work day Decrease in records code in LT Decrease in records code in ST # of Coders Total decrease in records coded per week (LT) Total decrease in records coded per week (ST) IP OPS

42 Coding Career Ladder Program Purpose and Summary PURPOSE: Cultivate a pipeline of experienced coding professionals Offers existing coding staff an opportunity for personal development and career growth Delivers an on-the-job training program Creates an environment that encourages retention of coders Promotes collaboration with AHIMA approved coding programs in the local community offering internship opportunities to students 42

43 Baptist Health South Florida CODING REVIEW 43

44 Documentation, Coding & Reimbursement Objectives Identify High Impact/Risk Services MDC, DRG, Code & Documentation Level Hospital Inpatient: Identify the Potential Impact to Reimbursement Hospital Outpatient: Identify High Impact Codes moving from ICD-9 to ICD-10 Conduct Chart Review Select high impact/high volume records to review Facility: 50 inpatient & 50 outpatient records per Acute Care Facility (Baptist Hospital; South Miami Hospital; Doctors Hospital; Homestead Hospital) Baptist Outpatient Services: 50 encounters Professional (Physician Office): 100 professional encounters Identify how claims translate from ICD-9 to ICD-10 how do the codes and guidelines change Identify how documentation will need to be enhanced to support ICD-10 Analytics Remote Chart Review 44

45 Potential Financial Impact of ICD-10 Review of Results of Analytics Hospital Total Claims MS-DRG Claims Total Negative Financial Impact BH 39,467 9, % 2.1% SMH 19,224 3, % 2.3% DH 11,608 2, % 2.1% HH 7,163 2, % 1.1% Total (T)/ Average (A) Recommendations: 82,366 (T) 17,782 (T) -0.5% (A); 1.95%; Total Positive Financial Impact Leverage results of analytics for ICD-10 Communication & Awareness Resolve current state accuracy issues Focus provider education Focus on the indirect reimbursement impacts Review managed care contracts As part of the coding & documentation review, we coded and grouped 100 of the 200 inpatient charts reviewed in ICD-10. These charts were selected based on high impact DRGs identified in the reimbursement analytics. The goal was to validate and identify the root cause of risk/opportunity. 26 charts experienced a shift in reimbursement, 19 due to changes in ICD-10 and 7 due to an error in current state ICD-9 coding. Of those that experienced a shift in reimbursement due to ICD-10, the risk/opportunity can be categorized into four major categories: 1. Change in DRG Definition (40%) 2. Change in Coding Guideline (16%) 3. Need for enhanced physician documentation (8%) 4. Perceived error in CMS Mapping/DRG Definition (8%) 45

46 Coding & Documentation Review Example Results of Chart Review Inadequate physician documentation in both inpatient and outpatient settings to support the extra level of specificity required by ICD-10 Example: Account ##########; physician documents partial small bowel resection with no further specificity To code the appropriate root operation ICD-10 for the procedure being performed, physician documentation needs to identify the exact portion of the small intestine that was removed. If the physician documents removal of an entire portion of ileum or jejunum for example, this would then be coded to resection instead of excision. MS-DRG Reimbursement Impact: ($6,261.27) Audit Report; separate reports for each hospital and inpatient/outpatient; Baptist Outpatient Services and Baptist Health Medical Group Symptoms, signs and/or working diagnoses were coded when a definitive diagnosis has been established (outpatient) Physician scripts/orders lack level of specificity necessary for ICD-10 (outpatient) All secondary diagnosis documented by physician are not being reported (outpatient) Unspecified diagnosis codes and specified diagnosis codes of a condition or injury were reported Illegible physician handwriting All inpatient procedure codes not being reported Reoccurring trends & summary results outlined in the Report of Findings & Recommendations 46

47 Baptist Health South Florida BUDGET 47

48 ICD10 Project Budget Capital Budget Operating Budget Systems/Vendors External/Other Training and Education Content Training Workflow/Redesign System Remediation 48

49 ICD10 Project Budget Systems/Vendors Mapping/Translation Tool Siemens Custom Interfaces RelayHealth Bridgetable Claims and Remits M*Modal AHCA Education and Training ICD10 Training Course Content 49

50 ICD10 Project Budget External/Other Training and Education AHIMA ICD10 Trainer Academy and Training Materials Coding Career Ladder Program Training Content Development Coding Career Ladder Program Training Materials Outsourced Coding ICD10 Project Contracted Resources Physician Champions Participant/Learner Training Hours Excluding Provider Training Hours Work Effort Dual/Parallel ICD9/ICD10 environment - workflow redesign effort Data assessment/redesign Mapping and Translation Coding Career Ladder Program Resources System Remediation Design/build leveraged to capture level of specificity to support ICD-10 Support dual/parallel environment for application and integrated testing Commitment to speech recognition with development of templates to guide physician documentation. 50

51 Baptist Health South Florida AWARENESS and GOVERNANCE 51

52 Awareness Campaign Project Status Communication ICD-10 Awareness Campaign Status Reports HIM (weekly) Status Reports IT (weekly) ICD-10 Steering Committee (quarterly) Updates to Senior Leadership (as needed) Phase Inform (Awareness) Telling me what s going on and who to contact Clarify (Understanding) How will this change affect my job, roles and responsibilities? Convince (Acceptance) How do I use the new process and/or system in my job? Involve (Commitment) How did we ever do business without it? Increase Specificity of Message Using Similar Communication Channels throughout campaign Objectives Communication of ICD-10 Governance Structure and key contacts Build awareness around the transition to ICD-10: o What is it? o Why the change? o Timeline o A Walk Through ICD-10 Highlevel pictorial demonstrating the use of diagnosis information throughout BHSF The Sell Why Does This Matter to Me? Education and training requirements and timeframes Systems upgrade plans Workflow redesign (if applicable) Real-life examples of the application of ICD-10 codes, examples include: Complexities of mapping and translation Physician documentation (high impact/high volume diagnoses) Reimbursement under ICD-10 How ICD-10 and the increased level of specificity will be leveraged to provide better care: better data = better patient care. Communication Channels Monthly blasts Posters throughout BHSF entities Dedicated ICD-10 Newsletter Medical Memo (physician-only) -blasts Dedicated ICD-10 Newsletter Medical Memo (physician-only) Department-level meetings -blasts Dedicated ICD-10 Newsletter Medical Memo (physician-only) Department-level meetings -blasts Dedicated ICD-10 Newsletter Medical Memo (physician-only) Department-level meetings Timeframe January - June 2012 June 2012 December 2012 November 2012 October 2013 October 2013 December

53 ICD-10 Project Governance 53

54 ICD-10 Project Governance 54

55 Baptist Health South Florida TESTING AND DUAL CODING 55

56 Baptist Health South Florida Invision PA /12 Enable ICD10 to Invision Production Enable Coding Interface to Production HIM Dual Coding 3/13 Test Coding from Invision PM to PA Use OML to Control ICD9/10 on Claims Activate PRCLF in Test Test Coding Interface to Invision PM Test with Claim Scrubber and Payers 56

57 An Orientation to ICD-10: Helpful Tools There are several publicly available websites that can help increase general awareness and understanding of the ICD-10 mandate and its impact to the health care industry; some recommendations include:

58 Florida Blue ICD-10 Pulse Survey An Orientation to ICD-10: Next Steps Availity ICD-10 Webinar Series: The Availity Health Information Network presents a four-part ICD-10 Webinar Series to deliver FREE education in response to impending diagnosis and procedure code changes a value of $129 per participant through sponsorship with Scrubin Uniforms and Florida Blue. National experts will directly address the necessary steps in transitioning to the new health code sets. One-hour seminars started Aug. 23 and run through Nov. 8, so register now. For more information, including CEU Credit, and to register, simply visit Florida Blue Open Line Friday Sessions: Our next session will be held Friday, October 19, 2012, beginning at 9:30 a.m. ET. Topic and special guest TBA. 58

59 An Orientation to ICD-10 Helpful Tools Questions and Discussion (Time Permitting) Thank You 59