What You Need to Know About ICD-10

Revenue Cycle Solutions Consulting & Management Services What You Need to Know About ICD-10 Documentation in an ICD-10-CM/PCS World A Physician Practice Perspective

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About Today s Speaker Shamim Noorani, MPH Project Lead for The Valley Hospital s ICD-10 Implementation Initiative Has partnered with large health systems and community hospitals to improve revenue cycle performance Works with multiple Advisory Board members on ensuring a successful transition from ICD-9 to ICD-10 Other areas of concentration include strategic planning, market analysis, and revenue cycle optimization For more information, contact: Shamim Noorani, MPH Associate Director 202.568.7147 NooraniS@ 5

Our Firm in Brief 3,600 + 2,200 + 1,500 + Hospitals and health care organizations in our membership Health care professionals employed Hospitals using our performance technologies RESEARCH AND INSIGHTS PERFORMANCE TECHNOLOGIES CONSULTING AND MANAGEMENT TALENT DEVELOPMENT Memberships Offering Strategic Guidance and Actionable Insights National Peer Collaboratives Powered by Web-Based Analytic Platforms Seasoned, Hands-On Support and Practice Management Services Partnering to Drive Workforce Impact and Engagement Dedicated to the most pressing issues and concerns in health care 300+ industry experts on call 200+ customizable forecasting and decision-support tools Leading provider: Over 50% of inpatient admissions in the United States flow through our technology platforms Over 1.5 million user sessions annually Key challenges addressed: physician performance, population health, revenue cycle, referral growth, surgical profitability, and supply/ service cost 2,500+ years of operator experience in hospital and physician practices Principal terrains: hospitalphysician alignment/practice management, transition to valuebased care, revenue cycle optimization, hospital margin improvement Range of engagements from strategy/diagnostic to best practice installation to interim management to fully managed services Impacted the achievement of 76,000+ executives, physicians, clinical leaders, and managers 17,000+ outcomes-driven workshops tailored to partners specific needs Survey Solutions Customized strategies for improving employee and physician engagement National health care-specific benchmarking database of 480,000 respondents 165,000 + health care leaders served globally $500 + million in realized value per year 1,300 + engagements completed 6,200 + employee-led improvement projects 6

The Valley Hospital s ICD-10 Physician Education Approach A Three Phased Approach Phase 1 January-March 2014 Distribute high-level physician awareness Begin ICD-10-related messaging in Med Staff Bulletin Launch Physician Champion Intensive Schedule specialty specific education sessions Phase 2 Phase 3 October- December 2014 Ongoing education and support Reinforcement of ICD-10 concepts Sustainability plan April September 2014 Initiate specialty specific physician education Provide tip sheets to physicians by specialty Host on-site sessions and offsite webinars for select focus areas ICD-10 case study examples and focused messages What is in it for ME? 1 3 5 Completion of the ICD-10 specialty specific training curriculum will provide CME credits 2 Better indication of Severity of Illness (SOI) and Risk of Mortality (ROM) Better information to support and drive quality of care 7 4 Greater specificity provides insight for patients and other providers Greater opportunities for advanced medical research 6 Protect your bottom line

Road Map for Discussion 1 ICD-10-CM/PCS: What Changes? 2 Impact on Physician Practices 3 Documentation Best Practices 4 Resources and Q&A 8

ICD-10-CM/PCS: What Changes? ICD-9 Deconstructed Understanding where we are History of ICD-9 World Health Organization (WHO) endorsed ICD-9 codes for use worldwide U.S. developed clinical modification (ICD-9-CM) in 1979 Expanded number of diagnosis codes; developed inpatient procedure coding system ICD-9 Uses Today Calculate Payment: Medicare Severity-Diagnosis Related Groups (MS-DRGs) Adjudicate Coverage: diagnosis codes for all settings Compile statistics Assess quality Current ICD-9 Users ICD-9-CM Diagnoses: used by all types of providers ICD-9-CM Procedures: used only by inpatient hospitals Current Procedural Terminology (CPT): used for all ambulatory and physician procedure reporting Why a New System? ICD-9 cannot accurately describe the diagnoses and inpatient procedures of care delivered in the 21st century 9

ICD-10-CM/PCS: What Changes? ICD-10-CM/PCS Quick Facts to understand where we re going ICD-10 Regulatory Requirements All HIPAA transactions will require the use of ICD-10-CM/PCS codes The compliance deadline is October 1, 2014 Institutional, outpatient and professional services claims submitted with a date of service or discharge on or after the compliance deadline must contain ICD-10-CM (diagnosis) codes ICD-10-PCS (procedure) codes will also be required for inpatient institutional services only CPT codes remain unchanged as a means to define procedures conducted in the clinic and physician practice settings Significant Changes on the Horizon This migration from the current ICD-9 standard to the ICD-10 standard will represent one of the greatest changes in health care information in many years. Joseph C. Nichols, MD Source: Nichols, J.C. (2011). ICD-10 A primer. Advisory Board Applications and Technologies Collaborative. 10

ICD-10-CM/PCS: What Changes? October 1, 2014 Transition from ICD-9-CM/PCS to ICD-10-CM/PCS Benefits and Goals of ICD-10-CM/PCS Provides better detail and a more accurate depiction of patient severity Improves care management of patients Obtains reliable and robust clinical data that can be used to make intelligent, data-driven decisions related to all aspects of health care Allows for more accurate payment for new procedures Improves disease management through capture of morbidity and mortality data Offers a better understanding of the value of new medical procedures Provides more specific data to address global disease emergencies Reduces the number of miscoded, rejected and improper claims for reimbursement Provides comprehensive data for improved fraud and abuse monitoring Add Source: 2011, The Clinical documentation Improvement Specialist's Guide to ICD-10 p.9 Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPR, C-CDI, CCDS and Sylvia Hoffman, RN, C-CDI, CCDS. 11

ICD-10-CM/PCS: What Changes? ICD-10 Substantially Increases Code Volumes Increase in Codes from ICD-9 to ICD-10 ICD-10 Code Set Characteristics ~68K ~87K >50% Percentage of ICD-10 codes related to musculoskeletal conditions ~25% Percentage of ICD-10 codes related to fractures ~14K ~4K 36% Percentage of ICD-10-CM codes that are different due to distinguishing between right vs left ICD-9 Diagnosis Codes ICD-10 Procedure Codes 12

ICD-10-CM/PCS: What Changes? ICD-10-CM Captures More Information New codes are more descriptive Characteristic ICD-9-CM Diagnosis Codes (Vol. 1 & 2) ICD-10-CM Diagnosis Codes Field Length 3-5 characters (except for the 1 st character for E and V codes) 3-7 characters Acuity Capture Limited inclusion of co-morbidities, complications, severity, manifestation, and, risk Includes many of these parameters within codes Laterality Does not distinguish laterality (left vs. right vs. bilateral) Usually includes laterality where appropriate Encounter Does not define initial vs. subsequent encounters Includes these concepts Available Space for New Codes Expansion ability is limited Alphanumeric support and place holder characters provide significant ability to expand the codes sets Consistency of Terms Consistency of terms and definition has been a challenge Consistency for terms and concepts has been improved Code Combination Combination codes are limited Combination codes are frequent, with multiple distinct medical concepts per code 13

Introduction to ICD-10-CM Diagnosis Coding Structure ICD-10-CM codes will contain 3-7 alphanumeric characters with the following structure α # α/# α/# α/# α/# α/# Category Sub-categories (Etiology, Anatomic Site, Severity, Laterality, Complication) Extension (3-16 options depending on category) Key ICD-10-CM Documentation Concepts Specific anatomical location Type (primary, secondary, unspecified) Acuity (acute, subacute, chronic, acute on chronic, or unspecified ) Trimester (1,2,3,unspecified) Degree (mild, moderate, severe, or unspecified; total/complete vs partial/incomplete) Episode of Care (Initial, Subsequent, Sequelae) Laterality (Right, Left, bilateral, or unspecified) Number of fetus (1-5, other) 14

ICD-10-CM/PCS: What Changes? More Specific Codes Requires More Specific Documentation Physician documentation drives successful ICD-10-CM coding A provider sees a patient in a [subsequent encounter] for a [non-union] of an [open] [fracture] of the [right] [distal] [radius] with [intra-articular extension] and a [minimal opening] with [minimal tissue damage] ICD-9 Code Description 813.52 Other Open Fracture of Distal End of Radius (Alone) ICD-10 Code Description S52571M Other intra-articular fracture of lower end of right radius, subsequent encounter for open fracture type I or II with nonunion For all codes related to fractures of the radius: Volume of ICD-9-CM codes = 33 Volume of ICD-10-CM codes = 1,818 15

ICD-10-CM/PCS: What Changes? All Codes Change No Familiar Favorites to Choose From ICD-9-CM 250.02 Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled ICD-10-CM E11.65 Type 2 diabetes mellitus with hyperglycemia Well Not Exactly Not much will change. I use 250.0x for diabetes in my office now. In the future, I will still use 250.0x. I will just need to add more information in the record to support it. 250.43 Diabetes with renal manifestations, type I [juvenile type], uncontrolled E10.21 Type I diabetes mellitus with diabetic nephropathy AND E10.65 Type I diabetes mellitus with hyperglycemia VPMA 300+ bed facility Required ICD-10 Concepts: Type, Clinical details of disease manifestation or complications 16

Road Map for Discussion 1 ICD-10-CM/PCS: What Changes? 2 Impact on Physician Practices 3 Documentation Best Practices 4 Resources and Q&A 17

Impact on Physician Practices Impact Spans Acute and Ambulatory Settings Addressing documentation and query impacts Potential physician workflow disruptions derive from new documentation requirements and increased query volumes that may exist to facilitate code assignment. Hospital: Coding Challenges Documentation Additional clinical details must be noted. Queries Additional requests from coders attempting to enter procedures and diagnoses into information systems. Additional requests from documentation improvement staff. 18

Impact on Physician Practices Challenges in the Physician Practice Area Coding challenges yield operational and financial impacts Coding Challenges Operational Challenges Financial Challenges Drivers of Coding Challenges Insufficient physician documentation Code structure, number, detail, rules, sequencing, definitions, and relationships Paper encounter form What it Affects Practice management system Encounter form Staff training Physician documents patient and procedure details Coder tries to crosswalk codes Increase in denied claims from payer 19

Impact on Physician Practices Impact on Day-to-Day Operations ICD-10-CM creates structural challenges in the physician office Coding Challenges Operational Challenges Financial Challenges Drivers of Operational Challenges Workflow disruptions Training time Coding productivity Updates to electronic health record systems Redesign of the encounter form What it Affects Patient flow in the office Coding efficiency Public health reporting Clinical and quality reporting Encounter forms Practice management system EMR Traditional Paper Encounter May be an Ineffective Coding Tool Create and Implement Strategies Early to Prevent Workflow Crisis Source: Nichols, J.C. (2011). ICD-10 Physician impacts. Advisory Board Applications and Technologies Collaborative. 20

Impact on Physician Practices How Practice Finances are Impacted ICD-10 will impact physician practice revenue Coding Challenges Operational Challenges Financial Challenges Drivers of Financial Impact 10-20% estimated increase in denials Processing rules Remediation of medical policies Crosswalk complications Differences in authorization and referral triggers Increased scrutiny of documentation to prevent fraud and abuse What it Affects Conversations with vendors Conversations with payers Budget for new or updated technology Revenue from lost productivity and increase in denials Physicians Discuss ICD-10 with Vendors Source: Nichols, J.C. (2011). ICD-10 Physician impacts. Advisory Board Applications and Technologies Collaborative. 21

Road Map for Discussion 1 ICD-10-CM/PCS: What Changes? 2 Impact on Physician Practices 3 Documentation Best Practices 4 Resources and Q&A 22

Documentation Best Practices Understand Coding the Medical Record Coders rely primarily on physician documentation Able to Code/Capture: Unable to code from: ED Physician Notes History and Physical Progress Notes Consultation MD Orders Discharge Summary Operative / Procedure Note Nursing Notes Pathology Report Lab X-rays (exception: can be utilized for laterality and specific type or site. Example: # of rib fractures and site specificity) Ancillary documentation (exception: stage of pressure ulcers and BMI can be captured from ancillary documentation if there is a corresponding diagnosis by the physician) Only the documentation of a credentialed, treating provider can be used for hospital coding. Examples include: Attending Physicians Surgeons Anesthesiologists Consulting Physicians Interventional Radiologists Residents Nurse Practitioners Physician Assistants A provider is defined as any physician or health care practitioner who is legally accountable for establishing the patient s diagnosis. (Official Coding Guidelines October 2012). 23

Documentation Best Practices Specific Items for Consideration What does more robust documentation look like? Coders Unable to Assume Documentation Intention Secondary diagnoses, comorbid conditions Robust H&P, D/C summary, past vs. current conditions Clinical indicators Modifiers matter! (POA, resolving, suspected, severity, relationships, etc.) 24

Documentation Best Practices Defining Detailed Documentation The following phrases elude data assignment and additional information is required: The following diagnoses are detailed documentation with no changes required: Will Rehydrate Dehydration Unable to Void Urinary Retention Shortness of Breath Acute Respiratory Failure Pulmonary infiltrate Suspected Pneumonia (type) Elevated Creatinine Acute Kidney Injury or Acute Renal Failure The above represent descriptors, lab values or other test results The above represent clearer diagnostic statements 25

Diagnoses in the Outpatient and Clinic Setting Unspecific Diagnoses Examples! The most common and problematic documentation issue in the Outpatient and Clinic Settings is the lack of specificity of diagnoses documented. Diabetes: not clearly noted to be controlled or uncontrolled, type 1 or 2 or whether there were complications related to DM (i.e., neuropathy). Carcinoma: often described as history of carcinoma while the patient is actually still under treatment for carcinoma; diagnosis frequently lacks specificity around malignant vs. benign, type, and/or site Fracture: often unclear whether the patient is suffering from an acute fracture or aftercare for a fracture that has occurred previously vs. nonunion vs. malunion Acute/Chronic/or Further Described: many diagnoses (i.e., bronchitis, sinusitis, conjunctivitis, hepatitis, otitis media) lack this specificity 26

Documentation Best Practices ICD-10-CM Documentation Concepts Important to capture dysfunction A routine patient evaluation reveals presence of congestive heart failure [systolic] or [diastolic]. ICD-9 Code Description 428.21 Congestive heart failure, unspecified ICD-10 Code Description 150.21 Acute combined systolic (congestive) and diastolic Bottom Line: Specific physician documentation will be necessary to capture the specificity between the two most commonly encountered types of heart failure, given two different treatment options. Source: Advisory Board Research 27

Documentation Best Practices ICD-10 Documentation Concepts Important to capture history and type A provider sees a patient in an outpatient setting for a [past] dependency of [tobacco] use. ICD-9 Code Description 305.1 Tobacco use disorder ICD-10 Code Description F17.211 F17.213 Nicotine dependence, cigarettes, in remission Nicotine dependence, cigarettes, with withdrawal Bottom Line: Additional, specific physician documentation will be necessary to capture the history of tobacco dependence and type (cigarette, chewing tobacco, etc.) In ICD-10. Source: Health Data Consulting 28

Documentation Best Practices ICD-10 Documentation Concepts Important to capture disease origin A routine patient evaluation reveals presence of a respiratory infection. ICD-9 Code Description 466.0 Acute bronchitis ICD-10 Code Description J20.2 Acute bronchitis due to streptococcus Bottom Line: Additional, specific physician documentation will be necessary to capture the cause of the bronchitis. Source: Health Data Consulting 29

Documentation Best Practices ICD-10 Documentation Concepts Important to capture cause of disease A routine patient evaluation reveals reason for a patient s obesity. ICD-9 Code Description 278.00 Obesity, Unspecified ICD-10 Code Description E66.09 Other obesity due to excess calories Bottom Line: Additional, specific physician documentation will be necessary to capture the origin of obesity. Source: Health Data Consulting 30

Documentation Best Practices ICD-10-CM Documentation Tips Details Matter Specify acuity: acute, chronic, or acute on chronic Specify level of severity: mild, moderate, severe or profound Link causal agents to specific diagnosis(es): i.e., constipation due to dehydration; otitis media due to strep pneumonia 31

Ten Ways to Improve Documentation Now Below are the elements most commonly missed in clinical documentation. Often times the intent of the physician to capture these elements can be construed, but the clarity and specificity needed by the coding professionals is not present. The list below is not in any ranked order. Top 10 Considerations for Improvement 1. Document the reason for admission 2. Clearly document whether diagnosis was Present on Admission (POA) 3. Link symptoms to diagnosis 4. If patient is empirically treated prior to confirming a diagnosis, describe such a diagnoses as probable, likely, presumed, can t rule out, etc. in progress notes and discharge summary. Clearly document any diagnoses that have been resolved or ruled out 5. Capture all specificity 6. Prevent conflicting documentation between different caregivers (i.e.: attending vs. consulting) 7. Document the clinical significance (diagnosis) for each abnormal lab value and all diagnostic test results 8. Avoid symbols and non-approved abbreviations as shorthand 9. Link associated diagnoses with manifestations, indwelling devices, and/or medications 10. Include all clinically significant diagnoses, findings, procedures, and treatment provided in the discharge summary 32

Road Map for Discussion 1 ICD-10-CM/PCS: What Changes? 2 Impact on Physician Practices 3 Documentation Best Practices 4 Resources and Q&A 33

ICD-10 Apps There are numerous mobile apps dedicated to providing tips and strategies for proper documentation in ICD-10 Apps allow the user to enter a disease or condition of interest and view any relevant ICD-10 information Most apps are free and available on iphone, Android and other mobile devices 34

ICD-10 Apps Android Apps: Diseases Codes ICD-10 - Trofo Systems ICD 10 Lite 2012 - ipremiumapps Find-A-Code ICD10/ICD9 +GEMs - Find A Code, LLC ICD-10 Search - Queo Sistemas Medisoft ICD-10 Medical - www.medicalbilllingsoftware.com ICD 10 Codes 2012 Free - JTO Dev Team ICD 10 - appgroup lab ICD 10 Professional - AppHouse Software ICD 10 HD 2012 - ipremiumapps ICD-10-CM - Webpatient.net ICD-10 Doc Guide - Precyse iphone Apps: ICD 10 On the Go Medical Codes - VLR Software HCPCS Pro - 2011 Codes SvmSoft ICD10 Codes - Black Knight Lab ICD-10 Virtual Code Book Precyse University STAT ICD-10 Coder - Austin Physician Productivity, LLC AHIMA s ICD-10 PCS Flash Cards AHIMA ICD 10 HD 2013 Eslam Farhat ICD 10 Reference Grupo CRM ICD-10 Search The Coding Institute ICD 10 Nirmala T V ICD 10 Mobile SvmSoft And many more! And many more! 35

ICD-10 Resources Develop custom action plans to help prepare for ICD-10 implementation Library of references for all ICD-10: From clinical documentation to vendors Template library to augment your action plan http://www.roadto10.org/ 36

ICD-10 Resources Implementation roadmaps available for different providers Readiness assessments including prioritization tools and vendor questionnaires http://www.ahima.org/topics/icd10 37

The Valley Hospital s Physician Portal 38

The Valley Hospital s Physician Portal! More information on how you can access this information will come from the Office Manager Advisory Board. 39

The Engagement Team James Green, MBA Senior Partner GreenJ@ 202-266-5443 Samantha Hauger Partner HaugerS@ 202-266-6679 Emeric Palmer, MD Medical Consultant PalmerE@ 202-266-5600 Shamim Noorani Associate Director NooraniS@ 202-568-7147 Paul Gallo Senior Project Consultant GalloP@ 202-266-5511 Ben Beadle-Ryby Associate Director BeadleB@ 202-266-5323 Nick Tanner Project Consultant TannerN@ 202-568-7065 40