ICD 10 Preparation for NSMM

Transcription

1 This document explains regulation changes coming in 2014 that will impact how we collect and document clinical appropriateness using diagnosis codes (ICD-9 conversion to ICD-10). Please familiarize yourself with this prior to the National Sales & Marketing Meeting in November. There is a session planned where we will discuss how local market teams can position themselves as a resource to our partners and providers around this subject matter. Clinical documentation begins with the patient ordering process by the referring providers and continues along the patient continuum, including radiologists, providing documentation (see Figure 1). The final diagnosis codes are then assigned by coding professionals and are included in claims submitted to the payers. The assignment of appropriate codes ensures providers like us meet medical necessity requirements and ensures accurate and timely reimbursement, along with reduced denials from payers. That said, the ICD-10 clinical documentation requirement, which has been adopted as an international standard, is far more rigorous in regards to documentation specificity as there are five times the number of potential diagnosis codes than in ICD-9, which is the current diagnosis mechanism we are using. Medical providers nationally see this conversion as daunting and they are looking for guidance so they can ensure their patients continue to receive required care. As you learn more about what our internal team is doing to make this transition, the goal is to provide sales and operations leaders, nationally, they can use to help guide our customers as well. If we are not prepared for the ICD-10 conversion and its corresponding need for increased documentation specificity by October 1, 2014, our claims payments could be delayed and significantly impacted by increased denials. What is ICD-10? The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) published by the World Health Organization (WHO) provides codes to classify diseases and a wide variety of signs, symptoms, abnormal findings, complaints, social circumstances and external causes of injury or disease. Under this system, every health condition/situation can be assigned to a unique category and given a code. ICD is a coding system of diseases and signs, symptoms, abnormal findings, complaints, social circumstances and external causes of injury or diseases that is used internationally to classify morbidity and mortality data for vital health statistics tracking and in the U.S. for health insurance claim reimbursement. The ICD is revised periodically and is currently in its tenth edition in most of the nations, except a few like United States which still is continuing to use the previous edition, i.e. ICD-9 (see Figure 2).

2 Fax/Order (85%) Portal Information is received and reviewed Is it enough to schedule patient? Yes Patient is scheduled (if not already completed on the portal) Goes from order entry to Insurance team Services provided Patient provides supplemental (differentiation) No Patient Call ins Physician Call Associate reaches out to referring physician s office to get additional Order will entered into Fusion but will not assigned a date (typically won t book a time) Coders will validate procedure 1 Walk-ins Coders send back account to operations to see if there is additional Yes Does the coder still need additional? No The center works to obtain clinical from referring physician or to have an addendum completed Coder completes coding account and post charges Notes 1. All orders will be validated for government insurances and for any commercial insurances where additional clinical is needed for coding Notes from Meeting Complete updates to order forms as well as portals and interfaces mandatory field in appointment notes How do we get better from the interfaces

3 Figure 2 - Countries Using ICD-10 for Reimbursement Countries Year of Adoption United Kingdom 1995 Nordic Countries 1997 France 1997 Australia 1998 Belgium 1999 Germany 2000 Canada 2001 The conversion to ICD-10 codes requires providers to collect more relevant clinical documentation on each patient. That is because the ICD-10 code sets includes greater detail, changes in terminology, and expanded concepts for injuries, laterality, and other related factors (Figure 3). Figure 3 Comparing ICD-9 to ICD-10 ICD-9 ICD Digits 3-7 Digits First Digit is alpha (E-V) or Numeric Digit 1 is alpha; digits 2 and 3 are numeric; digits 4-7 are alpha or numeric Total of nearly 13,000 codes More than 68,000 codes Lacks detail Very specific Lacks laterality Has laterality ICD-9 Diagnosis Code Examples Acute otitis media Acute appendicitis Coma ICD-10 Diagnosis Code Examples B01.2 Varicella pneumonia K21.0 Gastro-esophageal reflux disease with esophagitis O Twin pregnancy, unspecified, third trimester

4 Here is an example from the American Medical Association on how ICD-10 requires more clinical documentation from a provider: If a patient is seen for treatment of a burn on the right arm, the ICD-9 diagnosis code does not distinguish that the burn is on the right arm. If the patient is seen a few weeks later for another burn on the left arm, the same ICD-9 diagnosis code would be reported. Additional documentation would likely be required for a claim for the treatment to explain that the burn treated at this time is a different burn from the one that was treated previously. In the ICD-10 diagnosis code set, characters in the code identify right versus left, initial encounter versus subsequent encounter, and other clinical (see Figure 4 comparisons). It s important to note, the orthopedic section of codes is expanding more than any other section of the new code sets. For example, in describing a diagnosis of adhesive capsulitis of the shoulder, ICD-9 had just one code (726.0). ICD-10 has three codes adhesive capsulitis of unspecified shoulder (M75.00), adhesive capsulitis of right shoulder (M75.01), and adhesive capsulitis of left shoulder (M75.02). Figure 4 ICD Comparisons ICD-9-CM Diagnosis Codes ICD-10-CM Diagnosis Codes Loss of weight R63.4 Abnormal weight loss R22.0 Localized swelling, mass or lump in head Swelling in head and neck R22.1 Localized swelling, mass or lump in neck D17.1 Benign lipomatous neoplasm of skin and subcutaneous tissue of trunk D17.39 Benign lipomatous neoplasm of skin and Lipoma of skin or subcutaneous tissue subcutaneous tissue of other sites Malignant neoplasm, breast lower-outer quadrant Benefits of moving to ICD-10? C Malignant neoplasm of lower-outer quadrant of right female breast C Malignant neoplasm of lower-outer quadrant of left female breast C Malignant neoplasm of lower-outer quadrant of right male breast C Malignant neoplasm of lower-outer quadrant of left male breast ICD-9 is 30 year old system No more room to add new codes Improved ability to measure health care services due to clinical specificity of the codes Increased sensitivity when refining grouping and reimbursement methodologies Enhanced ability to conduct public health surveillance New system uses full code titles that appropriately reflect advances in medical knowledge and technology Decreased need to include supporting documentation with claims

5 Preparing for the ICD-10 Deadline Providers will not be able to continue to report ICD-9-CM codes for services provided on or after October 1, The only exceptions are Worker s Compensation and Auto Liability claims, which may accept either ICD-9 or ICD-10. Clinical provider claims will not be paid if they are not prepared for this compliance. Everyone who is covered by HIPAA must transition to ICD-10. It is not limited to Medicare. To help us plan and prepare for this conversion, a representative cross-functional team including market operations (clinical and administrative), transcription, IT, revenue cycle management, sales, marketing, among others, is meeting on a bi-monthly basis to develop a roll-out plan so our teams and systems are ready for the ICD-10 requirement (see Figure 5). What does ICD-10 mean to CDI-Insight? Systems preparedness Impact on clinical providers/office and radiologists clinical documentation o Training is a critical piece of the conversion to ICD-10 and the increased need for more specific clinical documentation both with our internal teams, and inside the referring provider office. Education on documentation specificity o Radiologists o Coder education o Market teams and technologists Figure 5 - Internal Preparation to Mitigate Impact to Our Business Operations Revenue Cycle Management Information Technology Evaluating the clinical documentation process to establish best practices and help simplify and streamline documentation. o Ordering physician communication o Ordering forms o Patient clinical forms o Documentation in Fusion RIS FOA o Documentation in aries technologists o Diagnostic report radiologist Education and Training Internal and External Realization of potential payment delays and increased denials Payer testing; considerations of dual ICD-10 and ICD-9 capabilities Billing system capabilities Denial management process to ensure Intensive coder training education Process for communicating back to markets/radiologists related to documentation or order issues Metric development System requirements o Fusion RIS (Radiology Information System) Not ICD -10 Ready o Billing Systems Nex Gen Upgrade o CDI EMR Pain and Vascular o Interfaces Prepare for ICD-10 codes At the National Meeting, you will hear more about the steps we re taking internally as well as the impact of the ICD-10 conversion on our referring providers and customers.