ICD-10 RSPMI Provider Education

Transcription

1 ICD-10 RSPMI Provider Education Arkansas DHS ICD-10 Preparation & Implementation Cathy Munn, MPH RHIA CPHQ Sr. Consultant 1

2 Agenda Why ICD-10 & Why Now? Industry Update Key Points to Remember Impact of the Change Providers Payers Review of ICD-10 Codes & Changes Arkansas DHS Preparation & Planning Provider Preparation Next Steps & Resources 2

3 ICD-10-CM/PCS ICD-9-CM: International Classification of Diseases, 9 th revision, Clinical Modification ICD-10: Developed by the World Health Organization as the nomenclature for all countries ICD-10-CM: International Classification of Diseases, 10 th revision, Clinical Modification US only ICD-10-PCS: International Classification of Diseases, 10 th revision, Procedure Classification System US only 3

4 Federal Mandate Final Rule Originally Published by HHS on January 16, 2009 requiring the adoption of ICD-10 on October 1, 2013 NO GRACE PERIOD Dates of Service (outpatient) After 10/1/2013 Dates of Discharge (Inpatient) After 10/1/2013 Federal Mandate Updated Timeline: February 14, 2012 CMS announces they will reexamine the pace of implementing ICD-10 May 17, 2012 All comments due to HHS for consideration prior to publication of the final rule August 27, 2012 Revised compliance date announced by CMS stating a one-year extension would be granted October 1, 2014 is the revised ICD-10 Implementation Compliance Date 4

5 Things to Remember ICD-10-CM (diagnoses) will be used by all providers in every health care setting ICD-10-PCS (procedures) will be used only for hospital claims for inpatient hospital procedures ICD-10-PCS will not be used on physician claims This has change has no impact on Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes CPT and HCPCS will continue to be used for physician and ambulatory services including physician visits to inpatients DSM-5 codes have been released; however DSM-5 is not HIPAA compliant for claims or transactions 5

6 Important Information Systems will have to utilize both ICD-9-CM and ICD- 10-CM for overlap e.g. backlog, Arkansas Medicaid allows providers 365 days to submit a claim. Inpatient discharges occurring on or after will use ICD-10-CM and ICD-10-PCS codes regardless of date of admission. Outpatient dates of service occurring on or after will use ICD-10-CM codes There will be period of time when payers will be processing both ICD-9 and ICD-10 claims. 6

7 A Few ICD-10 Benefits Better data will be available for: Measuring the quality, safety, and efficacy of care Designing payment systems and processing claims for reimbursement Conducting research, epidemiological studies, and clinical trials Setting health policy Operational and strategic planning and designing healthcare delivery systems Monitoring resource utilization Improving clinical, financial, and administrative performance Preventing and detecting healthcare fraud and abuse Tracking public health and risks 7

8 Current Competing Priorities ACOs/ Patient Centered Medical Home Public Reporting & Quality Measures ICD-10: Key to the success of each initiative EHR/ MU Value vs. Volume 8

9 ICD-9 vs. ICD-10 Diagnosis Codes ICD-9 Diagnosis Codes 13,000 ICD-10 Diagnosis Codes 68, Characters 3-7 Characters First character is numeric or alpha (E or V) Use of decimal after 3 rd character First character is alpha Use of decimal after 3 rd character Characters 2-7 are alpha or numeric letter U is not used Use of dummy placeholder X for future code expansion E codes reference External Causes of Injury & Poisoning in ICD-9. E references the Endocrine system in ICD-10 V codes reference Health Status & Contact with Health Services in ICD-9 V Y codes reference External Causes of Morbidity in ICD-10 9

10 ICD-9 Procedure vs. ICD-10-PCS ICD-9 Procedure Codes 4,000 ICD-10 Procedure Codes 87, Digits 7 Digits All digits are numeric Example: Angioplasty has 3 codes Example: Artery suture has 1 code Alpha or numeric composition Numbers 0-9 Letters O & I are omitted Example: Angioplasty 1298 coding combinations Example: Artery suture 195 coding options The increase in the number of procedure codes is driven by the increased specificity, granularity & laterality contained within the ICD-10 codes. 10

11 Patient Flow Impact Revise for ICD- 10 reporting Back end processes Start Patient Encounter Diagnose Patient Providers change coding practices based on ICD-10 Update data repositories to accommodate new coding Claim priced based on revised fee schedules Revise authorization process Payment & Remit Price Claim Check Auth Select provider & contract Code Claim Submit Claim Receive Claim Begin Adjudication Update practice management system Update claims submission process Update system to accept claims Update benefit logic & edits Determine Benefits Check Eligibility 11

12 Impact on Providers First Things First: Impact Assessment & Gap Analysis Evaluate Vulnerabilities Systems Operations and Processes Clinical Documentation 12

13 System Impacts Identify your current systems and work processes that use ICD-9 codes. This could include: Practice Management Systems Reports Electronic Medical Record Systems Clinical Documentation Billing Systems Encounter Forms and Superbills Public Health and Quality Reporting Protocols & Reports A good rule of thumb: Wherever ICD-9 codes appear today, ICD-10 codes will need to replace them in the future 13

14 System Impacts If applicable, talk with your practice management/ehr vendor(s) about accommodations for both ICD-9 and ICD-10 codes Contact your vendor(s) and ask what updates they are planning for your practice management/ehr system and when they expect to have it ready to install/update/test Check your contract to see if upgrades are included or if there is an additional cost Discuss implementation plans with any clearinghouses or billing services you may use 14

15 Operational Impacts 15

16 Operational Impacts Discuss implementation plans with all your clearinghouses, billing services, and payers to ensure a smooth transition Be proactive, don t wait for vendors to contact you Ask about their plans for ICD-10 compliance and when they will be ready to collaboratively test their systems Ask to see their roadmap that supports their claims of readiness Utilize CMS checklists and resources 16

17 Operational Impacts Talk with your payers about how ICD-10 implementation might affect your contracts. Because ICD-10 codes are much more specific than ICD-9 codes, payers may modify terms of contracts, fee schedules or reimbursement methodologies 17

18 Operational Impacts Identify potential changes to work flow and business processes Consider changes to existing processes including: Clinical documentation Prior authorization Encounter forms and Superbills Report generation Operational Quality and Public Health reporting Federal and State reporting Involvement in outreach initiatives 18

19 Operational Impacts Assess staff training needs Identify the staff in your office who code, or have a need to know the new codes.anticipate that everyone in your office will require some level of awareness training There are a wide variety of training opportunities and materials available through a variety of resources: Professional Associations AAPC, AHIMA Online Courses ICD10 Monitor, Contexo University Webinars ICD10 Monitor, HC Pro Onsite Training Train the Trainer If you are a small office, think about collaborating with other like provider types 19

20 Operational Impacts Budget for time and costs related to ICD-10 implementation including: Expenses for system changes and software updates Resource materials Training Modifications to forms and Superbills Other budgetary considerations: Unanticipated payment delays, appeals & denials Understand your operational metrics benchmark for efficiency Establish a line of credit 20

21 Billing Forms/Superbills - How Will They Change? Increased size Increased specificity Examples can be found at along with other valuable ICD-10-CM resources 21

22 New Concepts and Features with ICD-10 22

23 Chapter Titles Character A and B C00 to D48 D50 to D89 E F G H00 to H59 H60 to H95 I J Chapter Title Certain infectious and parasitic diseases. Neoplasms. Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism. Endocrine, nutritional and metabolic diseases. Mental and behavioral disorders. Diseases of the nervous system. Diseases of the eye and adnexa. Diseases of the ear and mastoid process. Diseases of the circulatory system. Diseases of the respiratory system. 23

24 Chapter Titles Character K L M N O P Q R S and T U Chapter Title Diseases of the digestive system. Diseases of the skin and subcutaneous tissue. Diseases of the musculoskeletal system and connective tissue. Diseases of the genitourinary system. Pregnancy, childbirth and the puerperium. Certain conditions originating in the perinatal period. Congenital malformations, deformations and chromosomal abnormalities. Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified. Injury, poisoning and certain other consequences of external causes. This letter is currently left vacant. V, W, X and Y External causes of morbidity and mortality. 24

25 Billing Forms/Superbill: Adjustment Disorder Source FY2013 ICD-9-CM Diagnosis Target FY2013 ICD-10-CM Source Code Title Diagnosis Adjustment disorder with depressed mood F43.21 Prolonged depressive reaction F Separation anxiety disorder F93.0 Emancipation disorder of adolescence and early adult life F94.8 Specific academic or work inhibition F94.8 Adjustment disorder with anxiety F43.22 Adjustment disorder with mixed anxiety and depressed mood F43.23 Other adjustment reactions with predominant disturbance of other emotions F43.29 Other adjustment reactions with predominant disturbance of other emotions F94.8 Target Code Title Adjustment disorder with depressed mood Adjustment disorder with depressed mood Separation anxiety disorder of childhood Other childhood disorders of social functioning Other childhood disorders of social functioning Adjustment disorder with anxiety Adjustment disorder with mixed anxiety and depressed mood Adjustment disorder with other symptoms Other childhood disorders of social functioning 25

26 Anxiety State, Unspecified Source FY2013 ICD-9- CM diagnosis Source Code Title Anxiety state, unspecified F Panic disorder without agoraphobia F41.0 Target FY2013 ICD-10- CM diagnosis Target Code Title Anxiety disorder, unspecified Panic disorder [episodic paroxysmal anxiety] without agoraphobia 26

27 Schizophrenia Source FY2013 ICD-9- CM Diagnosis Source Code Title Target FY2013 ICD-10- CM Diagnosis Target Code Title Simple type schizophrenia, unspecified F20.89 Other schizophrenia Simple type schizophrenia, subchronic F20.89 Other schizophrenia Simple type schizophrenia, chronic F20.89 Other schizophrenia Simple type schizophrenia, subchronic with acute exacerbation F20.89 Other schizophrenia Simple type schizophrenia, chronic with acute exacerbation F20.89 Other schizophrenia Simple type schizophrenia, in remission F20.89 Other schizophrenia Disorganized type Disorganized schizophrenia, unspecified F20.1 schizophrenia Disorganized type Disorganized schizophrenia, subchronic F20.1 schizophrenia Disorganized type Disorganized schizophrenia, chronic F20.1 schizophrenia 27

28 Mood Disorder Source FY2013 ICD-9- CM Diagnosis Target FY2013 ICD-10- Source Code Title CM Diagnosis Mood disorder in conditions classified elsewhere F06.30 Mood disorder in conditions classified elsewhere F06.31 Mood disorder in conditions classified elsewhere F06.32 Mood disorder in conditions classified elsewhere F06.33 Mood disorder in conditions classified elsewhere F06.34 Target Code Title Mood disorder due to known physiological condition, unspecified Mood disorder due to known physiological condition with depressive features Mood disorder due to known physiological condition with major depressive-like episode Mood disorder due to known physiological condition with manic features Mood disorder due to known physiological condition with mixed features 28

29 Attention Deficit Disorder Source FY2013 ICD-9- CM Diagnosis Target FY2013 ICD-10- Source Code Title CM Diagnosis Attention deficit disorder without mention of hyperactivity F90.9 Attention deficit disorder with hyperactivity F90.0 Attention deficit disorder with hyperactivity F90.1 Attention deficit disorder with hyperactivity F90.2 Attention deficit disorder with hyperactivity F90.8 Attention deficit disorder with hyperactivity F90.9 Target Code Title Attention-deficit hyperactivity disorder, unspecified type Attention-deficit hyperactivity disorder, predominantly inattentive type Attention-deficit hyperactivity disorder, predominantly hyperactive type Attention-deficit hyperactivity disorder, combined type Attention-deficit hyperactivity disorder, other type Attention-deficit hyperactivity disorder, unspecified type 29

30 Oppositional Defiant Disorder Source FY2013 ICD-9- CM Diagnosis Target FY2013 ICD-10- Source Code Title CM Diagnosis Oppositional defiant disorder F91.3 Target Code Title Oppositional defiant disorder 30

31 Clinical Documentation Practices If it s not documented.it s not done Outcome Data Liability Reimbursement 31

32 Clinical Documentation Practices Clinical documentation is the first step in reaching the ultimate goal of better disease and risk management outcomes and data. Clinical documentation improvement best practices provide accurate coding and clinical data. Accurate documentation = accurate coding Accurate coding = richer data & understanding patient needs Ultimately leading us to better patient outcomes 32

33 Clinical Documentation Practices Most of the new concepts introduced in ICD-10 codes are concepts that physicians should be documenting now. Based on 125 clinical documentation engagements performed by 3M Consulting Services, it was found physician documentation does not support coding at the highest level of specificity 30 to 40 percent of the time. Documentation requirements vary greatly by specialty or clinical domain. Codes related to ophthalmology have changed little in scope; however, codes related to the musculoskeletal system have increased dramatically. Over 50% of the ICD-10 codes are related to musculoskeletal conditions. Over 17,000 ICD-10 codes (~25%) are related to fractures. 33

34 Clinical Documentation Practices AHIMA Online Education Physician Series Clinical Documentation for ICD-10: Principles & Practice Short, self-paced training modules Case-based, real life examples Provides more than 200 bite-sized, on-demand, specialtyspecific training modules that can be accessed anytime or anywhere with a mobile device. (computer, tablet or smartphone) Delivers 3-5 minute modules that cover physician s most billed diagnoses & conditions making learning targeted and relevant to their practice specialty. 34

35 Important Changes Beyond New Concepts Additional information you may need to know. 35

36 New Changes & Concepts Repeating Patterns Of the 69,000 ICD-10 codes, over one third are the same with the exception of the concept of right vs. left. Considering that most of these codes also have an unspecified side option, the ratio is even higher. Combination Codes Many diagnoses that required multiple codes in ICD-9 have been combined to 1 code in ICD-10. Cardiology, Diabetes & Accidental Poisoning are examples. Laterality About 25,000 (36%) of all ICD-10 CM codes are different only in that they distinguish right vs. left 36

37 Changes to E & V Codes in ICD-10 E codes reference External Causes of Injury & Poisoning in ICD-9 E code references the Endocrine system in ICD-10 Thyroid gland disorders: E00 E07 Diabetes codes: E08 E13 Disorders of glucose regulation & pancreatic internal secretion: E15 E16 V codes reference Health Status & Contact with Health Services in ICD-9 Z codes reference Health Status & Contact with Health Services in ICD-10 V Y codes reference External Causes of Morbidity in ICD-10 37

38 Some Things Really Don t Change Codes have more detail but are still divided into chapters/related diagnoses Each specialty creates CHEAT SHEETS: Long lists and Short lists of the most commonly used codes CMS.gov has free programs with GEMS (general equivalence mappings) Utilize CMS, coding resource, and specialty specific guides cardiologists use cardio codes, endocrinologists use endo codes, etc. 38

39 CMS Resources 39

40 CMS Resources 40

41 This Isn t Payer Versus Provider ICD-10 poses challenges for both payers and providers Readiness for payers and providers There is a potential for 1-2 years of uncertainty after implementation for payers and providers Data integrity and comparability Readiness will yield real financial advantage for those who execute well Cash flow 41

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43 Arkansas DHS Current State Arkansas Medicaid has been working on ICD-10 for over two years Progress to date: Operational assessment - complete Remediation of Medical Policy, Edits and Audits - complete Remediation of Pharmacy Policy & Edits - under review Provider Manuals - under review Gathered systems requirements - under review Risk Remediation Plan - under review Internal & external testing scenarios - under review Arkansas DHS reports, forms, and brochures - under review Ongoing Provider outreach - continues through 2014 Meetings/Webcasts Provider Bulletins Newsletters Updates ICD-10 Website Per CMS; external testing should begin October,

44 Arkansas DHS Assistance Continued Provider Outreach Provider outreach & training Several venues over next 18 months Periodic Arkansas DHS updates System updates/remediation efforts: HP MMIS Xerox/ACS SmartPA Arkansas DHS all integrated & stand-alone systems Arkansas DHS ICD-10 Website: Arkansas DHS ICD-10 Frequently Asked Questions document ICD-10 mailbox established for submission of questions & comments 44

45 Now What? 45

46 Communication & Planning Engage the support of leadership Define your strategy & approach to ensure success Understand the financial implications of non-compliance Ensure everyone understands the impact of ICD-10 Receptionist Nursing Staff Physicians Coders Billing Staff CFO/COO Senior Practice Management Staff Share regular updates & communication briefings with staff 46

47 Operational Assessment Understand which systems & processes will be impacted Understand the impact that the transition will have on people, process & technology; both internal & external to the practice Staff & providers Education & awareness Training just in time Workflows Office through-put & documentation Code utilization within the practice Superbill assessment Coding & billing turn-around-time/cash flow Denials & resubmission of claims Systems upgrades/enhancements Practice management systems Billing transmissions EDI Vendor readiness 47

48 Documentation Assessment Facilities, provider practices and specialty providers should examine their patient population in terms of: High volume/high cost Begin translating your codes from ICD-9 to ICD-10 based on volume Patient demographic; Medicare, Medicaid, Commercial insurance Be in contact with your large volume payers to understand their approach & strategy for ICD-10 Diagnoses that lead to the highest denial, physician query and re-bill rates 48

49 Testing DMS is working to deliver clinical scenarios via the AR ICD-10 Website for providers & facilities to initiate testing DMS must employ end to end testing based on CMS mandates. E2E testing should include: Creation of the claim Submission to payer/edi vendor/clearinghouse via 837 Adjudication of claim Reporting back to the provider via EOP/835 Adjustments/denials/resubmissions Report creation Denial tracking & analysis 49

50 Industry Web Site Resources /Downloads/ICD10SmallandMediumPractices508.pdf 50

51 For More ICD-10 Information White Papers (including but not limited to) ICD-10 A Primer ICD-10 Clinical Documentation ICD-10 Physician Impact ICD-10 Advantages ICD-10 Specified or Unspecified Checklists published by CMS for providers (small, medium and large) at: 10ImplementationTimelines.html 51

52 CMS Resources 52

53 AR Medicaid ICD-10 Icon 53

54 Questions & Comments We have brains in our head & feet in our shoes. Today is our day; our (ICD-10) mountain is waiting so let s get on our way.dr. Seuss 54