WSMA WSMOS Preparing for ICD-10

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1 WSMA WSMOS Preparing for ICD-10

2 Michelle M. Lott, CPC, CPMA Health Insurance Coding Specialist, WSMA Bob Perna, MBA, FACMPE Senior Director, WSMA Practice Resource Center Phone:

3 Agenda Overview of ICD-10-CM/ICD-10-PCS ICD-10 For Oncology Preparing and Planning for ICD-10 Implementation Clinical Documentation Improvement Strategies for Successful Implementation 3

4 ICD-9-CM is more than 3 decades old: Running out of code numbers Uses outdated terminology Insufficient specificity/detail Insufficient for reporting new medical technologies Has a direct impact on: Quality of our nation s health care data Ability for U.S. to maintain global clinical data comparability 4

5 Benefits of the ICD-10 Coding System Measure the quality, safety, and efficacy of care Reduce the need for attachments to explain the patient s condition Design payment systems and process claims for reimbursement Conduct research, epidemiological studies, and clinical trials Support operational and strategic planning Design health care delivery systems Monitor resource utilization 5

6 Benefits of the ICD-10 Coding System Improve clinical, financial, and administrative performance Prevent and detect health care fraud and abuse Track public health and risks 6

7 Possible Delay of ICD-10-CM HHS s statement follows remarks by CMS Acting Administrator, Marilyn Tavenner, that CMS would reexamine the pace of the ICD-10 implementation. On February 15, 2012, Health and Human Services (HHS) Secretary Kathleen G. Sebelius announced that HHS will initiate the rulemaking process to postpone the compliance deadline for implementation of ICD-10-CM/PCS. On April 9, 2012 the proposed rule change was announced delaying ICD-10-CM by 1 year; Implementation: October 1, 2014

8 Updates to ICD-9-CM & ICD-10-CM Last regular annual update for ICD-9-CM and ICD-10-CM/PCS: October 1, 2011 Limited updates for ICD-9-CM and ICD-10-CM: October 1, 2012 and October 1, 2013 Update resumption: October 1,

9 What is ICD-10-PCS? Procedural coding system for inpatient procedures only for facility coding Developed by CMS Replaces the third volume of ICD-9-CM Does not replace CPT/HCPCS for outpatient procedure codes 9

10 ICD-10-CM Versus ICD-10-PCS ICD-10-CM used in both the outpatient and inpatient setting. ICD-10-PCS used only in the Inpatient Setting ICD-10-PCS requires a new set of definitions of medical terms related to institutional procedures. Used only in the United States Requires more Anatomy and Physiology Medical Terminology Pathophysiology 10

11 A Comparative Overview - Structure ICD-9-CM Differences Three (3) to five (5) characters First digit is numeric or alpha (E or V) ICD-10-CM Differences Three (3) to seven (7) characters First digit is alpha 2 nd, 3 rd, 4 th, 5 th digits are numeric 2 nd and 3 rd digits are numeric; 4 th, 5 th, 6 th, 7 th digits can be alpha or numeric No placeholder Placeholder x Similarities Similarities Always at least three (3) characters Decimal placed after first three (3) characters All categories are three characters Decimal placed after the first three (3) characters 11

12 ICD-10-CM Structure Definitions 12

13 ICD-10-CM Structure Definitions 13

14 Example: Weeks of Gestation = Z3A 14

15 4 th, 5 th and 6 th Characters Example: Poisoning by, adverse effect of an underdosing of Penicillins = T36.0 T36.0x1 Poisoning by Penicillin, Accidental T36.0x2 Poisoning by Penicillin, Intentional self-harm T36.0x3 Poisoning by Penicillin, assault T36.0x4 Poisoning by Penicillin, undetermined T36.0x5 Adverse effect of Penicillin T36.0x6 Underdosing of Penicillin 15

16 Always alpha Example: Open Wound of Head = S01 S01.01: Laceration with foreign body scalp Code requires 7 th character to indicate initial encounter 16

17 Agenda Overview of ICD-10-CM/ICD-10-PCS ICD-10 For Oncology Preparing and Planning for ICD-10 Implementation Clinical Documentation Improvement Strategies for Successful Implementation 17

18 ICD-10 for Oncology The "ICD-10-CM Official Guidelines for Coding and Reporting" includes a section on coding guidelines for neoplasms. Most notably, the ICD-10-CM sequencing guideline for anemia associated with malignancy. When admission/encounter is for management of an anemia associated with the malignancy, and the treatment is only for anemia, the appropriate code for the malignancy is sequenced as the principal or first-listed diagnosis. 18

19 ICD-10 for Oncology Sequencing of neoplasm codes (I.C.2.l.1. thru I.C.2.l.6.) Encounter for complication associated with a neoplasm (I.C.2.l.4.) When encounter is for management of a complication associated with a neoplasm, and treatment is only for the complication, the complication is coded first, followed by the appropriate neoplasm code. Exception to this guideline is anemia:» When admission/encounter is for management of anemia associated with malignancy and treatment is only for anemia, malignancy should be sequenced first as the principal (first-listed) diagnosis followed by D63.0 Anemia in neoplastic disease. 19

20 ICD-10 for Oncology Because neoplasms can occur anywhere in the body, coding professionals might wonder where to begin refreshing their anatomy and pathophysiology knowledge. This is going to be essential for hospital billing departments that have to implement ICD-10- PCS. Morphology Codes Morphology codes are no longer listed in the Alphabetic Index alongside the descriptors and standard ICD-10-CM codes. 20

21 ICD-10 for Oncology: Neoplasms (C00-D48) ICD-10-CM Specific guidelines are: Guidelines I.C.2 General neoplasm guidelines Guideline I.C.2.a Treatment directed at the malignancy Guideline I.C.2.b. Treatment of secondary site Guidelines I.C.2.c. Coding and sequencing of complications Guideline I.C.2.d. Primary malignancy previously excised Guidelines I.C.2.e. Admissions/encounters involving chemotherapy, immunotherapy and radiation therapy Guidelines I.C.2.l. Sequencing of neoplasm codes 21

22 ICD-10 for Oncology ICD-10-CM provides codes for reporting neoplasm sites with greater precision. In some instances, ICD-10-CM provides greater detail on the type of neoplasm for malignant neoplasms and for benign and other histologic behaviors. Chapter 2 in ICD-9-CM contains nearly 960 codes and Chapter 2 in ICD-10-CM contains more than 1,540 codes. 22

23 ICD-10-CM for Oncology Documentation requirements for neoplasms require specificity in both the site and laterality components. Type Malignant (Primary, Secondary, Ca in situ) Benign Uncertain Unspecified behavior Location(s) (site specific) If malignant, any secondary sites should also be determined Laterality, in some cases 23

24 ICD-10-CM for Oncology Example: Malignant neoplasm of the breast has 54 choices, and requires specification of male/female breast, the site of the neoplasm on the breast, and laterality. In addition, a code for estrogen receptor status is required, if known. Code example: C Malignant neoplasm of upper-outer quadrant of the right female breast and Z17.1 Estrogen receptor status negative status [ER-]. 24

25 ICD-10-CM Oncology Diagnosis: Invasive ductular carcinoma of breast, completely excised. ICD-9-CM Code: ICD-10-CM Code: C Rationale: Neoplasm; breast; female; upper outer quadrant left breast. It is important to note that location is very specific in ICD-10-CM with laterality also an issue, good documentation for specificity is required for proper code assignment. 25

26 ICD-10-CM For Oncology In ICD-10-CM, primary malignant neoplasm of the prostate is code C61, which is a one-toone match with ICD-9-CM code 185. However, for metastatic prostate cancer, codes for the site of the metastasis are more specific. Secondary sites requiring more specificity include the lungs (C78.01 right or C78.02 left), kidneys (C79.01 right or C79.02 left), other urinary organs, bone and bone marrow (C79.51 bone or C79.52 bone marrow), adrenal glands (C79.71 right or C79.72 left). 26

27 Does ICD-10-CM/PCS Affect Cancer Registrars? Cancer registrars use a list of cancer diagnosis codes assigned by coders to identify cases of reportable neoplasms. Some registries also include complication and comorbidity codes. Chapter 2 in ICD-10-CM corresponds to the ICD-O-3 codes already used by cancer registries. 27

28 ICD-10-CM for Oncology Lymphoma and Leukemia Code categories for lymphoma include: C81 Hodgkin lymphoma, C82 Follicular lymphoma, C83 Non-follicular lymphoma, C84 Mature T/NKcell lymphomas, C85 Other specified and unspecified types of non-hodgkin lymphoma, C86 Other specified types of T/NK cell lymphoma. The increased code specificity for follicular lymphomas (Code category C82) includes identification of the grade. 28

29 ICD-10-CM for Oncology Neoplasms of the Liver WSMOS Preparing for ICD-10 In ICD-10-CM there are unique codes for liver cell carcinoma, hepatoblastoma, angiosarcoma of liver, and other sarcomas of liver. When coding these conditions in ICD-10-CM, it is useful to have an awareness of the different codes for primary malignant neoplasms of the liver. 29

30 Agenda Overview of ICD-10-CM/ICD-10-PCS ICD-10 For Oncology Preparing and Planning for ICD-10 Implementation Clinical Documentation Improvement Strategies for Successful Implementation 30

31 Organizational Planning WSMOS Preparing for ICD-10 Create an organizational planning body Build a Transition Project Plan Develop a Communication Schedule for Stakeholders Identify organizational champion for ICD-10-CM transition Project Issue Log 31

32 Information Technology Readiness Conduct IT Landscape Assessment Front & Back-end Applications Clinical Programs EHR Registries Reporting & Tracking Programs Other Servers Workstations 32

33 Information Technology Readiness Assess IT Operational Readiness EHRs Meaningful Use Clinical Improvement Programs Staffing Needs System implementation readiness Clearinghouses PM systems Software Upgrades Vendor Assessment 33

34 Operational Readiness WSMOS Preparing for ICD-10 Identify operational data flows as well as process workflows w/in those impact areas Assess organizational documentation impacts Assess organizational report/reporting impacts Conduct Clinical Documentation Readiness Assessment Develop operational contingency plans 34

35 Educational Readiness Develop training strategy WSMOS Preparing for ICD-10 Assess all management and staff to identify appropriate groups who will need training in ICD- 10-CM Assess current skill levels of identified groups Develop training levels based on size of your organization/skill level of staff Determine who needs additional training beyond ICD-10-CM code sets 35

36 Educational Readiness WSMOS Preparing for ICD-10 Determine training modalities Determine who will provide training and where Determine training time requirements 36

37 Financial Readiness WSMOS Preparing for ICD-10 Evaluate productivity impact Assess External Party Readiness Develop transition project budget Develop operating budget going forward 37

38 Financial Readiness Sustainability in the face of potential financial impacts Delayed payments due to utilization of new codes Increase in account receivables Cash flow/line of credit risks due to possible negative revenue cycle impacts Industry estimates indicate there could be up to a five-year stabilization of cash flow post ICD-10 cut over. 38

39 Financial Readiness - Mitigation Establish a solid financial baseline/revenue cycle up front What does our operation look like today with ICD-9? What things do I need to think about from a modeling standpoint going forward? What do I need to monitor on the back end? 39

40 Agenda Overview of ICD-10-CM/ICD-10-PCS ICD-10 For Oncology Preparing and Planning for ICD-10 Implementation Clinical Documentation Improvement Strategies for Successful Implementation 40

41 Clinical Documentation Improvement (CDI) - General ICD-10-CM and ICD-10-PCS offer much more specificity because of the expansion of codes. While it is still possible to assign nonspecific codes, it is imperative that the most specific code be reported to maximize ICD-10- CM/PCS's ability to provide meaningful data on patient care and severity. Current documentation practices should be assessed and a plan developed to improve health record documentation. 41

42 Conduct Clinical Documentation Improvement (CDI) Assessment - Identify high frequency diagnoses Monitor for a 6-12 month period preimplementation Identify and target risk areas for clinical documentation improvement Integrate findings into coder training and compliance program Focus educational feedback for physicians/other clinicians 42

43 Documentation Improvement Program First, run a report in your computer system and sort it by diagnosis code. Next, start with your top ten and run another report listing patients that had those diagnoses appended to them. Pull 10 to 20 charts with your top used diagnosis code. Review the ICD-10-CM guidelines (if there are any) for the chapter in which the diagnosis is located. Then, review the notes for diagnosis ONLY. 43

44 Documentation Improvement Program Look at the history and the assessment and code it under ICD-10-CM. Put together a report based on the diagnosis: how many notes could be coded under ICD-10-CM? How many notes need more specific information to code? How many notes had to be coded to an unspecified code? Take these findings to each provider and review them to show the specificity in ICD-10-CM and what is needed in the documentation to support 44 the diagnosis.

45 Documentation Improvement Program Depending on how well the provider did on the assessment, you may either perform another assessment on the same diagnosis, or move on to the next diagnosis on your "top ten" list. The facility/office should have a target percentage for the assessments that all providers should meet. Reports should be kept on each assessment to show progression of the providers. Do repeat assessments! 45

46 Documentation Improvement Program Once the assessments begin, they should continue until the implementation date of October 1, How often they occur depends on the number of providers you have, the number of different specialties, the type of specialties, and how the providers perform. When you start to officially use the code set, then it will become part of the regular audit process. 46

47 Documentation Improvement Program Challenges The cumbersome, manual processes for identifying cases for daily reviews. Once case reviews are underway, the physician query process can present some of the most daunting challenges in the CDI program. Inaccessibility of physicians. Excessive time required for ongoing follow-up with physicians to ensure that responses and suggested changes are received. 47

48 Documentation Improvement Program Challenges Lack of system integration. Lack of appropriate management tools needed for tracking, monitoring and reporting the CDI process. Costs of having a Consultant conduct the review 48

49 Agenda Overview of ICD-10-CM/ICD-10-PCS ICD-10 For Oncology Preparing and Planning for ICD-10 Implementation Clinical Documentation Improvement Strategies for Successful Implementation 49

50 Strategies for successful Implementation of ICD-10 CM Make the Case for Relevance Demonstrate through outreach education the key points (above) about the impacts that ICD- 10 will have on physicians and their offices. Make the Case for Good Documentation Beyond coding, good documentation is just good practice. New documentation requirements are not unreasonable and in general are consistent with best practices for medical assessment and decision making. 50

51 Strategies for successful Implementation of ICD-10 CM Find a Physician Champion Physicians respond better to colleagues or other physicians with shared medical practice understanding. With the proper support, these champions can help bring this message forward and help develop training efforts. 51

52 Strategies for successful Implementation of ICD-10 CM Don t Try to Turn Physicians into Coders Physicians should focus on what they are trained to do. Coders should focus on proper documentation and use their knowledge of the codes available and the definition and rules to assist Physicians. 52

53 Resources WSMOS Preparing for ICD-10 CMS National Center for Health Statistics American Academy of Professional Coders (AAPC) American Hospital Association (AHA) American Health Information Management Association (AHIMA) Workgroup for Electronic Data Interchange (WEDI) 53

54 Questions? 54

ICD-10 RSPMI Provider Education April 16, Cathy Munn MPH RHIA CPHQ Sr. Consultant

ICD-10 RSPMI Provider Education April 16, 2014 Cathy Munn MPH RHIA CPHQ Sr. Consultant Agenda Status of ICD-10 Transition Who, What, Where, When & Why Industry Update Impact of the Change Providers Payers