Materials and Resources for 12/5 and 12/12 ICD-10 Webinars

Transcription

1 Materials and Resources for 12/5 and 12/12 ICD-10 Webinars If you haven t already, we encourage you go AHCA s website and purchase ICD-10 Essentials for LTC: Your Guide Preparation and Implementation at ds.asp Also, HCProhas developed ICD-10 curriculum and training materials specifically for LTC providers, please access HCPro Diane Brown, BA, CPRA written permission of HCPro, a division of BLR. No claim asserted any U.S. Government or American Medical

2 ICD-10-CM Preparation: Are You Ready? Program 1 12/05/2014 presented by Diane Brown, BA Direcr of Post Acute Education HCPro Short Polling Start! Please share at what stage you are in your ICD-10-CM preparation Completed internal staff training, converted all existing codes, ready go Just started some staff training Plan begin next spring No firm plans at this time written permission of HCPro, a division of BLR. No claim asserted any U.S. Government or American Medical

3 Why Is Coding So Important? Communicates information about patient care, care delivery, standards of care, morbidity, even demographics Covered entities must use the valid medical codes set specified by the organization responsible for maintaining that code set <65 FR & 82477, 65 FR & 82799> ICD-10-CM Mandate The Protecting Access Medicare Act of 2014 law, signed April 1, 2014 pushes back the transition ICD-10-CM until 2015 The federal register, dated August 4, 2014, identifies 10/1/2015 as the official transition date ICD-10-CM written permission of HCPro, a division of BLR. No claim asserted any U.S. Government or American Medical

4 Delay in ICD-10-CM Transition Continue move forward with your transition plans we now have more time prepare Use the opportunity wisely Plan strategy Educate Operationalize transition in manageable segments COMPLIANT DIAGNOSIS CODING BASICS AND TRANSITION ISSUES written permission of HCPro, a division of BLR. No claim asserted any U.S. Government or American Medical

5 ICD-10-CM and ICD-10-PCS ICD-10-CM diagnosis codes used for ALL types of services (IP, OP, professional, PAC) CPT and HCPCS II will continue be utilized for outpatient and professional services procedures Clinical Modification (CM) is added for the United States Gives more specific detail needed for the indexing of medical records, medical care review, ambulary and other medical care programs Purpose of ICD Codes in LTC Collect diagnostic and statistical data Support clinical decision-making Verify medical necessity Validate need for supportive procedures, treatments, and therapies Correctly code diseases on the MDS, UB-04, medical reports, therapy treatments, and ancillaries Supports reimbursement for services provided written permission of HCPro, a division of BLR. No claim asserted any U.S. Government or American Medical

6 International Classification of Diseases Timeline /1/ ICD adopted by WHO 1979 ICD-9-CM adopted by U.S ICD-10 developed by the WHO NCHS started studying ICD-10 ICD-10-CM will be adopted by U.S. Why do we need update ICD? Room for expansion Lack of detail Mortality reporting Benefits should include Fewer rejected claims Fewer improper claims Codes reflect modern medicine and updated medical terminology Improved disease management Standardization of disease moniring written permission of HCPro, a division of BLR. No claim asserted any U.S. Government or American Medical

7 LTC Payment Systems Do not currently rely on ICD codes for reimbursement, unlike other venues of healthcare However, medical review processes require accurate ICD coding or a denial may occur Payers Require That the services they reimburse be medically necessary All contracrs use data analysis identify coding errors Medicare reviewers analyze ICD diagnosis codes Coding is rapidly becoming a prime target for audits Embrace accurate coding! written permission of HCPro, a division of BLR. No claim asserted any U.S. Government or American Medical

8 ICD Updates Updates will be on a limited basis both ICD-9-CM and ICD-10-CM until implementation Major update ICD-10-CM will occur one year post implementation (10/1/2016) ICD-10-CM Official Draft Code Set Published effective 10/1 each year Facilities must use current, up--date manual Note: Residents with existing diagnosis codes that are updated require staff change the new or updated code in the computer written permission of HCPro, a division of BLR. No claim asserted any U.S. Government or American Medical

9 ICD-10-CM Official Draft Coding Guidelines Section I of the ICD-10-CM Manual Set of rules accompany and complement the official conventions and instructions provided within the ICD-10-CM itself Adherence these guidelines when assigning ICD-10-CM diagnosis codes is required under HIPAA AHA Coding Clinic The Central Office of AHA on ICD-10-CM represents a long-standing public and private secr collaboration between the Department of Health and Human Services (DHHS) and: American Hospital Association (AHA) American Health Information Management Association (AHIMA) Centers for Medicare and Medicaid Services (CMS) National Center for Health Statistics (NCHS) written permission of HCPro, a division of BLR. No claim asserted any U.S. Government or American Medical

10 AHA Coding Clinic Published quarterly by the AHA and endorsed by CMS Provides guidance on interpreting and applying the ICD-10-CM and is used in claims review The purpose: To promote accuracy and consistency in the use of ICD-10-CM Offers coding guidelines and advice based on adherence the statistical classification scheme of ICD-10-CM and the definitions specified in the Uniform Hospital Discharge Data Set (UHDDS) LTC coding guidance published for ICD-10 Coding Sources for the SNF Hisry and physical Lab reports can confirm or negate a suspected condition Xrayresults can confirm or negate a suspected condition Therapy Progress notes may indicate Incident reports may contain written permission of HCPro, a division of BLR. No claim asserted any U.S. Government or American Medical

11 Locating Your Coding Resources? ICD-10-CM Official Guidelines cmguidelines_2015%209_26_2014.pdf General Equivalency Mapping (GEMs) Files for m CMS, ICD-10-CM ex.html 21 Let s Compare ICD-9-CM ICD-10-CM Characters 5 numeric 7 alpha-numeric, expandable;1 st character is always a letter Body system chapters Laterality No Added (R, L) Dummy placeholder x No Yes, for expansion Fractures require knowing open, closed, healing status, and encounter for 7 th digit No Yes Combination codes Very few Many and improved Diabetes Injuries Posperative complications Very generic Separated by Type I or II Grouped by type of injury Generic Grouped bymostly by body part Distinguishesbetween intraoperative complications and postprocedural disorders written permission of HCPro, a division of BLR. No claim asserted any U.S. Government or American Medical

12 ICD-10-CM Code Structure ICD-10 Format Can be 3 7 characters Category Subcategory: Etiology, anamical site, severity Extension X X X X X X X 1 ST Alpha 2 nd Numeric 3 rd alpha / numeric 4th alpha / numeric 5th alpha / numeric 6th alpha / numeric 7th alpha / numeric Examples of ICD-10-CM Codes Digits Code Description 3 I10 Essential (primary) hypertension 4 N36.0 Urinary tract infection, site not specified 5 I25.10 Arterosclerotic heart diseaseof native coronary artery without angina pecris (includes CAD and ASHD, NOS) 6 Z Presence of right artificial hip joint 7 S72.002S Fracture of unspecified part of neck of left femur, sequela Reminder: ICD-10-CM uses updated medical terminology. In the beginning, this may present some challenges 24 written permission of HCPro, a division of BLR. No claim asserted any U.S. Government or American Medical

13 ICD-10-CM Number of Codes ICD-10-CM diagnosis codes = >71,000 ICD-9-CM diagnosis codes = <14,000 Content of ICD-10-CM Manual ICD-10-CM Official Draft Guidelines for Coding and Reporting Conventions, chapter specific instructions, principal diagnosis selection, etc Alphabetic Index of Diseases and Injuries (Volume 2) Tabular List of Diseases and Injuries (Volume 1) written permission of HCPro, a division of BLR. No claim asserted any U.S. Government or American Medical

14 Coding Basics Review all the Guidelinesfor specific instructions before using the Alpha Index and the Tabular List Locate the condition, diagnosis, or sympm in the Alpha Index Read all instructions, cross references before going the Tabular Index Confirm code or codes found in the Tabular List Read instructions, notes, exclusions, etc May be located at the beginning of chapter, category, or code level Assign code be sure code specified digits 27 Example of Alpha Index Structure Main term Subterm: 1 st level Subterm: 2 nd level Infection, infected, infective (opportunistic) B99.9 with drug resistant organism see resistance (), drug lymphangitis see Lymphangitis organ dysfunction (acute) R65.20 abscess (skin) code by site under Abscess Absidia see Mucormycosis Acanthamoeba see Acanthamebiasis Acanthocheilonema (perstans) B74.4 accessory sinus (chronic) see sinusitis acromioclavicular M00.9 Actinobacillus A28.8 mallei A24.0 muris A25.1 written permission of HCPro, a division of BLR. No claim asserted any U.S. Government or American Medical

15 Chronic Obstructive Pulmonary Disease (COPD) 1. Locate in Alpha under Disease, then site Disease, diseased pulmonary (see also Disease, lung) artery I28.9 chronic obstructive J44.9 with acute bronchitis J44.0 exacerbation (acute) J44.1 lower respirary infection (acute) J Read notes ensure you select the code with the correct information 29 Tips for Use of the Tabular List Find the chapter that contains the code you are investigating or confirming from the Alpha Index Read any instructions at start of chapter Locate the section and category Read any additional instructions or clarifications Follow through with instructions Select code written permission of HCPro, a division of BLR. No claim asserted any U.S. Government or American Medical

16 Tips for Use of the Tabular List Always code highest number of digits Develop the habit of cross-checking all the codes assigned in the Tabular List You can use this method identify and correct coding problems prior submission the MAC/FI or let them find the problem for you! Tabular List (or Volume 1) Chapter Classification of Diseases Codes 1 Certain Infectious & Parasitic Diseases A00-B99 2 Neoplasms C00-D49 3 Diseases of the Blood & Blood-Forming Organs and Certain Disorders Involving the Immune Mechanism D50-D89 4 Endocrine, Nutritional and Metabolic Diseases E00-E89 5 Mental, Behavioral, and Neurodevelopmental Disorders F01-F99 6 Diseases of the Nervous System G00-G99 7 Diseases of the Eye and Adnexa H00-H59 8 Diseases of the Ear and Masid Process H60-H95 9 Diseases of the Circulary System I00-I99 10 Diseases of the Respirary System J00-J99 11 Diseases of the Digestive System K00-K95 written permission of HCPro, a division of BLR. No claim asserted any U.S. Government or American Medical

17 Tabular List (or Volume 1) Chapter Classification of Diseases Codes 12 Diseases of the Skin & Subcutaneous Tissue L00-L99 13 Diseases of the Musculoskeletal System and Connective Tissue M00-M99 14 Diseases of the Geniurinary System N00-N99 15 Pregnancy, Childbirth, and the Peurperium O00-O9A 16 Certain Conditions Originating in the Perinatal Period P00-P96 17 Congenital Malformations, Deformations, and Chromosomal Abnormalities 18 Sympms, Signs and Abnormal Clinical and Laborary Findings, Not Elsewhere Classified 19 Injury, Poisoning and Certain Other Consequences of External Causes Q00-Q99 R00-R99 S00-T88 20 External Causes of Morbidity V00-Y99 21 Facrs Influencing Health Status and Contact with Health Services Z00-Z99 Example of Tabular List Chapter 10. Diseases of the Respirary System (J00 J99) Chapter Heading Chronic Lower Respirary Diseases (J40 J49) J44 Other chronic obstructivepulmonary disease(4 th ) (Read: Includes notes,code also note, Use additional code notes, Excludes 1 notes before proceeding) J44.0 Chronic obstructive pulmonary disease with acute lower respirary infection Use additional code identify the infection J44.1 Chronicobstructive pulmonary disease with (acute) exacerbation Decompensated COPD Decompensated COPD with (acute) exacerbation J44.9 Chronic obstructive pulmonary disease, unspecified Chronic obstructive airway disease NOS Chronic obstructive lung disease NOS Code Block Category Subcategory written permission of HCPro, a division of BLR. No claim asserted any U.S. Government or American Medical

18 What is a Physician Query? A query is defined as a question posed a provider obtain additional information or clarifying documentation in order improve the specificity and completeness of the data used assign diagnosis codes in the patient s health record (See attachment for more information) When To Do A Physician Query Medical record documentation has clinical indicars of a diagnosis, but no documentation is present about the condition Patient is admitted with sympms when there is evidence of an underlying cause Documentation indicates a greater level of specificity then the code selected by clinician A treatment is documented without listing a corresponding diagnosis written permission of HCPro, a division of BLR. No claim asserted any U.S. Government or American Medical

19 Prevalence of conditions Number of codes be converted Number of new patients per month Number of bills sent each month SCOPE OF THE IMPLEMENTATION 37 MDS Item Prevalence of Common Clinical Conditions Frequency 2013 Frequency 2003 H0300 Incontinence (from frequent 100%) 61% 58% I0700 Hypertension (HTN) 73% 57% I4800 Dementia, Non-ALZ (ALZ=15%) 42% 37% I2900 Diabetes, type unspecified (DM) (eg. Diabetic retinopathy, nephropathy, and neuropathy) 33% 26% I0600 Heart Failure (eg. CHF, pulmonary edema) 20% 22% I2300 UTI (in the last 30 days) 8% 9% I6200 Asthma, COPD, or Chronic Lung Disease 21% 16% I1200 GERD or ulcer 32% N/A I3700 Arthritis 28% 30% I1500 Renal insufficiency, Failure, ESRD (*failure only) 11% 5%* I4500 Cerebrovascular Accident (CVA), TIA or Stroke 17% 23% I5950 Psychotic Disorder (*Schizophrenia) 11% 5%* I6500 Cataracts, Glaucoma, or Macular Degeneration 14% 23% J1900A Falls since admission (*incl. falls prior adm) 17% 15%* Set-3-0-Frequency-Report.html written permission of HCPro, a division of BLR. No claim asserted any U.S. Government or American Medical

20 Code Conversion Using GEMs Used promote consistency ICD-9 and ICD-10 codes are very different and ICD-10 offers much more specificity Software vendors should have them available in their systems However, mapping and conversion always needs human intervention! 39 Code Conversion Using GEMs Some mappings will be an exact match UTI, site not specified ICD-9 = ICD-10 = N39.0 Some mappings will be an approximate match that need confirmation Some mappings will be have a cluster of matches when more specificity is offered Some mappings will be have no match Encounter for rehabilitation ICD-9 = V57 ICD-10 = Use procedure codes instead 40 written permission of HCPro, a division of BLR. No claim asserted any U.S. Government or American Medical

21 Conversion of Existing Codes Using the GEMS, try translating some ICD-9- CM codes ICD-10-CM codes Identify where human intervention is needed Remember, the purpose of the GEMs is create a useful, practical, code code translation reference dictionary for both code sets, and offer acceptable translation alternatives wherever possible 41 Using the GEMS for Conversion The ICD-9 ICD-10 (and the reverse) GEMS are in.txt file format with 3 columns ICD-9-CM code ICD-10-CM code Flags A L L The 1 st digit 0 in the Flag column indicates an exact match that needs confirmation The 1 st digit 1 in the Flag column indicates an approximate match, that needs confirmation and frequently additional information 42 written permission of HCPro, a division of BLR. No claim asserted any U.S. Government or American Medical

22 Convert CHF from ICD-9 ICD-10 in GEMS 4280 I The flag 1 indicates an approximate match Check documentation see if there is additional documentation that could be coded under ICD-10-CM, such as whether it is due hypertension, which requires coding the hypertension 1 st Source system is less specific than many of the alternatives in the target system Convert Type 2 diabetes from ICD-9 ICD-10 in GEMS E The flag 1 indicates an approximate match Check documentation see if there is additional documentation that could be coded under ICD-10-CM, such as whether there are complications specified. If complications are specified, then this would not be the correct code (E118 or other) The target contains many translation alternatives, but the least specific is the one highlighted written permission of HCPro, a division of BLR. No claim asserted any U.S. Government or American Medical

23 Convert Aftercare of healing traumatic fracture of hip (right) V5413 ******** The flag 1 indicates an approximate match There are approximately 70+ possible combinations, all require specificity related the situation and all need confirmation Needs laterality Aftercare of a traumatic fracture, is no longer an acceptable alternative Source system is less specific along the laterality axis and the target system contains the more specific translation alternatives New Encounter Coding Determine how improve the diagnostic information flow from the physician staff Do you have the specificity you need code? When can you obtain clarification so that it does not impede billing and cash flow? 46 written permission of HCPro, a division of BLR. No claim asserted any U.S. Government or American Medical

24 Updating Existing Codes Make sure build updating in your process May need test with your software vendor Every MDS demands updating codes Every UB-04 demands updating codes 47 MANAGING THE TRANSITION ISSUES FOR ICD-10-CM written permission of HCPro, a division of BLR. No claim asserted any U.S. Government or American Medical

25 Plan Now Identify resources and conversion options (GEMs) Transition core or project team Preparation list by department with due dates Examine and implement workflow changes External partner collaboration Education timeframe Vendor responsibilities Information system readiness and evaluation Secure budget LTC Processes Requiring Accurate Coding Skilling and medical necessity Physician certification and recertification authorize skilled care MDS Assessment, including sections B, C, D, G, H, I, J, K, O Significant change elements: New sympms? New disease, exacerbation SNF PPS and case management SNF Billing 50 written permission of HCPro, a division of BLR. No claim asserted any U.S. Government or American Medical

26 Update Workflow Process Determine the role of the following: Admissions team and case managers Clinical team (MDS, unit managers, CNAs, weekend staff, DoN, therapist, dietician, social worker, etc) Medical records staff Billing and business office managers Coding Process and Workflow Who is responsible for coding decisions on billing forms? How is the process currently completed? What are the current stumbling blocks? MDS UB-04 Medical review Try diagram your current workflow process before you make any changes written permission of HCPro, a division of BLR. No claim asserted any U.S. Government or American Medical

27 Team Communication Inform staff and contracrs Contact vendors Contact payers Monir vendor prep Monir payer prep Education and Testing Levels of education Train the trainers Core team General staff Timing of education High-level training for test team Level 1: internal Level 2: external Gap analysis written permission of HCPro, a division of BLR. No claim asserted any U.S. Government or American Medical

28 Stay tuned for the 2 nd webinar in this series... Today s webinar is part one of a two part series. The second webinar is December 11 th at 2:00pm EST, titled, ICD-10-CM Steps Accurate LTC Coding Information System Importance Dual coding When? How? 56 written permission of HCPro, a division of BLR. No claim asserted any U.S. Government or American Medical

29 Materials and Resources for 12/5 and 12/12 ICD-10 Webinars If you haven t already, we encourage you go AHCA s website and purchase ICD-10 Essentials for LTC: Your Guide Preparation and Implementation at ds.asp Also, HCProhas developed ICD-10 curriculum and training materials specifically for LTC providers, please access Follow-up: Savings and a freebee... Medicare Boot Camp Long-Term Care Version. Participants of this webinar, are eligible for $100 in savings. Click here register and save Download free whitepaper written permission of HCPro, a division of BLR. No claim asserted any U.S. Government or American Medical

30 We can do this Let s get ready now Questions? written permission of HCPro, a division of BLR. No claim asserted any U.S. Government or American Medical