Financial Implications of ICD 10 in 2016

Transcription

1 Financial Implications of ICD 10 in 2016 Matthew Menendez Takeaways 1. ICD 10 is not finished it has just begun 2. Continue to refine your ICD 10 strategy 3. What percentage of specified codes is your practice using? 4. Evaluate current processes to Protect Physician Productivity 5. Get the right code the first time to Improve Revenue Cycle Efficiency Goals for Today Why are we still talking about ICD 10? Good News / Bad News in 2015 Outlook and Risks for 2016 How to Mitigate Risk: Physician Productivity Revenue Cycle Q&A 1

2 Why are we still talking about ICD 10? CMS expected denials to increase 100% 200% because of ICD 10 1 Denials did not increase at all 2 Why? ICD 10 was not as difficult as expected Claims data much better than predicted Real impact not seen yet (1) assn.org/ama/pub/news/news/2014/ icd10 cost estimates increased for most physicians.page (2) sheets/2015 Fact sheets items/ html Preventative Maintenance A Cautionary Tale Good News / Bad News in 2015 Good News We survived October 1 st Stakeholders were prepared Claims process was largely successful Patient care did not suffer CMS delayed denials due to unspecified codes Bad News CMS delayed denials due to unspecified codes Poor workflows are successful today Bad habits are reinforced Practice leadership lost focus on ICD 10 2

3 CMS & AMA Announcement July 6, 2015 CMS will not deny claims because of lack of specificity before 10/1/16 CMS will not penalize providers for lack of specificity in PQRS or VBM programs before 10/1/16 CMS will authorize advance payments if Medicare contractors unable to pay claims CMS will appoint an ICD 10 Ombudsman to monitor and resolve provider issues ICD 10 will not be delayed again AMA will work with CMS to prepare physicians CMS Claims Data Metrics October 1 27 Historical Baseline* Total Claims Submitted 4.6 million per day 4.6 million per day Total Claims Rejected due to incomplete or invalid information Total Claims Rejected due to invalid ICD 10 codes 2.0% of total claims submitted 0.09% of total claims submitted 2.0% of total claims submitted 0.17% of total claims submitted Total Claims Rejected due to invalid ICD 9 codes Total Claims Denied 0.11% of total claims submitted 10.1% of total claims processed 0.17% of total claims submitted 10% of total claims processed t sheets/2015 Fact sheets items/ html False Sense of Security PM / EHR Vendor (Day 1) Clearinghouse / Payer (Day 10) Claims Adjudication (Day 30) Revenue Cycle / Physician Practice (???) 3

4 What ICD 10 codes are you using? V91.07XD Burn dues to water skis on fire, subsequent encounter T14.8 Other injury of unspecified body region V95.40XA Unspecified Spacecraft accident injuring occupant, Initial Encounter Risk of Unspecified Codes Short Term Risk (6 18 months) Denied claims Increasing AR Physician productivity loss Coding productivity loss Georgia Medicaid Long Term Risk (2 5 years) Value Based Reimbursement Flat or declining revenue Risk based models financial penalties Hierarchical Condition Categories (HCC) ACO and Medicare Advantage Data on Code Use Frequency Top 200 ICD 9 codes based on NIH outpatient frequency 31.5% of ICD 9 codes are unspecified Using GEMS forward mapping 75.5% appear to be 1 to 1 Using GEMS forward mapping 41.5% mapped to unspecified ICD 10 4

5 Unspecified Code Example OA lower leg OA lower leg >>> M17.9 OA knee unspecified Unspecified on type of osteoarthrosis Unspecified on which knee Code Description M17.0 Bilateral primary osteoarthritis of knee M17.10 Unilateral primary osteoarthritis, unspecified knee M17.11 Unilateral primary osteoarthritis, right knee M17.12 Unilateral primary osteoarthritis, left knee M17.2 Bilateral post traumatic osteoarthritis of knee M17.31 Unilateral post traumatic osteoarthritis, right knee M17.32 Unilateral post traumatic osteoarthritis, right knee M17.4 Other bilateral secondary osteoarthritis of knee M17.5 Other unilateral secondary osteoarthritis of knee M17.9 Osteoarthritis of knee, unspecified Unspecified Code Example Congestive Heart Failure >>> I50.9 Heart failure, unspecified Unspecified type of heart failure and unspecified onset Code Description I50.20 Unspecified systolic congestive heart failure I50.21 Acute systolic congestive heart failure I50.22 Chronic systolic congestive heart failure I50.23 Acute on chronic systolic congestive heart failure I50.30 Unspecified diastolic congestive heart failure I50.31 Acute diastolic congestive heart failure I50.32 Chronic diastolic congestive heart failure I50.33 Acute on chronic diastolic congestive heart failure I50.40 Unspecified combined systolic and diastolic congestive heart failure I50.41 Acute combined systolic and diastolic congestive heart failure I50.42 Chronic combined systolic and diastolic congestive heart failure I50.43 Acute on chronic combined systolic and diastolic congestive heart failure I50.9 Heart failure, unspecified Unspecified Code Example Pain in limb Pain in limb >>> M Pain in unspecified limb Unspecified on anatomical location Unspecified on laterality 5

6 Code Description M Pain in right arm Pain in limb 31 different ICD 10 Codes SAT Test Time drain to read through all the descriptions M Pain in left arm M Pain in arm, unspecified M Pain in right leg M Pain in left left M Pain in leg, unspecified M Pain in unspecified limb M Pain in right upper arm M Pain in left upper arm M Pain in upper arm, unspecified M Pain in right forearm M Pain in left forearm M Pain in forearm, unspecified M Pain in right hand M Pain in left hand M Pain in hand, unspecified M Pain in right finger M Pain in left finger M Pain in finger, unspecified M Pain in right thigh M Pain in left thigh M Pain in thigh, unspecified M Pain in right lower leg M Pain in left lower leg M Pain in lower leg, unspecified M Pain in right foot M Pain in left foot M Pain in foot, unspecified M Pain in right toe(s) M Pain in left toe(s) M Pain in toe(s), unspecified Organization and Display Matters Organize the codes to highlight required ICD 10 detail Organize the codes to minimize the time required to differentiate the choices Do not display unspecified codes that might be problematic Data on Code Use Frequency Top 200 ICD 9 codes based on NIH outpatient frequency 31.5% of ICD 9 codes are unspecified Using GEMS forward mapping 75.5% appear to be 1 to 1 Using GEMS forward mapping 41.5% mapped to unspecified ICD 10 Assuming 30 patients per day and 3 diagnosis per patient 80% of encounters would have an unspecified code 24 coding questions per provider per day 6

7 Big Question for 2016 How do we get the right code the first time without turning doctors into coders? Workflow Process Physician Delayed Reimbursement Physician Productivity Loss Billing Biller Productivity Loss PM System Clearinghouse Payer ICD 10 Costs Small Practice Medium Practice Large Practice Pre Implementation Training $2,700 $3,000 $4,800 $7,900 $75,100 Assessment $4,300 $7,000 $6,535 $9,600 $19,320 Vendor/Software Upgrades $0 $60,000 $0 $200,000 $0 $2,000,000 Process Remediation $3,312 $6,701 $6,211 $12,990 $14,874 $31,821 Testing $15,248 $28,805 $47,906 $93,098 $538,034 $3,006,901 Sub Total $25,560 $105,506 $65,452 $323,588 $538,034 $3,006,901 Post Implementation Productivity Loss $8,500 $20,250 $72,649 $166,649 $726,487 $1,666,487 Payment Disruption $22,579 $100,349 $75,263 $334,498 $752,630 $3,344,976 Sub Total $31,079 $120,599 $147,912 $501,147 $1,479,117 $5,011,463 Grand Total $56,639 $226,105 $213,364 $824,735 $2,017,151 $8,018,364 Source: The Cost of Implementing ICD 10 for Physician Practices, Nachimson Advisors, LLC assn.org/resources/doc/washington/icd 10 costs for physician practices study.pdf 7

8 ICD 10DONITIS $100K to $150K Loss Per Physician Per Year ICD 10 Options Hire Certified Coders Salary Range $47,421 $64,807 + Benefits Shortage of Coders + Increasing Demand AAPC Recommends Hours of Training 20% Decrease in Productivity in ICD 10 Mandate EHR Use for All Physicians Too Many Clicks Disliked by Physicians in ICD 9, Hated in ICD 10 Fundamental Problem of Code Search Cheat Sheets, Cross Walk or Paper Encounter Forms High utilization of unspecified codes Electronic Superbill AccelaCAPTURE Protects Physician Muscle Memory Improves Revenue Cycle Efficiency Workflow Process Physician Delayed Reimbursement Physician Productivity Loss Billing Biller Productivity Loss PM System Clearinghouse Payer 8

9 Code Search Example 9

10 Code Search Example ICD 10 Superbill ICD 10 Superbill 10

11 ICD 10 Superbill ICD 10 Superbill ICD 10 Superbill 11

12 ICD 10 Superbill Big Question for 2016 How do we get the right code the first time without turning doctors into coders? Revenue Cycle with Payers BIG Impact to MD AND Big impact to reimbursement and staffing levels for billing teams CPT codes must have an appropriate dx for reimbursement ICD 9 ICD 10 Cat and Mouse game with insurance companies This dx goes with this CPT If this dx was primary If a patient presents with this dx, we always Non uniformity across payers ICD 9 this evolved over time, never static but stable volume of change ICD 10 was a one day conversion but coding impact delayed Aftershocks of changes to reimbursement for 3, 6, 12 months of rapid change The volume of changes will be significant. What, who, how will you manage? What happens if you don t? 12

13 Closed Loop Denial Prevention Denied Claim / New Policy Closed Loop Denial Prevention New Rule Built Rule fires for all employees every time Closed Loop Denial Prevention Takeaways 1. ICD 10 is not finished it has just begun 2. Continue to refine your ICD 10 strategy 3. What percentage of specified codes is your practice using? 4. Evaluate current processes to Protect Physician Productivity 5. Get the right code the first time to Improve Revenue Cycle Efficiency 13

14 Contact Information Matthew Menendez VP, ICD 10 Specialist White Plume Technologies, LLC x Questions 1. CMS agreed not to deny claims for unspecified codes until when? 2. CMS predicted denials would increase by what percentage because of ICD 10? % % % % 3. Denials actually increased by what percentage after ICD 10? % % % % 4. How do unspecified codes present short term financial risks to physician practices? 5. How do unspecified codes present long term financial risks to physician practices? 14