Beyond ICD-10 Implementation

Transcription

1 Beyond ICD-10 Implementation Michigan Osteopathic Association Practice Managers Program May 13,2016 Sheri Patton, RHIA Manger, Medical Code Management AHIMA Approved ICD-10-CM/PCS Trainer *NOTE: The information in this document is not intended to impart legal advice. This overview is intended as an educational tool only and should not be relied upon as legal or compliance advice.

2 Agenda ü Fun Facts about ICD-10 implementation at BCBSM ü Issues post implementation Review of claims Coding of encounters Additions to benefit tables ü Documentation guidelines and suggestions ü Contact information ü Questions

3 Ten Fun Facts about ICD-10 implementation at BCBSM Count ICD-10 Facts 61,000,000 Clearing house transactions tested with the top 35 clearing houses 2,000,000 Lines of NASCO benefit code modified for ICD ,200 Hours of labor engaged to complete ICD-10 remediation (295 person years) 197,000 Claims tested for payment neutrality using DRGs 17,100 Providers attending BCBSM ICD-10 webinars, presentations and training sessions 4,914 NASCO system test cases 2,555 The number of days the project lasted (7 years) 696 ICD-10 project tasks in the 2015 project plan 98 Providers and facilities completed end to end testing 87 ICD-10 articles were published in the Record, Physician and Hospital newsletters 3

4 Post Implementation Activities: Claims Review Reviewed claims which paid and rejected to ensure they processed correctly. Focus on rejections with large number of claims Did we miss including codes on the benefit tables? Accurate use of codes by the providers? Use of the CMS GEMs for code selection Monitoring use of unspecified codes 4

5 Post Implementation Activities: Claims Review Rejection Reasons Did we miss including codes on the benefit tables Was coding different than our expectations? We missed some 7 th characters and had to add them for chiropractors and PT/OT/speech benefit tables Understanding the place holder and 7 th character usage Communication from some offices thought they had to add Xs to every code to make all diagnosis codes 7 characters long. CMS and AHA hosted webinars to provide additional guidance on 7 th characters and to differentiate between initial and subsequent visits. Focus is on treatment rendered rather than just seeing a new physician. 5

6 Post Implementation Activities: Physician Office Activities Monitoring use of unspecified codes EHRs not giving the choice of right, left or bilateral Follow up with record review to identify a more specific May make a difference for payment of benefits for the member Use of Benefit Explainer to verify benefits for a member Group may not pay for procedure (i.e. vaccines) May have a diagnosis or location restriction Understanding the place holder and 7 th character usage Following the Official Coding Guidelines 6

7 Post Implementation Activities: Claims Review 7 th Character Usage Initial encounter: As long as patient is receiving active treatment for the condition Examples :surgical treatment, emergency department encounter and evaluation and continuing active treatment by the same or a different physician Subsequent encounter: After patient has received active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase. Examples: cast change or removal, an x-ray to check healing status of fracture, removal of external or internal fixation device, medication adjustment, other aftercare and follow-up visits following treatment of the injury or condition. For aftercare of injury, assign acute injury code with the 7 th character for subsequent encounter. Sequela: Complications or conditions that arise as a direct result of a condition (scar formation after a burn). 7

8 Post Implementation Activities: Claims Review Official Coding Guidelines CMS required the Medicare Advantage plans to implement edits related to the coding guidelines, specifically Excludes1 Notes Excludes1 definition: (laymen's terms) You can t code these conditions together, because these conditions cannot occur together. Examples: Diabetes 1 and 2 Congenital and acquired hydrocephalus When codes with an Excludes1 note was present with the other code specified as being excluded the claims were rejected. As part of our review we found errors in the logic and the edit was turned off at that time, until corrections could be made. 8

9 Just because it maps, doesn t mean it s right ICD-9 code 990, Effects of radiation, unspecified Complication of Phototherapy Radiation therapy Radiation sickness Excludes specified adverse effects of radiation (such as a burn) ICD-10 code T66XXXA(or D or S), Radiation sickness, unspecified (forward and backward mapping) Excludes1 specified adverse effects of radiation (such as a burn T20-T31, need location and degree) Is this really what the patient had, or did they have an adverse effect? 9

10 Z Codes: Factors Influencing Health Status and Contact with Health Services Encounter for Immunization, Z23 Use with both the procedure codes for the immunization an the administration of the immunization We frequently saw submission of code Z41.8, Encounter for other procedures for purposes other than remedying health state used for the administration procedure code. Person with feared complaint in whom no diagnosis is made, Z71.1 Used mainly for patients having lab work done. Labs will report this code if they aren t given a diagnosis code. Provide the reason for the test, including a preventive exam BMI, Z68 codes Report as a secondary diagnosis 10

11 Z Codes: Factors Influencing Health Status and Contact with Health Services Z3A codes for Weeks of Gestation Use only as a secondary diagnosis code Code first the complications of pregnancy, childbirth and the puerperium Codes were being used as the first listed diagnosis on obstetric claims as the reason for the ultrasound Z51.11 Encounter for antineoplastic chemotherapy Should be listed as first (principal) diagnosis Medicare was requiring Medicare Advantage claims with Z51.11 listed as secondary to be rejected. Concerns voiced by Michigan Society of Hematology and Oncology regarding specific drugs which have to be submitted with specific diagnosis codes. 11

12 Implementation Success: 4 Lessons from CMS and how BCBSM Succeeded Lesson 1: Be Customer Focused CMS CMS: start from the needs of the people who will live with the implementation; listening, learning, understanding the resource and technical assistance needs, concerns over payment/cash flow Response was the Road to 10 aimed specifically at smaller physician practices providing info on clinical documentation, clinical scenarios and other specialty specific resources BCBSM: our primary premise was to process claims the same way in ICD-10 as we did in ICD-9, we also listened and learned from the provider community We created the testing tool for both hospitals and physician offices We spoke at approximately 150 meetings between 2014 and 2015, provided webinars on a monthly basis 12

13 Implementation Success: 4 Lessons from CMS and how BCBSM Succeeded Lesson 2: Be Highly Collaborative CMS: worked in partnerships with AMA, AHA, AHIMA, state medical societies, physicians and other clinicians, billing vendors, DME suppliers and other stakeholders. Response was the Road to 10 aimed specifically at smaller physician practices providing info on clinical documentation, clinical scenarios and other specialty specific resources BCBSM: we worked in partnerships with other clearinghouses, vendors, state and national associations as well as our competitors We created the testing tool for both hospitals and physician offices We spoke at approximately 150 meetings between 2014 and 2015, provided webinars on a monthly basis We formed a consortium with our competition, 5 plans speaking with one voice Provided resources to the community in a variety of ways 13

14 Implementation Success: 4 Lessons from CMS and how BCBSM Succeeded Lesson 3: Be Responsive and Accountable CMS: anticipate the challenges, make them visible and be accountable for solving them. Challenge was for every system that connected to Medicare Response was to create Ombudsman office with a 3 business day response time. In the first month they received 1000 inquiries and met the 3 day turnaround on each one. BCBSM: we had the same goals We performed months of testing on millions of claims to anticipate any issues we might have created. Contact to us was in the way of provider outreach staff, provider inquiry, and ICD-10 inquiry mailbox Provided resources to the community in a variety of ways During the first quarter we had daily phone calls for our command and control center to identify and work to resolve issues identified. 14

15 Implementation Success: 4 Lessons from CMS and how BCBSM Succeeded Lesson 4: Be Driven by Metrics CMS: Daily spreadsheets and scorecards keep complex implementations on track. Receiving fewer claims? Generating more denials? Particular state having trouble with processing Medicaid claims. BCBSM: we had the daily (early on twice daily) Command and Control meetings/calls to identify issues, determine solutions and implement those solutions. Also to determine, were were We monitored increased paper claim submission, EDI rejections Reviewed claims paid and rejected to determine if paid correctly and if rejected, root cause Monitored percentage of calls to PIO, ICD-10 generated less than 1% of calls during 4Q15 15

16 New Codes Fiscal year 2017 New PCS Codes 71,974 codes in FY ,625 for FY additions 734 revisions 175 revisions to both long and short titles 312 revisions to long title only 247 revisions to short title only ICD-10 Coordination and Maintenance Committee March 9 15 Topics were discussed Agenda can be reviewed at link below Link to file M-Meeting-Materials-Items/ MeetingMaterials.html Downloads box FY2017 New-Revised-ICD-10-PCS Codes 16

17 New Codes Fiscal year 2017 New CM Codes 69,823 codes in FY 2016??? for FY additions 313 deletions 351 revisions??? revisions to both long and short titles??? revisions to long title only??? revisions to short title only ICD-10 Coordination and Maintenance Committee March Topics discussed most were for FY 2018 implementation date Agenda at link below. Link to file Not available as of 3/15/16, but keep checking the cdc.gov website. The file is supposed to be released this week. 17

18 General Equivalence Mappings CMS committed that GEMs would be refreshed and available for 3 years, so they will be available through October 1,

19 General Documentation Criteria Legible Visit date Standard Abbreviations Use of Symbols (subjective portion only, not in Assessment/Plan to describe a diagnosis) Signature and Credential (may use initials if full name appears on signature page or letterhead) On every visit Handwritten Electronic requires authentication Must be password protected and used exclusively by the individual provider Signature log (update annually) 19

20 General Documentation/Coding Tips: Unconfirmed Diagnoses Unconfirmed Diagnoses Conditions must be clearly documented to be coded Coders should not assume or infer a condition Example: Medical record shows Coumadin as current medication but condition not documented For physician/outpatient records do not code conditions that are not definitive Such as: Probable Possible Questionable Suspected Rule out Differential diagnosis lists 20

21 General Documentation/Coding Tips: History of History of History of means the patient no longer has this condition History of conditions often appear in the record s PMH Frequent documentation errors regarding use of History of: Coding a past condition as active Coding History of when condition is still active Condition must be active on DOS in order to code Incorrect Documentation H/O CHF, meds Lasix H/O angina, meds Nitroquick H/O COPD, meds Advair Correct Documentation Compensated CHF, stable on Lasix Angina, stable on Nitro COPD controlled with Advair This material is copyrighted material of BCBSM, all rights reserved Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensees of the Blue Cross and Blue Shield Association.

22 Documentation Changes: ICD 10 CM Increased Specificity: Since there are many new coding options in ICD 10 CM, the codes can capture the specifics that are documented. Document as specifically as possible when documenting the patient s condition. Pain: When documenting pain, include the following: Acuity (acute or chronic) Location (right knee behind the patella, LUQ, RUQ) Underdosing: Underdosing is an important concept and term in ICD 10 CM, it allows identification of when a patient is taking less of a medication than is prescribed. Document intentional, unintentional, non-compliance, and if known why: financial hardship, age related debility. This material is copyrighted material of BCBSM, all rights reserved Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensees of the Blue Cross and Blue Shield Association.

23 Diabetes: Documentation Changes: ICD 10 CM Type 1 or Type 2, due to underlying condition, drug or chemical induced, or other specified. Combination codes to identify complications Hypertension: When documenting hypertension identify: Type (essential, secondary) Causal relationship (renal, pulmonary, etc) Asthma: Cause Severity (mild, moderate, severe) Temporal factors (acute, chronic, intermittent, persistent, status asthmaticus, acute exacerbation). This material is copyrighted material of BCBSM, all rights reserved Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensees of the Blue Cross and Blue Shield Association.

24 Documentation Changes: ICD 10 CM Well child exam and screening: Age in days, months or years as appropriate Exam type: well child, sports or school physical, hearing Findings: normal vs. abnormal findings (additional code) Z code is not to be used if the exam is for diagnosis of suspected condition or treatment purposes. Trimester: Documentation of trimester is required Definitions included in coding materials Substance use, abuse and dependence: Documentation should specify, if combination, use most severe form.. This material is copyrighted material of BCBSM, all rights reserved Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensees of the Blue Cross and Blue Shield Association.

25 Documentation Changes: ICD 10 CM Fractures When documenting fractures, include the following parameters: Type e.g. Open, closed, pathological, neoplastic disease, stress Pattern e.g. Comminuted, oblique, segmental, spiral, transverse Etiology to document in the external cause codes Encounter of care E.g. Initial, subsequent, sequela Healing status, if subsequent encounter e.g. Normal healing, delayed healing, nonunion, malunion Localization e.g. Shaft, head, neck, distal, proximal, styloid Displacement e.g. Displaced, non displaced Classification e.g. Gustilo-Anderson, Salter-Harris Any complications, whether acute or delayed e.g. Direct result of trauma sustained This material is copyrighted material of BCBSM, all rights reserved Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensees of the Blue Cross and Blue Shield Association.

26 Resources The BCBSM website for ICD-10 information has moved. Here is the new link. CMS has created a new Next Steps Toolkit (5 pages) 0NextStepsToolkit pdf Topics include: Assessing your progress Key Performance Indicators Addressing your findings Troubleshooting Maintaining your progress Keeping your systems and coding resources up to date 26

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29 Coding Clinic 1 st Quarter 2016 Coding of heart failure There is new information in the first quarter 2016 edition of Coding Clinic related to the terminology used for Congestive Heart Failure Documentation needs to identify whether the condition is as acute and chronic Interpretation of Diabetes with It is best to query the provider if the relationship between diabetes and other conditions is not clarified in the documentation If documentation specifies DM is NOT the underlying cause of the other condition DO NOT code it as a diabetic complication This material is copyrighted material of BCBSM, all rights reserved Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensees of the Blue Cross and Blue Shield Association

30 2017 Diagnosis Code Updates Changes in multiple chapters to split out hemorrhage from hematoma and split out procedure on organ in body system from following other procedure. Chapter 2 Neoplasms New codes for gastrointestinal stromal tumor of several sites Deleted term classical from Hodgkin lymphoma Expanded code D49.5 to add 5 th character Chapter 3 Diseases of Blood and Blood Forming Organs Added codes regarding mast cell Chapter 4 Endocrine, Nutritional and Metabolic Diseases Diabetes codes for retinopathy (all types of diabetes E08-E13) Diabetic retinopathy codes expanded to 7 characters including right, left, bilateral and unspecified (260) Separate hypercholesterolemia into unspecified and familial Chapter 5 Mental, Behavioral and Neurodevelopmental Disorders Added specificity by expanding several codes Obsessive-compulsive disorder now includes a code for hoarding Additional codes for eating disorders Added code for transsexualism and revised gender identity disorder to dual rule transvestism This material is copyrighted material of BCBSM, all rights reserved Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensees of the Blue Cross and Blue Shield Association

31 2017 Diagnosis Code Updates Continued Chapter 6 Diseases of the Nervous System Added codes for bilateral limbs Chapter 7 Diseases of the Eye and Adnexa Added 94 codes primarily related to laterality Chapter 8 Diseases of the Ear and Mastoid Process Added codes for laterality of pulsatile tinnitus Chapter 9 Diseases of the Circulatory System Added codes related to hypertensive urgency, emergency and crisis Collapsed site specific nontruamatic subarachnoid hemorrhage into one code Added codes for bilateral thrombosis of various sites Expanded codes for cognitive deficits following various types of cerebral hemorrhage, infarction and cerebrovascular disease Chapter 11 Diseases of the Digestive System Added codes related to: Colitis Periodontitis Ischemia and infarction of small and large intestine Necrotizing enterocolitis, irritable bowel syndrome and constipation Expanded specificity for codes related to megacolon and various types of pancreatitis This material is copyrighted material of BCBSM, all rights reserved Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensees of the Blue Cross and Blue Shield Association

32 2017 Diagnosis Code Updates Continued Chapter 12 Diseases of the Skin and Subcutaneous Tissue Added a codes for excessive and redundant skin and subcutaneous tissue Chapter 13 Diseases of the Musculoskeletal System and Connective Tissue Added codes for laterality for several conditions Added codes for specific levels of cervical region disorders Added codes for femoral fractures Added codes for periprosthetic fracture Chapter 14 Diseases of the Genitourinary System Revisions to code descriptions Added codes for other types of incontinence Expanded specificity of dysplasia of prostate and other specified disorders of male genital organs Expanded specificity of inflammatory disorders of breast and several reproductive organ conditions Expanded specificity of hypertrophy of vulva and dyspareunia codes This material is copyrighted material of BCBSM, all rights reserved Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensees of the Blue Cross and Blue Shield Association

33 2017 Diagnosis Code Updates Continued Chapter 15 Pregnancy, Childbirth and the Puerperium Added specificity to abdominal, tubal, ovarian and ectopic pregnancies Revision to 29 codes descriptions Added 43 new codes in several categories, many related to trimester or other timeframe Added specificity for maternal care for fetal deformities, scar from previous c- section and third degree perineal laceration during delivery Chapter 16 Certain conditions Originating in the Perinatal Period Revisions of code descriptions from suspected to be affected to affected Codes added for light or small for gestational age Chapter 17 Congenital Malformations, Deformations and Chromosomal Abnormalities Added specificity to codes related to aortic deformities, longitudinal vaginal septum and metatarsus varus Chapter 18 Symptoms, Signs and Abnormal Clinical and Laboratory Findings Added codes for the National Institute of Health Stroke Scale Added codes for urinary symptoms and other urinary findings Added specificity to Glasgow.com This material is copyrighted material of BCBSM, all rights reserved Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensees of the Blue Cross and Blue Shield Association

34 2017 Diagnosis Code Updates Continued Chapter 19 Injury, Poisoning and Certain Other consequences of External Causes Added codes for: Related to base of skull fracture For laterality of occipital fracture and orbital floor For laterality of various locations of jaw and facial fractures For laterality of dislocation and sprain of jaw For other and unspecified fracture of foot, various types of calcaneous, metatarsal and toe fracture (w/ laterality) For stenosis of coronary and peripheral vascular stents For breakdown, displacement, leakage, or infection of various urinary catheters and stents For complications of male specific prosthesis Related to erosion or exposure of implanted mesh or bulking agent For complications related to electronic neurostimulator or other nervous system device For unintended awareness under general anesthesia Revision of codes descriptions is several code categories Deleted concussion codes Deletion of codes related to periprosthetic fractures This material is copyrighted material of BCBSM, all rights reserved Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensees of the Blue Cross and Blue Shield Association

35 2017 Diagnosis Code Updates Continued Chapter 20 External Causes of Morbidity Deleted of codes regarding accidents specific to SUVs Addition of codes regarding accidents without terminology specific to type of vehicle Addition of codes regarding contact with sharp objects Deletion of codes related to cause of cuts Addition of codes related to overexertion Chapter 21 Factors Influencing Health Status and Contact with Health Services Addition of codes for : Observation and evaluation of newborns, condition ruled out Various reasons for encounters Pregnant state, gestational carrier Encounter for desensitization to allergens scopic or other procedures converted to open Long term (current) use of oral hypoglycemic drugs Family history of SIDS May be some additional codes to be effective 10/1/2016. This material is copyrighted material of BCBSM, all rights reserved Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensees of the Blue Cross and Blue Shield Association