ICD-10 is Here! What Now? Process, Pitfalls and Proactive Solutions

ICD-10 is Here! What Now? Process, Pitfalls and Proactive Solutions Maureen McCarthy, RN, BS, RAC-MT President & CEO Celtic Consulting, LLC www.celticconsulting.org Define ICD-10 Discuss the impact of ICD-10 Identifying training needs Explain how physician documentation can affect reimbursement Review ICD-10 coding tips for SNFs Point out claims processing tips Discuss the QA process under ICD-10 Identify areas at risk for errors Provide 2 take away tools for QA monitoring 1

ICD=International Classification of Diseases 10 th revision ICD was developed to reflect care and services being provided to patients, it collects uniform data for research & education on disease patterns and causes of death. Some WHO countries using it since 1995 ICD-10 code sets are used to report medical diagnoses and inpatient procedures. ICD-9 codes will be updated to ICD-10 codes Mandatory roll-out is 10/1/2015 per CMS Regardless of health care setting 2

ICD-9 produces limited data about patients medical conditions and hospital inpatient procedures. ICD-9 is 35 years old (1979) ICD-9 limits the number of new codes that can be developed 14,025 now ICD-10 will have over 68,000 codes More room for expansion of codes Many ICD-9 categories are already full Insufficient to properly diagnose conditions ICD-10 is more specific than ICD-9 ICD-10 CM/PCS Clinical Modification/Procedure Coding System ICD-10 PCS Inpatient procedure coding ICD-10 CM Diagnosis coding 3

Up to 7 characters to complete Codes will include much more specific medical data Where this encounter falls within the episode of care (initial, subsequent, etc.) Use of placeholder s to fill out the characters Combines some ICD-9 codes together Decimal still used after 3 rd character Differences between ICD-9 & ICD-10 Includes injuries and external causes as ICD-9 did Adds laterality Which side of the body (R, L or Bilateral) Utilizes placeholders to hold the spot where a character may not be needed Each character will explain more specific data about that code 4

ICD-10 CM is for use in ALL U.S. healthcare settings (except hospitals- PCS) Uses 3-7 digits (alphanumeric) instead of the 3-5 digits currently being used in ICD-9 Much more specific than ICD-9 Format of code sets in manual similar to ICD-9 Being used in the rest of the world ICD-10 will affect diagnosis and inpatient procedure coding for everyone covered by HIPAA May affect some providers who do not bill Medicare/Medicaid, but provide services Will not affect CPT coding for Part B (outpatient services) procedures Except for the identification of medical diagnoses Could be potential claim processing issues 5

MACs will have limited responsibility for education and preparation for ICD-10 transition. Providers themselves are ultimately responsible for education and training. 11 In addition to the initial conversion, there will be updates to the ICD-10 item sets, as well as claims processing changes that may affect payment processing. First Quarterly Release October 1 Second Quarterly Release January 1 Third Quarterly Release April 1 Fourth Quarterly Release July 1 Coming in 2017... ICD-11 12 6

Health care providers, clearinghouses, MACs, DME providers, practitioners Claims through 9/30/15 will use ICD-9 Claims beginning 10/1/15 will need ICD- 10 codes Verify split claims are coded correctly Can t accept ICD-9 & 10 together on a claim CMS delayed the transition to ICD-10 for at least 4 states with Medicaid programs managed by private insurers Impact: Claims will be processed using ICD-9 codes MDS assessments will still require ICD-10 codes for those same residents Your teams will need to dual code for the entirety of the delay! 14 7

Develop an implementation strategy Assess the impact to your organization Develop a timeline for all departments Contact software vendors to inquire about their compliance plan for implementation If you have proprietary software, much more coordination is needed between IT, clinical, med records, finance, rehab, etc. Or software that interacts with yours 1. Assessment Phase (Impact study) 2. Planning Phase 3. Communication Phase 4. Operational Implementation 5. Testing 6. Transition 7. Quality Assurance & Auditing 16 8

Assessment Understand the impact of the conversion Systems analysis of current coding needs Process evaluation-who codes & how they do it Staff identification of transition team Clinical Medical Financial Operational/ IT Establish accountability of each team member 17 Successful transition will depend significantly on the quality of the project leaders and their knowledge and abilities. With a project that impacts all facets of an organization it will be crucial to have a formal written plan, at least initially, to assist the team in focusing their efforts. 18 9

Make sure all staff responsible for ANY diagnosis coding areas are identified Medical records, admissions, nursing, rehab, MDS, billing, discharge planners, physicians & extenders, IT Establish how ICD-10 information is used in your organization, have all members been consulted? 19 Both clinical and billing departments play an important role in ICD-9 coding currently, so both will need to have an in-depth analysis. Is the data flow bi-directional, effecting both The coding knowledge or lack of knowledge of the clinical staff reviewing may negatively impact the facilities ability to care for those patients. 20 10

Referral verification and the obtaining of prior authorizations may be completed by admissions staff or administrative clinical staff. Hospital records are reviewed at the facility level including ICD coding When is the primary medical diagnosis assigned during the stay? 21 The purpose of the clinical coding education assessment is to determine which staff will need to gain skills using ICD-10 or mapping tools and what pre-requisite education must occur prior to intense ICD-10 education. Do you have the right person in place? 22 11

Education Detailed understanding of: Medical terminology Anatomy & Physiology Pharmacology Most recent ICD-10 manual Access to website Patient records- who places codes into the medical record once at the facility? Are they using those they find on the hospital records? Acute codes will not be acceptable on SNF claims. Those coding in the SNF will need to know the new coding requirements and be able to translate ICD-9 to ICD-10. 24 12

Make sure all staff responsible for ANY diagnosis coding areas are identified Medical records, admissions, nursing, rehab, MDS, billing, discharge planners, physicians & extenders, IT Establish how ICD-10 information is used in your organization, have all members been consulted? Do any members need additional training or a refresher? 25 Staff identification- who codes now? MDS Coordinator Rehab Manager Infection control Nursing administration Medical staff (physician & extenders) Admissions Unit secretary Will they have access to coding resources 26 13

Determine where codes are used Care authorizations Certifications Medical records Claims MDS MAR (medication administration record) Diagnostic testing 27 Clinical staff- frequently nurses must select diagnosis codes when ordering medications for residents as well as identifying resident diagnosis for care plan development. How do they code now? What resources do they use? Who reviews the codes and determines if they are the most appropriate? 28 14

MDS staff- Although ICD-9 coding and MDS coding are not identical, it will be necessary for the MDS coordinators to have knowledge of the appropriate codes. RAI guidelines for coding Section I of the MDS assessment, have very specific criteria which limits the codes appropriate for the document. PPS assessments need to include the correct ICD codes to support skilled services being billed to Medicare, and current status of resident. 29 Is dual coding an option, meaning coding both ICD-9 and ICD-10, until the updated data is provided? How much time does MDS staff spend on ICD9 coding currently? How will this affect MDS completion time and end of month billing practices including triple check processes? 30 15

What affect does ineffective clinical documentation have on cash flow? Is anyone monitoring the results? 31 Physicians / APRN/ PA-CNS Are their diagnoses descriptions specific enough within the problem list or progress notes? Are they available to assist with coding when there are questions or discrepancies? How will the facility get appropriate codes timely? 32 16

Physicians can capture more information and better understand important details But only if they ASK for the information Allows coders to use a single code to report both disease and a manifestation of that disease The same system applies to injuries as well 33 The importance of consistent, complete, documentation can not be over emphasized. Without such documentation the application of all coding guidelines is a difficult, if not impossible task. CMS ICD-9-CM Coding Guidelines 2011 Conversion of existing clinical data from ICD-9 to ICD-10 will take a significant amount of time (65% decreased productivity) Incorporation of more clinical detail in documentation will be necessary 17

Crosswalks may not provide enough information for accurate coding of ICD-10 from ICD-9 One ICD-9 code can be represented by 300 ICD-10 codes Don t rely on crosswalk alone Review communication tool 35 Rehab Managers and Therapist- Rehab evaluations contain patient diagnosis to support the skilled rehabilitation services being provided. Are the rehab staff facility employees or are they a contracted service? Do they code their own diagnosis assignment or does some other staff member? What is the plan to audit the rehab staff for appropriate ICD-10 codes? 36 18

Some payers require specific diagnosis to be documented by the physician before they will a cover the expense of a medication. Consultant pharmacists reviewing the medical record documentation for appropriate diagnosis codes for the prescription of certain meds Does the pharmacy notify the facility of inappropriate codes? Will they in the future? 37 Forms usually include the diagnosis code for the condition requiring the test. Clinical staff usually nursing place ICD- 9 codes onto the request forms derived from the information in the medical record. Does your facility have a specific form or location for the codes presently? Does the form need to be updated? Who reviews the forms to assure the appropriate level of specificity? Who does the lab communicate with if the code is not correct? How does this effect staff efficiency as well as patient care? Who orders Durable Medical Equipment (DME)? Does the person ordering the diagnostic tests know which codes should be used? Do they have updated diagnosis coding resources or manuals they can utilize? 38 19

Once the assessment is completed: Planning Budgeting Staffing Decreased productivity Hardware/Software Engage and update technology vendors Reimbursement Claims delay impact MDS rejections 39 Now that you ve collected all the information Budget for it Did you consider: IT assessment Hardware needs New computers Additional access points Wiring upgrades Upgrades to operating systems Software upgrades 40 20

Clinical budget may include Staff training-retraining Coding manuals Increased staffing hours/decreased productivity, More time needed to verify codes MDS Claims auditing Documentation auditing 41 What are the aspects of the communication phase? Educate your project manager on ICD-10 Establish a transition team Develop a communication plan Revisit & revise your implementation timeline, adjust as necessary Share progress or barriers with team 21

Organizational awareness is key to developing a successful communication plan It will ensure that all of your staff understands their roles and responsibilities, including deadlines. Think of your communication plan, A formal roadmap to the transition 43 So the team knows, what, when, why and how the process will take place Assign roles and responsibilities clearly Include Timelines Project milestones Secondary tasks Set firm deadlines initially Identify communication methods Email Scheduled live meetings Conference calls 44 22

Current claims system testing internal End-to-end testing with MACs Evaluate billing and payer vendors for readiness Upgraded claims system testing- internal and external MDS submission testing Also test any other software which may utilize ICD codes Pharmacy, lab, diagnostics, rehab, etc. 45 Now that you have identified many of the processes which currently use ICD-9 coding, as well as the staff that use these codes, you can begin to formulate a plan for transitioning to ICD-10 coding. Conversion of existing clinical data from ICD-9 to ICD-10 will take a significant amount of time Incorporation of more clinical detail in documentation will be necessary 46 23

Update resident s medical diagnoses as the resident becomes due for an exam or use the MDS OBRA schedule, so that outdated diagnoses are cleaned up prior to transition deadline. Be as descriptive as possible Identify multi chronic conditions and manifestations 47 Workflow process changes including updates Policy and procedure modifications Form and template revisions Upgrades to existing electronic systems Resource purchasing Staff training Obtain clinical documentation training Obtain coding education Implementation of software 48 24

What can I do if I haven t started? If you haven t already. start now! Include a timelines for task completion Identify who is responsible for each task Clearly delineate milestone events that can not be pushed off Identify resources that will be needed Computers, finances, staff, etc. Involve you medical staff! 25

Have all residents been converted to ICD-10? Were all diagnoses converted, or just a few? MDS does not require all diagnoses, who is handling the conversion of the remaining diagnoses Additional diagnosis for conditions unrelated to MDS coding will need to be converted as well 51 Areas of Concern Some pricing models have codes attached State Federal Veteran s Administration Workers Comp Insurance companies 52 26

Get your claims with dates of service PRIOR to 10/1/2015 submitted before the deadline!!! Chances are there will be a backlog of claims going in, so the earlier the better for prior period claims. 54 27

How did the ICD-10 diagnosis coding system change? Are there new rules I will have to learn? Review a few of the main coding concerns for SNF providers 55 Granularity- level of hierarchy and the amount of information the increase hierarchy provides to the diagnostic description. Laterality - right and left designation - right usually character 1 - left usually character 2 - bilateral usually character 3 - unspecified is either 0 or 9 depending on 5 th or 6 th character 28

List of terms and their corresponding codes are divided into 4 parts: Index of Diseases and Injury Index of External Causes of Injury Table of Neoplasms Table of Drugs and Chemicals A structured list of codes divided into chapters based on body system or condition 29

Tabular List contains categories, subcategories and codes Characters can be letters or numbers Category = 3 characters (first is always letter) Subcategory= 4 or 5 characters Codes= 3,4,5,6 or 7 characters Each level after category is subcategory and the final level is a code Each chapter begins with a list of blocks or subchapters of three character categories Chapter 2: Neoplasms (C00-D49) C00-C75 Malignant neoplasms, stated C00-C14 Lip, oral cavity and pharynx C15-C26 Digestive organs 30

4th Further defines site, etiology and manifestations Includes 3 character category, a decimal and an additional character Ex: D69 Purpura and other hemorrhagic conditions D69.0 Allergic purpura D69.1 Qualitative platelet defects 5th 6th The most precise level of specificity Ex: J10.8 Influenza due to other identified virus with other manifestations J10.81 Influenza due to other identified influenza virus with encephalopathy J10.82 Influenza due to other identified virus with myocarditis 31

7th Some categories require 7 th character If code is not 6 characters a dummy placeholder X must be used Mostly found in Injury and Fracture codes Tabular List instructions should guide assignment S83.0 Subluxation and dislocation of patella S83.00 Unspecified subluxation and dislocation of patella S83.001 Unspecified subluxation of right patella The 7 th character is required A= initial encounter D= subsequent encounter S= sequela 32

7 th character in fractures includes more specificity than laterality alone Open or Closed as well as routine or delayed healing and mal vs non union **Review chapter specific guidelines before assigning codes in this chapter The conventions are general rules for use of the classification independent of the guidelines Conventions are used both in the Alphabetical Index and the Tabular List 33

Alphabetical Index NEC= not elsewhere classifiable same as other specified - a specific code is not available for a condition (use other specified in the Tabular list) NOS= not otherwise specified same as unspecified. Tabular List NEC= not elsewhere classifiable same as other specified this list contains a NEC entry under the code to identify the code as the other specified NOS= same as Alphabetical Index definition In the Tabular List to enclose synonyms, alternative wording or explanatory wording. In the Alphabetical Index they are used to identify manifestation codes. 34

Used in both Alphabetical Index and Tabular List to enclose supplemental words that may be present or absent in the statement of disease without affecting the assignment of the code. Referred to as nonessential modifiers Used after an incomplete term in the Tabular List needing one or more of the modifiers that follow to make it assignable to a given category 35

Words following a comma are essential modifiers. Ex: C50.31 Malignant neoplasm of lowerinner quadrant of breast, female other and other specified are used when the information in the medical record provides detail but a specific code does not exist. unspecified codes are used when the information in the medical record is insufficient to assign a more specific code. Some categories do not have and unspecified code so other specified may be used. 36

Found in the Tabular List Immediately under a three character code title to further define or give examples of the content of the category G30 Alzheimer s Disease INCLUDES Alzheimer s dementia senile and presenile forms List of terms included under some codes that are conditions that the code should be used for May be synonyms Not an exhaustive list 37

EXCLUDES 1 Indentifies codes that CANNOT be used a the same times as the code above. The two conditions cannot occur together. NOT CODED HERET CODED HERE! EXCLUDES 2 Indicates that the condition excluded is not part of the condition represented by the code and may be used if the patient has both conditions. NOT INCLUDED HERE! Excludes Notes 1 & 2 G25.0 Essential tremor Familial tremor Excludes11 tremor NOS (R25.1) G24 Dystonia Includes dyskinesia Excludes 2 athenoid cerebral palsy (G80.3) 76 38

These are conventions seen in codes that have both an underlying etiology and multiple body system manifestations. Etiology codes use use additional code notes Manifestation codes use code first notes Manifestation code titles will include in diseases classified elsewhere H42 Glaucoma in diseases classified elsewhere Code first underlying condition, such as: amyloidosis (E85.-) aniridia (Q13.1) Lowe s syndrome (E72.03) Reiger s anomaly (Q13.81) specified metabolic disorder (E70-E90) 39

Selection of principal diagnosis/first listed code is based on the conventions in the classification that provide sequencing instructions. If no specific instructions then the condition that brought the patient to the healthcare setting and was/is the primary focus of treatment 79 When two or more interrelated conditions potentially meeting the definition of principle diagnosis either condition may be sequenced first, unless the circumstances of the admission, the therapy provided, the Tabular List or the Alphabetic Index indicate otherwise. 80 40

Also referred to as additional or Other diagnoses Affects patient care in terms of requiring clinical evaluation or therapeutic treatment or diagnostic procedures or extended length of stay or increased nursing care and/or monitoring. 81 How do I audit for compliance, once the ICD- 10 transition is complete? Clinical code assignment Assignment of primary and secondary codes MDS assessments UB04 Claims Supportive documentation 82 41

Auditing Now that you have identified many of the processes which currently use ICD-9 coding, as well as the staff that use these codes, you can begin to formulate a plan for auditing ICD-10 coding. Use some of the same areas you identified during your assessment phase 83 Operational Review Workflow process changes including updates Policy and procedure modifications Form and template revisions Upgrades to existing electronic systems Available resources Staff training Obtain clinical documentation training Obtain coding education Implementation of software 84 42

Identify who uses ICD codes currently, as well as who does the coding. UB04 claims, MDS, physicians & extenders, clinical staff, therapists, external customers/vendors, pharmacy, etc. Be prepared for potential reimbursement delays due to transition issues with payers or processing errors Quality Assurance & Auditing Payer acceptance of ICD-10 codes Review of rejected and denied claims for correction Resubmission of corrected claims Review claims auditing tool Who s code is it?... Do the codes reported on the claim coincide with the codes reported by MDS, rehab or the physician? 86 43

Monitor appropriateness of diagnosis codes on your claims prior to submission Do all diagnoses agree? All required codes reported? Were any claims denied/returned/suspended Update triple check processes to include diagnosis review, if not already included 87 Use resources available form multiple areas You aren t in it alone! Buddy up with a local facility for help Call your consultants to help You are on the Road to Transition! 88 44

Thank You Maureen McCarthy, BS, RN, RAC-MT President/CEO Celtic Consulting, LLC 507 East Main Street, Suite 308 Torrington, CT 06790 860-321-7413 mmccarthy@celticconsulitng.org 89 45