Nicole D. Harper, Ph.D., MBA, RHIA, CCS-P, C-CDI Director, Revenue Cycle St.Vincent Health Indiana
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1 Nicole D. Harper, Ph.D., MBA, RHIA, CCS-P, C-CDI Director, Revenue Cycle St.Vincent Health Indiana Pat Schmitter CPC, CPC-I Senior Healthcare Consultant Approved ICD-10-CM Trainer AHIMA/AAPC VEI Consulting - Indiana 1
2 Discuss expected industry impacts resulting from the ICD-10 implementation Define a proactive approach to preparing for organizational success beyond Oct. 1, 2014 Summarize concurrent activities that can be used to support a positive implementation Identify pitfalls to avoid as we approach golive
3 201 DAYS and counting!!!!
4
5 10%-50% decrease in coder productivity DNFB and A/R fourfold increase x9mos $50-$100 million in productivity losses among physicians Backlogs in adjustments and inquiries Error rates up to 6%-10% (annual ICD updates) 10%-25% increase in denial rates 10+% of charts = documentation insufficiency Potential 10%-25% increase in RAC/MIC take backs
6 Code set will increase to ~69,000 new codes Physicians will have to document more information The ICD-10 implementation date is NOT subject to change
7 ICD-10 Incorporates: Greater specificity Need for improved documentation of clinical data Information relevant to patient care encounters Ability to document risk factors Efficacy of Physician peer-to-peer education Opportunity to recruit physician champions
8 Expected Benefits of ICD-10 More-accurate payments for new procedures Fewer miscoded, rejected, and improper reimbursement claims Better understanding of the value of new procedures Improved disease management Better understanding of health care outcomes Higher quality information for measuring healthcare service quality, safety, and efficiency
9 Education & Training Increased Documentation Costs** Est. ~ $80k per Physician Business Process Changes Health Plan Contracting IT System Changes Cash Flow Disruption
10 10
11 Group presentations General overview By specialty Classroom Increments of 1 hour or less Web Video vs. text vs. combination Internal vs. external training sources
12 Use specific examples of relevance to audience Documentation gap analysis can help identify problem areas Focus on areas that represent change Guideline change Change in desired specificity Focus on high volume, problem prone topics -- May not be your top 50 DRGs/Diagnosis -- Have you considered your NOS/NEC volume?
13 Physician Education & Training Accountability Make sure stakeholders clearly understand responsibility to ICD-10.. How does MY ROLE impact the organization? Take time to enjoy what you are doing right!!
14 Specialty specific Physician education Impact to Medical Decision Making Commercial Insurance Plans Value based purchasing Contracting Physician Score Cards Health Information Exchanges Meaningful Use
15 Documentation leads to identification of diagnoses and procedures Resource utilization (quality management, patient outcomes, etc) Support the length of stay, medical necessity & continuity of care Morbidity and mortality scores Increase communication (i.e. physician documentation, coding updates/guidelines, Case Management) Appropriately Represent Case Mix Index Precise data capture for public reporting (i.e. Healthgrades, Care Science, WebMD) Audits may occur years after the patient was in the hospital documentation has to stand up to the test of time
16 Outcome of defaulting to NOS codes Physician Staffing/Interruption to Office Process & Flow Time associated with reworking/researching information needed to adjust claims Identification of problems that lead to claims being rejected Educating the provider/entity on data elements necessary to fix a rejected claim Unable to translate ICD-9 to ICD-10 What about GEMS mapping??
17 Key Strategies for Compliant Documentation Helping the provider understand what is necessary. Keeping the lines of communication open between providers and relevant staff. Ensure that providers/staff have access to current documentation education and materials. Encourage networking between peers.
18 18
19 Pre-registration, scheduling & registration Understanding the process Provider/Hospital Staff/Coding Communication (Encounter) Form/Smart Set Updates Insurance verification/eligibility requirements Prior Authorization Medical Necessity (LCD/NCD/ABN) ICD Codes vs Narrative Diagnosis Financial Counseling
20 The Basics of the ICD-10 Change An example of structural change ICD-9 X X X. X X Category Etiology, anatomic site, manifestation X X X. X X Category ICD-10 X. X Etiology, anatomic site, Extension manifestation An example of (1) ICD-9 code being represented by multiple ICD-10 codes Diabetes mellitus with neurological Manifestations type I not stated as uncontrolled. Type... E E E E I diabetes mellitus with diabetic neuropathy, unspecified Type I diabetes mellitus with diabetic mononeuropathy Type I diabetes mellitus with diabetic amyotrophy Type I diabetes mellitus with other diabetic neurological complication
21 A glimpse at specificity ICD-9-CM Fracture of femur, shaft, closed ICD-10-CM S72301A Unspecified fracture of shaft of right femur, initial encounter for closed fracture S72301G Unspecified fracture of shaft of right femur, subsequent encounter for closed fracture with delayed healing S72302A Unspecified fracture of shaft of left femur, initial encounter for closed fracture S72302G Unspecified fracture of shaft of left femur, subsequent encounter for closed fracture with delayed healing S72309A Unspecified fracture of shaft of unspecified femur, initial encounter for closed fracture S72309G Unspecified fracture of shaft of unspecified femur, subsequent encounter for closed fracture with delayed healing S72322A Displaced transverse fracture of shaft of left femur, initial encounter for closed fracture S72322G Displaced transverse fracture of shaft of left femur, subsequent encounter for closed fracture with delayed healing S72323A Displaced transverse fracture of shaft of unspecified femur, initial encounter for closed fracture S72323G Displaced transverse fracture of shaft of unspecified femur, subsequent encounter for closed fracture with delayed healing S72324A Nondisplaced transverse fracture of shaft of right femur, initial encounter for closed fracture S72324G Nondisplaced transverse fracture of shaft of right femur, subsequent encounter for closed fracture with delayed healing S72326A Nondisplaced transverse fracture of shaft of unspecified femur, initial encounter for closed fracture S72326G Nondisplaced transverse fracture of shaft of unspecified femur, subsequent encounter for closed fracture with delayed healing S72331A Displaced oblique fracture of shaft of right femur, initial encounter for closed fracture S72331G Displaced oblique fracture of shaft of right femur, subsequent encounter for closed fracture with delayed healing S72332A Displaced oblique fracture of shaft of left femur, initial encounter for closed fracture S72332G Displaced oblique fracture of shaft of left femur, subsequent encounter for closed fracture with delayed healing S72325A Nondisplaced transverse fracture of shaft of left femur, initial encounter for closed fracture S72333A Displaced oblique fracture of shaft of unspecified femur, initial encounter for closed fracture S72321A Displaced transverse fracture of shaft of right femur, initial encounter for closed fracture S72325G Nondisplaced transverse fracture of shaft of left femur, subsequent encounter for closed fracture with delayed healing S72333G Displaced oblique fracture of shaft of unspecified femur, subsequent encounter for closed fracture with delayed healing S72321G Displaced transverse fracture of shaft of right femur, subsequent encounter for closed fracture with delayed healing
22 Outsource assistance Coding Policies & Procedures Injury Codes (Y Codes) What about Quality/Risk reporting?? Productivity Estimated 40% - 50% decrease Potential Loss of staff
23 Process/Workflow Changes Billing, denials, other.. Clinical Documentation Improvement Vendor/Payer Readiness Review/recognize patterns & trends Reimbursement simulation Data Analysis What is your back end NOT telling your front end?
24 24
25 Software Vendors Verify Software Versions Expected dates of installation/transition Impacts to contracts & future upgrades Billing Services Clearinghouses Healthplans Changes in format for data submission Policy & Operational Changes
26 What does upgrade really mean Codes only? Templates/Smart Sets/Interfaces? Will there be additional costs associated with the transition? Is there any education included in the system upgrade? 0 vs O 26
27 Testing Unit/Component Basic System Functionality Internal vs External Process Information Exchange End-to-End High $$ High Volume Entire Cycle Regression Testing Identify Errors
28 Testing crucial to ensuring systems actually work Minimize risks to reimbursement Issues should be mitigated PRIOR to go-live Necessary stage to ensure a smooth transition Are your Health Plans openly offering testing? What is your community doing? HIMSS/WEDI Testing Pilot End-to-End vs 5010 Develop Your Own Pilot!!!!
29 29
30 Industry vs Organizational Changes Contingency Planning Volume vs Cash Service Line Impact Specialty Impact Top 10 Diagnosis & Procedures?? Managed Care Contracting Awareness of Clinical/Quality reporting & its impact on reimbursement Physician participation
31 31
32 Track * Resolve * ReEducate How will you know when something is going wrong? Content vs Process Increase in claims processing errors Determine Baseline Significant decrease in productivity logs Expected vs Catastrophic Influx of inaccurate codes Common vs New Increased use of unspecified codes
33 Identify all of the processes you currently employ that involve an ICD-9 code Connect with your customers/vendors/payers Are there things you need to improve TODAY that will help ease the transition? Budget accordingly Prepare & train your staff (End-to-End) Test, test & test again. Even if CMS doesn t support it Implement Convert & Monitor Recommend adding Post Go-Live Phase to your plan!
34 Evaluating IT systems, interfaces, and customers that currently use ICD-9 codes and developing a transition plan Strategizing on ways to improve data capture and how to use that data Assessing training needs and developing programs to support both the initial and any ongoing training Managing expectations regarding productivity loss Appropriate budgeting for implementation resources, as well as the short and long term impacts on cash driven by reduced productivity and increased A/R Potential revision of work flows/processes
35 Five Points of Preparation 1. Everyone will be affected 2. Private and public health plans will not accept and pay based on ICD-9 codes used after DOS 10/01/ Automated conversions are not possible (forward & backward mapping of codes) 4. ICD-10 cannot wait for Electronic Health Records & other health IT initiatives 5. ICD-10 is more than a compliance activity
36 Preferred Proactivity Do you have the right people doing the right job? Do your experts have everything they need? What resources do you have lined up to support go-live? Are you prepared to provide training POST go-live? 36
37 Preventable Pitfalls Lack of Preparation Hurry up and Wait (Anticipate Act Adjust) Your EMR won t save you!!! Collaborate/combine efforts to maximize resource utilization Who is your ICD-10 Champion?
38 Contact Information Nicole D. Harper, Ph.D., MBA, RHIA, CCS-P, C-CDI Director, Revenue Cycle Management St.Vincent Health Indiana Pat Schmitter CPC, CPC-I Sr Healthcare Consultant VEI Consulting-Community Health Network
39 References American Health Information Management Association (AHIMA) Hay Group, Inc. Healthcare Information Management Systems Society (HIMSS) RAND Robert E. Nolan Company Pricewaterhouse Coopers tands/02_transactionsandcodesetsregulations. asp 18_5010D0.asp 3M Solutions
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