ICD-10 is Coming What s A Provider to do? Texas Osteopathic Medical Association Friday, January 31, 2014 Yolanda Doss, MJ, RHIA, CHPS Director, Compliance and Payment Advocacy Presentation developed for the AOA, and originally presented by Stanley Nachimson, Nachisom Advisors, LLC Yolanda Doss, MJ, RHIA, CHPS Responsibilities include: Helping to secure reimbursement for osteopathic services Securing the acceptance of osteopathic credentials Addressing Medicare issues HIPAA compliance Fraud and Abuse 1
Learning Objectives Following the presentation attendees should know: When the ICD 10 codes will be implemented The factors precipitating this significant change in diagnosis coding The preparations needed to avoid significant impact to payments, and Why improved documentation is critical Pre-Test Question The ICD 10 Final Rule implementation date was published in: 1. 1998 2. 2008 3. 2009 4. 2012 Pre-Test Question The ICD 10 Final Rule implementation date was published in: 1. 1998 2. 2008 3. 2009 4. 2012 2
Pre-Test Question ICD 9 is running out of codes. True or False Pre-Test Question ICD-9-CM is running out of codes. True or False Pre-Test Question There are 16,000 ICD 9 codes, this will increase to how many ICD 10 codes? 1. 25,000 2. 80,000 3. 68,000 4. 30,000 3
Pre-Test Question There are 16,000 ICD 9 codes, this will increase to how many ICD 10 codes? 1. 25,000 2. 80,000 3. 68,000 4. 30,000 Final Rules Issued To Change Coding Standard On January 16, 2009 HHS published 2 Final Rules One upgrading X12 and NCPDP HIPAA administrative transactions, with a January 1, 2012 compliance date One replacing ICD-9-CM with o ICD-10-CM for diagnoses o ICD-10-PCS for inpatient hospital procedures o With an implementation date of Oct 1, 2013 for the change (services provided on or after that date) That was over 4 years ago! What is happening now (2014) New Date - October 1, 2014 In February 2012, CMS said they would consider a delay based on industry status and concerns Groups were on both sides of the issue Final Rule published in August 2012 with new date Oct 2014 This caused many entities to put their ICD-10 plans on hold. CMS has reiterated the Oct 2014 deadline Time is now short (less than 1 year!) 4
Late Breaking News The Texas Department of Insurance has announced that Texas Workers Compensation System will transition to ICD 10 The Centers for Medicare and Medicaid Services (CMS) will be performing a testing week March 3-7. Register your practice through your CMS Contractor. Why Is There Such Controversy? Complexity of the code set Cost of implementation Competing initiatives (e.g. meaningful use, quality) Need for collaboration in implementation and testing Specific Changes Diagnosis Codes (ICD-9 to ICD-10-CM) Goes from 5 positions (first one alphanumeric, others numeric) to 7 positions, all alphanumeric From 13,000 existing codes to 68,000 existing codes Much greater specificity 5
Examples of ICD-10-CM Specificity Diabetes mellitus codes are expanded to include the classification of the diabetes and the manifestation. The category for diabetes mellitus has been updated to reflect the current clinical classification of diabetes and is no longer classified as controlled/uncontrolled: E08.22, Diabetes mellitus due to an underlying condition with diabetic chronic kidney disease E09.52, Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy with gangrene E10.11, Type 1 diabetes mellitus with ketoacidosis with coma E11.41, Type 2 diabetes mellitus with diabetic mononeuropathy1 Examples of ICD-10 Specificity Downs Syndrome ICD-9 758.0 ICD-10 Can be Q90.9, Down syndrome unspecified But, can also be o Q90.0 Trisomy 21, nonmosaicism (meiotic nondisjunction) o Q90.1 Trisomy 21, mosaicism (mitotic nondisjunction) o Q90.2 Trisomy 21, translocation Examples of ICD-10 Specificity Sports injuries now coded with sport and reason for injury ICD-9 code - Striking against or struck accidentally in sports without subsequent fall (E917.0) 24 ICD-10-CM Detail Codes 6
Examples of ICD-10 Specificity W21.00 Struck by hit or thrown ball, unspecified type W21.01 Struck by football W21.02 Struck by soccer ball W21.03 Struck by baseball W21.04 Struck by golf ball W21.05 Struck by basketball W21.06 Struck by volleyball W21.07 Struck by softball W21.09 Struck by other hit or thrown ball W21.11 Struck by baseball bat W21.12 Struck by tennis racquet W21.13 Struck by golf club W21.19 Struck by other bat, racquet or club W21.210 Struck by ice hockey stick W21.211 Struck by field hockey stick W21.220 Struck by ice hockey puck W21.221 Struck by field hockey puck W21.81 Striking against or struck by football helmet W21.89 Striking against or struck by other sports equipment W21.9 Striking against or struck by unspecified sports equipment W21.31 Struck by shoe cleats Stepped on by shoe cleats W21.32 Struck by skate blades Skated over by skate blades W21.39 Struck by other sports foot wear W21.4 Striking against diving board Specific Changes Enables laterality (right vs. left designations) Seriousness of condition e.g. mild, moderate, severe asthma Specific bone designation and fracture types in orthopedic situations Restructures reporting of obstetric diagnoses In ICD-9-CM, the patient is classified by diagnosis in relation to the episode of care. In ICD-10-CM the patient is classified by diagnosis in relation to the patient s stage of pregnancy (trimester) Issue No Clear Mapping Not always one ICD-9 to many ICD-10s Need more specific information to go from ICD-9 to 10 NCHS has published GEMs, general equivalence tables. Not a clear map Approximate Matches ICD-10 code M99.00 Segmentation and somatic dysfunction of head region is an approximate match to ICD-9 code 739.0 Nonallopathic lesions of head regions not elsewhere classified 7
Specific Changes to Procedure Code Reporting (ICD-9-CM to ICD-10-PCS). New Code Set for ICD-10 A US creation not used anywhere else Change from 5 to 7 positions Each position has a specific meaning. Only used for inpatient hospital procedures However, physician documentation for procedures will be a critical element. Example of PCS Code ICD-9-CM (sample code) 47.01 Laparoscopic appendectomy ICD-10-PCS (sample code) Laparoscopic appendectomy 0DTJ4ZZ 0 - Medical and Surgical Section D - Gastrointestinal system T - Resection (root operation) J - Appendix (body part) 4 - Percutaneous endoscopic (approach) Z - No device Z - No qualifier Why Make the Changes? Modernize Terminology Increased information for public health, biosurvellience, quality measurement ICD-9-CM running out of codes 8
Why Does This Matter? Diagnoses and procedure codes impact virtually every system and business process in plan and provider organizations, with significant impacts on reimbursements. Provider Impacts Key Impact - Documentation of Diagnoses - Codes must be supported by medical documentation - ICD-10-CM codes are more specific - Requires more documentation to support codes - Expect a 15% increase in documentation time (per AAPC) - Revenue Impacts of specificity o Denials o Additional Documentation o Contract revisions Provider Impacts Coverage and payment - New coding system will mean new coverage policies, new medical review edits, new reimbursement schedules - Changes will be made to accommodate increase specificity - May need to discuss changes with patients 9
Provider Impacts Contracts with plans - Coding more specific and includes severity - Renegotiations will be based on new coding, coverage, and reimbursement - Difficult to measure what the changes will mean to overall reimbursement Provider Impacts Billing and eligibility transactions - Updated transactions include support for ICD- 10 - New codes mean more specificity - How smooth the transition? - Expect increased reject, denials, and pends as both plans an providers get used to new codes. Provider Impacts Laboratory orders - Will need specific ICD-10-CM codes for laboratory orders - Expect coverage changes - Need to support the tests ordered 10
Provider Impacts Quality Measures/P4P New measures need to be determined based on ICD-10-CM codes Must renegotiate with provider groups Difficult to measure impact of change is it because of code set or because of changes in underlying practice Health Plan Impacts Contracting with providers and employers Coverage determinations Payment determinations Medical review policies Plan structures Statistical reporting Actuarial projections Fraud and abuse monitoring Quality measurements Expected Implementation and Operational Steps Training not just coders Providers Administrative Staff Systems Staff Business Process Analysis Where do you use diagnoses/inpatient hospital procedures? What are the interfaces that may need to be changed? What databases need to be changed? 11
Expected Implementation and Operational Steps Budgeting Resource Allocation Vendor discussions Software and services may need to be updated When will this be done for you? Cannot move into testing until you have updated products Workplan Impact on other initiatives What changes will plans be making and how do you respond? Need for close communications Expected Implementation and Operational Steps Documentation/Super bills Need increased documentation to support coding Superbills need to be updated/modified May need automated support based on increase in codes IT System Changes System analysis Programming Testing internally End to end testing Partner testing Expected Implementation and Operational Steps Patient education Communication with plans/trading partners External testing Transition 12
Timing How long will this take to do? Planning Internal work Vendor work (must track) Merging together Partner (clearinghouse/plan) work (must track) External end to end testing 9-12 months! Why Do We Need Testing? As we have seen, significant changes in operations Impact on all business processes Impact on cost and revenue Providers Health Plans How do we know this is going to work on Oct 1, 2014? Several Types of Testing IT Business Processes Unit (individual testing) Volume testing Comparison to ICD-9 results Vendor testing Internal External (trading partner) Compliance (it is an ICD-10 code) vs. Business 13
Differs from Previous HIPAA Testing Impact on business Provider needs to know result of processing Provider has to control this this is not a vendor process. Step by Step Internal Testing - Provider Start at the beginning Clinical scenario What is being documented and coded Can the bill be produced accurately? Can the claim be sent to the health plan properly from the business part of the system? Step by Step Internal Testing Health Plan Transaction received (authorization, eligibility, claim) Can it be brought into the system? Can the ICD-10 code be identified and interpreted accurately? Can an appropriate decision be made based on the transaction? Can the result be created? Can the answer be produced by the health plan system? 14
The Real Challenge End to End Testing Once both side feel their internal processes have been tested and are working properly Need agreed upon scenarios to test from start to finish Is the result that the provider (source of code) gets from a transaction what was expected? Did the health plan get what was needed from the provider to appropriately process the transaction? Scale of End to End Testing Theoretically, every provider should test with every health plan. There should be test systems in place on both sides that mirror production Clearinghouses can be leveraged as the middle providers send test transactions to them; they can then send to the payers Clearinghouses can help track payer readiness and payer issues But remember, clearinghouses don t do the payer testing, they just do the communications. Payers make the decisions on the transactions Prioritization In reality, we must prioritize: Heaviest volume Greatest revenue Most significant coding change Others? o Which health plans will be ready to test and when? o What and who will they test some transactions, some providers? 15
How To Test? Decide the situations that need to be tested Create test data Start at the beginning clinical data Test each system individually, then all together internally Test with trading partners Take results of each test, revise as necessary and retest Shared - Test Scenarios Consequences of Inadequate Testing Improper coding Revenue interruptions Misinterpretation of codes Lack of adequate documentation Improper decisions made at health plans Additional administrative costs Patient inconvenience Has happened in 5010 conversion 16
Timing Count backwards from Oct 1, 2014 Probably need between 6 months for external testing Probably need about 3 months for internal testing Means much of the work needs to be done by Jan 1, 2014 Post-Test Questions Laterality specification, left or right will be a new documentation requirement? True or False Post-Test Questions Laterality specification, left or right will be a new requirement? True or False 17
Post-Test Questions Training will be required for coders and payers only. True or False Post-Test Questions Training will be required for coders and payers only. True or False Post-Test Questions Which is not a consequence of inadequate testing: 1. Revenue Interruptions 2. Increased payment denials 3. Increased payments to physicians 4. Lack of adequate documentation 18
Post-Test Questions Which is not a consequence of inadequate testing: 1. Revenue Interruptions 2. Increased payment denials 3. Increased payments to physicians 4. Lack of adequate documentation www.osteopathic/icd-10 Practice Management Webinars www.osteopathic.org/pmwebinars Register for upcoming webinars View on-demand webinars 19
Practice Management Communications Free, timely and relevant practice management e-mail communications from the AOA. Physicians, practice staff, consultants and other health care partners are invited to sign up. Sign up by sending contact information to practicemanagement@osteopathic.org or by calling (800) 621-1773, ext. 8282. Questions? Staff Contacts Monica Horton, MPP, Director, Department of Practice Management and Delivery Innovations (312) 202-8090 phone (312) 202-8390 fax mhorton@osteopathic.org Yolanda Doss, MJ, RHIA, CHPS, Director, Compliance and Payment Advocacy (312) 202-8187 phone (312) 202-8487 fax ydoss@osteopathic.org 20
Staff Contacts Cynthia Penkala, CMM, CMPE, Director, Practice Transformation and Member Education (312) 202-8082 phone (312) 202-8382 fax cpenkala@osteopathic.org Kavin Williams, CPC, CCP, Health Reimbursement Policy Specialist (312) 202-8194 phone (312) 202-8494 fax kwilliams@osteopathic.org 21