Efficient ICD-10 Post Acute Care Preparation

Transcription

1 Efficient ICD-10 Post Acute Care Preparation April 30, :00 pm 2:30 pm PRESENTER: JOAN L. USHER, BS, RHIA, COS-C, ACE JLU HEALTH RECORD SYSTEMS TEL: (781) FAX: (781)

2 Learning Objectives 1. Review the planning process for a smooth ICD-10 Transition 2. Discussed will be Department specific planning 3. Review the types of education required for ICD Understand how ICD-10 will impact operations 2014 JLU Health Records Systems 2

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4 On October 1, 2015 ICD-10-CM will replace ICD- 9-CM diagnosis coding, which is used by all types of providers. ICD-10-PCS will replace ICD-9-CM procedure coding, which is used only by inpatient hospitals. CPT and HCPCS, which are used for medical supplies and physician office encounters, are not being replaced by ICD-10. 4

5 Category Alpha Code Format ICD-10-CM Format Etiology, Anatomical Site, Severity Extension X X X X X X X S72.001D Fracture femur, left S72 Fracture of femur 002 Femur, laterality left Extension D Subsequent Encounter 5

6 Up to 7 characters ICD-10-CM codes make greater use of letters Code I10 Diagnosis Hypertension Z47.1 Aftercare for Joint Replacement surgery E11.40 Diabetic neuropathy, type 2 Z Presence of artificial hip joint, left M80.021D Osteoporosis with pathological fracture humerus, right 6

7 Myths What is all the fuss? It is just a change in the coding system? Myth: In reality it is a documentation issue More documentation is needed from the referral source & MD 7

8 CHF - More Detailed Documentation Needed ICD-9-CM CHF ICD-10-CM CHF CHF # of possible codes = 1 CHF NOS I50.9 Heart Failure Unspecified Systolic (congestive) heart failure I50.2x Unspecified I50.20 Acute I50.21 Chronic I50.22 Acute on Chronic I50.23 Diastolic (congestive) heart failure I50.3x Combined systolic (congestive) & diastolic (congestive) heart failure I50.4x Number of possible codes = 13 8

9 Myths Organizations will code using the unspecified code choice Myth: Some Payer Sources have begun develop payment levels for specificity Myth: ICD-9 to ICD-10 is not a one to one translation 9

10 General Equivalence Mappings (GEMs) CMS created GEMs for organizations to use for comparative data Purpose to ensure that consistency in national data is maintained GEMs are needed to convert data ICD-9 and ICD-10 codes are quite different Allows movement between ICD-9 & ICD-10 Vendor should build into software system 10

11 ICD-9 to ICD-10 is not a one to one translation GEMs can be identical match, approximate match or no match Identical match: Parkinson's Disease = G20 However, has an Exclude1 Approximate match: Cellulitis of toe = L ICD-10 allows for laterality left, right toe Also has new code for lymphangitis of toe L Need to choose which is correct No match: Code not found, No equivalent diagnosis code Staging codes,707.2x, eliminated as Pressure ulcers coding includes the staging in ICD-10 11

12 Example: One ICD-10-CM Diagnosis Code may represented by multiple ICD-9-CM codes E Type II diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema ICD-9-CM Diabetes with ophthalmic manifestations, type II or specified type, not stated as uncontrolled Severe nonproliferative diabetic retinopathy Diabetic macular edema 12

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14 Example: One ICD-10-CM Diagnosis Code may be represented by multiple ICD-9-CM codes L Pressure ulcer of right buttock, stage III (includes laterality). ICD-9-CM Pressure ulcer buttock Stage III 14

15 Myths Getting information on laterality isn t a problem Myth: Laterality is needed for all injuries, certain CA, anywhere in the body where there is left, right or bilateral. Clinicians and providers will need to collect this information for completeness 15

16 Begin Now with Clinicians Laterality is now required as part of the ICD-10 Code structure. There are available codes for left, right and bilateral sides. Coding malignant neoplasm of the breast is determined by specific area or quadrant of breast, laterality and gender. Example: malignant neoplasm of upper-inner quadrant of right female breast C

17 Begin Now with Rehab Staff Deleted V57.89 code classification (PT, OT, SLP) Aftercare for Joint replacement Z47.1 Use additional code to identify joint (Z96.6-) Shoulder, elbow, wrist, hip, knee, ankle, finger, other (5 th character) Requires laterality (6 th character) Fracture aftercare is denoted by 7 th character extension 17

18 Begin Now with Physicians Documentation is key Ask physicians to document laterality as part of their diagnosis More specificity is required For etiology, anatomical site and severity Late Effects CVA 438.xx (I69.xxx) Expanded from 26 code choices to

19 ICD-10 Preparedness Stay the Course 19

20 Top 5 Areas Impacting Post Acute Care 1. Documentation by physicians/referral sources Difficulty obtaining detailed documentation from referral sources ICD-10 is dependent on Physicians for detailed information 2. Documentation by Clinicians Increased detail in narrative text 3. Effects all Departments Everyone will need some type of training/knowledge 4. Increased Budget Costs For training & preparation, implementation, computer upgrades 5. Cash Flow Vendor software needs to be ready to capture ICD-10 20

21 Current Level of Preparedness Awareness Preparation Activities Education Education: Online, Webinars, Classes EHR Vendors have been offering webinars Participate in CMS Open Door Forums Practice Coding Download e-books Purchase text book Ask Vendors when releasing ICD-10 version 21

22 Ways Post Acute Care is Preparing for ICD-10 Reviewing organization s coding model/processes Clinicians/RN coding, dedicated staff, HIM Professionals, certified coders, remote coding Beginning education to staff Mastering ICD-9 Beginner Level ICD-10 Reviewing documentation for level of details Sampling of coding active records under ICD-10 Review of collection of comorbidities and manifestations 22

23 ICD-10 Road Map Timeline Implementation Date October 1, 2015 Organize Assess Educate Implement Evaluate 23

24 Organize Establish a Steering Committee Develop a project plan with goals & timelines Be prepared to commit resources Establish Clinical Documentation Improvement (CDI) program Add to QI/PI Program Meet monthly 24

25 Assess Assess impact on ALL Departments 25

26 Assessing Readiness: Administration/Leadership Understand this major change effects all departments Steering Committee to report adherence to timeline Senior Leadership support on training needs and resource management 26

27 Assessing Readiness: IT System upgrades/changes Change to alphanumeric structure Field size expansion For codes For narrative descriptions of codes Loading of ICD-10 code tables Testing of edits for missing code characters Interfaces with other systems Internal testing of a claim submission with ICD-10 Codes External testing of a claim with a payer source 27

28 Vendor Readiness Start the Conversation with your vendor(s) Billing vendor, EHR Vendor, any outsourcing How will their products and services accommodate both ICD-9 and ICD-10 as the agency needs to work with claims for services provided both before and after the transition deadline for code sets? Talking to your vendors now about ICD-10 will help ensure that your transition goes smoothly Request a Readiness timeline 28

29 Payer Readiness Questions to ask payers: Who will be the primary contact for the ICD-10 transition? When will you be ready to accept test transactions? What do we need to test with you? Do you anticipate any changes in policy or delays in payment due to the changeover to ICD-10? If utilize clearinghouse have they tested with 3 rd party payers? Medicare testing March 2014 Will CMS perform more testing due to delay? 29

30 Assessing Readiness: Fiscal Conduct a Financial Impact Analysis Lost productivity Data conversion costs Running dual system Claims submission delay Discuss Operational and Capital Budgeting New systems Additional hardware More server space 30

31 Pre Establish a Budget for Implementation Costs Upgrades to IT Systems Concurrent Post Running Dual Systems Lost Productivity during implementation & training Additional Staff during transition Temp staff Staff turnover Continued Need for dual systems until all outstanding claims are paid Medicare Secondary Payers Claims in Appeal Status 31

32 Establish A Cash Flow Reserve Budget Payers anticipate an increase of denials (up to 10%) Due to agency ill preparedness Anticipate slow down in cash flow Due to payer ill preparedness Accountants are recommending a three month reserve of operating expenses 32

33 Productivity of Staff Expect a decrease in productivity for coding staff up to 30% Days to claim submission may increase 2-3 days 33

34 Assessing Readiness: Billing Continue to work on any issues with IT for transmission of claims Understand how to submit claims that span over the timeframe Understand how to read ICD-10 codes for any denials/rejections Dual systems maintenance during transition Assess readiness of payers 34

35 QI/PI Assessing Readiness: Auditing Audit records to determine if documentation reflects the care provided to ensure quality outcomes How ICD-10 fits with other internal and external initiatives Compliance Audit Records to determine if documentation supports level of detail required 35

36 Review Sampling of Records Run a report of the top ten diagnoses Review at least a 10% sampling of records Run a report by top 3 referral sources Review Referral Process What documentation is missing? How to communicate needed information from referral source? 36

37 Assessing Readiness: Coding Manager Orient IT manager on specifications of ICD-10 Orient other clinical managers on expected timeline Revise policies and procedures Establish Agency Coding Guidelines for consistent & accurate diagnostic selection Development of educational plan Identify different education needs of staff Establish Baseline Competency Identify who will provide training Review query tools & process Audit records to determine if appropriate code assignment 37

38 Educate Determine staff requiring education Determine the level of education needed General overview Detailed knowledge Ability to read codes Determine Method of Learning Classroom style, webinar, on-line courses Determine how to verify proficiency 38

39 Levels of Education Levels of Education: Awareness/General Knowledge (2-4 hours) Use/Professional Knowledge (4-8 hours) Applying Codes (16-24 hours) Practice coding & increase familiarity What steps could be taken to reduce the impact of decreased coding productivity? 39

40 Role Based Training Awareness/General Knowledge (2-4 hrs) Senior Leadership HR Clinicians (Nursing, PT, ST) Corporate Compliance Officer 40

41 Role Based Training Use/Professional Knowledge (4-8 hours) Billing Patient Accounts Manager Clinical Directors/Managers Liaisons Admissions/Intake Staff Utilization Review Infection Surveillance Information Systems Compliance Manager Medical Director/Associates 41

42 Role Based Training Applying Codes (average hrs) Quality Improvement Staff Coders 42

43 Educational Requirements: Coders Start NOW to measure baseline knowledge to identify gaps More detailed understanding of : Medical Terminology Anatomy and Physiology Pathophysiology Pharmacology Official Coding Guidelines Plan for attrition 43

44 Resources for Coders Coding Books Tablets with Coding Apps Phone Apps Quick Reference Guides Online Coding Applications 44

45 How to Begin to Assess Areas of Vulnerability Determine current level of specificity Are there a lot of NOS codes? Are there a lot of codes that end in 0? Are there a lot of codes that end in 9? Target areas of low specificity to determine if medical record has detail to support more specific coding 45

46 Begin Now with Admission Staff These staff are the face of the organization Have admission staff ask questions NOW to collect more detailed information Redesign pre-admission sheets for more detail of diagnoses Use Admission staff to educate referral source of needed information 46

47 Partnering with Physicians Outreach to PCP and Referral Sources Enlist the help of the Physician on PAC/Medical Director to speak to other physicians Host joint training sessions with office staff of smaller practices Ask Hospital to participate in their training Ask for Your Organization to be part of the MD training/information at the referral source site Offer to be guest speaker 47

48 Implement Complete IT system testing Begin dual coding 3-6 months before go live Ensure all staff have been educated Monitor workflow processes for efficiencies and/or backlogs 48

49 Evaluate Analyze case mix for any changes due to coding Reimbursement neutral Review workflow processes for best practice Analyze any backlog Review Productivity Standards Clinical Staff Coding & QI Staff Assess timely claims processing by payers Review dual system processing Assess Clinical Record Review Results for areas of incompleteness, less details Assess number of queries to clinicians Problem solve any claim submission issues 49

50 Major Milestones 2014 Assess & Data Gathering for preparedness Develop Educational Plan & Test for ICD-9 Competency Practice & Retrain April-June 2014 July Sept 2014 Oct Dec 2014 Analyze Current Coding Model Coding Model Determination Include training & practice time in Budget

51 Timeline April June 2014 Focus: Finish data gathering & preparedness Analysis of Coding Model Begin to revise any forms for better data collection Before delay, what was vendor readiness? Has payer testing started? 51

52 Timeline July-Sept 2014 Focus: Planning for Coding Function Develop Education Plan for Organization Who, What, When Determine ICD-9 competency of staff Assess for training needs If skills lacking in ICD-9; increase these skills first before proceeding to ICD-10 Using competency assessment Customize training based on need Begin Education with Coding Staff Begin Education with Referral/Intake, Liaisons Begin Budget Preparations Resources, Training, Time 52

53 Timeline October December 2014 Focus: Training Assess level of clinical documentation Purchase Coding Resources Invest in training Check in with EHR vendor Continue testing with payers 53

54 Testing with Payers End to End Testing is Critical To establish secure cash flow Most clearinghouses were ready to move forward CMS had limited testing??more testing options 54

55 Major Milestones 2015 Continue training ICD-10 Volume of Dual Coding Increases Test for ICD-10 Competency Validate payments are correct Jan-March 2015 Apr June 2015 July Sept 2015 Oct-Dec 2015 Evaluation of reimbursement +/- Grouper???? Episodic payments August 3 (60 days) Oct 1 Go Live 55

56 Timeline Jan-March 2015 Focus: Education Continue ICD-10 Mastery Begin Intermediate Level Training Dual coding of cases Assess any changes in reimbursement Check in with EHR vendor Testing QI rules 56

57 Timeline April June 2015 Focus: Increased Proficiency Increased volume of dual coding cases Check in with EHR vendor Increased screen capture Watch for CMS Grouper to be published 57

58 Timeline July-Sept 2015 Focus Practice & Gaining Proficiency Test for Proficiency in ICD-10 Remember increased proficiency = increased productivity Pre-go live for 60 episodic payments begins August 3 rd Review process for claims submission for split claims 58

59 Timeline October December 2015 Go Live & Assess Reimbursement Assess if claims are being paid correctly Clean up old claims/backlog Recheck case mix reports for Reimbursement Neutral Analyze any change factors 59

60 Time waits for no one. You can use it wisely or waste it. The choice is yours. 60

61 After a day of Coding. T73.3xxD Exhaustion due to excessive exertion, subsequent encounter 61

62 ABOUT THE SPEAKER: JOAN L. USHER, BS, RHIA, COS-C, ACE, President, JLU Health Record Systems, Pembroke, MA Degree, Health Information Management Certified OASIS and Coding Specialist AHIMA Approved ICD-10-CM Trainer Author, Rapid Reference Coding Guide, 2014 edition 2014 Author, Online ICD Coding Courses in partnership with Libman Education Contributing editor, Schraffenberger/Keuhn, Effective Management of Coding Services, AHIMA, 2009 Massachusetts Health Information Management Association (MaHIMA), BOD President, 2006 Co-Chair ICD-10 Task Force Professional Achievement Award Recipient, MaHIMA, 2008 American Health Information Management Association (AHIMA) delegate , member LTPAC Committee Taught ICD-9 coding for over 20 years and has educated over 10,000 people nationwide Home Care Alliance of MA, Board of Director member QI Committee, Facilitator ICD-10 Group Hospice & Palliative Care Federation MA, Board of Director , member QAPI Committee 62

63 Questions???? 63