CMS on Coding Requirements. The why: 2014 Hospice Wage Index rule. Disclaimer. Agenda. Objectives

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1 NHPCO's 14th Clinical Team Conference and Pediatric Intensive September 2013 Kansas City, MO Does Your Coding of Diagnoses Ensure Proper Payment? Exploring the New Coding Requirements Session PC04 PR E S E N T E D B Y R O N A L D J C R O S S N O, M D, F A A H PM Disclaimer 2 The information enclosed was current at the time it was presented. Medicare and other payer policy changes frequently; links to the source documents have been provided within the document for your reference. This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services. Acevedo Consulting Inc. and Gentiva Health Services employees, agents, and staff make no representation, warranty, or guarantee that this compilation of information is error-free and will bear no responsibility or liability for the results or consequences of the use of this information. This presentation is a general summary that explains certain aspects of the Medicare Program and other reimbursement and compliance information, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings. JEAN A C E V E DO, L H R M, C PC, C H C, C E N TC Agenda ICD-9: Why are we talking about this now? Purpose of ICD CMS on ICD-9 coding Coding Concepts & Guidelines Clinical considerations for updated coding Relatedness considerations Example cases of necessary critical thinking An Intro to ICD Objectives 1. Discuss determination of terminal diagnoses for patients entering hospice care including patients who present as debility, unspecified or adult failure to thrive 2. Discuss accurate ICD-9 coding of hospice diagnoses per the ICD-coding guidelines 3. Review ICD-10 coding principles, timeline for implementation and provider preparation 4 CMS on Coding Requirements 6 The why: 2014 Hospice Wage Index rule All of a patient s coexisting or additional diagnoses related to the terminal illness or related conditions should be reported on the hospice claims 72% of hospice claims report only one diagnosis 1

2 CMS on Hospital vs. Hospice Diagnoses 7 In analyzing frequently reported principal hospice diagnoses, data analysis revealed differences between reported principal hospice diagnoses and reported principal hospital diagnoses in patients who elected hospice within 3 days of discharge from the hospital. In analyzing data on cancer diagnoses of Medicare hospice beneficiaries for 2009 through 2011, Table 3 below shows that beneficiaries with a hospital-reported principal cancer diagnosis that elected hospice within three days of hospital discharge did not always have a hospice-reported principal cancer diagnosis. CMS on Hospital vs. Hospice Diagnoses 9 Although ICD-9-CM Coding Guidelines specify that the circumstances of an inpatient hospital admission diagnosis are to be used in determining the selection of a principal diagnosis, this guideline is not always being adhered to for the selection of the principal hospice diagnosis following a hospice beneficiary s inpatient hospitalization. It is unclear as to why there is this discrepancy in the hospital/hospice diagnosis patterns as ICD-9-CM Coding Guidelines are specific regarding principal diagnosis selection. CMS on Debility and Adult Failure to Thrive 10 There have also been noted changes in the diagnosis patterns among Medicare hospice enrollees, with a growing percentage of beneficiaries with non-cancer diagnoses. Specifically, there were notable increases between 2002 and 2007 in neurologically based diagnoses, including various dementia diagnoses. Additionally, there have been significant increases in the use of non-specific, symptomclassified diagnoses, such as debility and adult failure to thrive. In FY 2012, both debility and adult failure to thrive were in the top five claims-reported hospice diagnoses and were the first and third most common hospice diagnoses, respectively Alzheimer s and Other Dementias 11 Diagnoses in coding classification Mental, Behavioral, and Neurodevelopmental Disorders Not allowable as a principal diagnosis per ICD-9-CM coding guidelines Diagnoses in ICD-9-CM coding classification Diseases of the Nervous System and Sense Organs Can be used as principal diagnoses per ICD-9-CM coding guidelines To Make Matters Worse Hospice providers have listed the following as the primary terminal conditions*: tuberculin reaction, strep throat, family history of breast disease, and prickly heat, 12 just to name a few of the most outrageous. *Terri Deutsch, CMS health insurance specialist, Federation of American Hospitals meeting,

3 The take-away: 13 Imperative that hospice providers follow ICD-9- CM coding guidelines and sequencing rules for all diagnoses Pay particular attention to FTT, dementia and nonspecific coding Code the most definitive, contributory terminal illness in the principal diagnosis field with all other related conditions in the additional diagnoses fields for hospice claims reporting ICD-9 Coding: Concepts & Guidelines ICD-9 Purpose and Applications 15 Facilitate the collection of disease trends for comparison of mortality and morbidity data from different countries and specific populations. Establish healthcare quality and guidelines Government resource allocation Medical necessity for treatment Research- clinical trials Reimbursement ICD-9 Coding: CMS Rules Note: research for this presentation revealed the CMS Manual information on the following slides to be nothing new. Ch. 23 Claims Processing Manual Proper coding is necessary on Medicare claims because codes are generally used to assist in determining coverage and payment amounts. 17 Ch. 23 Claims Processing Manual 18 Rules for reporting diagnosis codes on the claim are: Use the ICD-9-CM code that describes the patient s diagnosis, symptom, complaint, condition or problem. Do not code suspected diagnosis. Use the ICD-9-CM code that is chiefly responsible for the item or service provided. Assign codes to the highest level of specificity. Use the fourth and fifth digits where applicable. Code a chronic condition as often as applicable to the patient s treatment. Code all documented conditions that coexist at the time of the visit that require or affect patient care or treatment. (Do not code conditions that no longer exist.) 3

4 Ch.11 Hospice Claims Processing Manual The full ICD-9-CM diagnosis code is required. The principal diagnosis is defined as the condition established after study to be chiefly responsible for the patient s admission.. Use full ICD-9-CM diagnoses codes including all five digits where applicable. 19 ICD-9 and Hospice Ch. 11, Hospice Claims Processing Manual 20 Principal Dx Code: The hospice enters diagnosis coding as required by ICD-9-CM Coding Guidelines. Hospices may not report V-codes as the primary diagnosis on hospice claims. The principal diagnosis code describes the terminal illness of the hospice patient and V-codes do not describe terminal conditions. And on Other Dx Codes: The hospice enters diagnosis coding as required by ICD-9-CM Coding Guidelines. Ch. 23 Claims Processing Manual 21. Interestingly, this Chapter lists specific requirements for ICD-9 coding for physicians, DMEPOS, hospitals, etc. but not a word on terminal illness diagnosis coding for hospices. And, the words prognosis or prognostication were not found in any CMS manual on ICD coding Dr. Crossno will talk about what the principal diagnosis means for hospice. So, let s look at ICD-9 guidelines and how those might impact Other diagnoses. Other Diagnosis ICD-9 Official Guidelines For reporting purposes the definition for other diagnoses is interpreted as additional conditions that affect patient care in terms of requiring: clinical evaluation; or therapeutic treatment; or diagnostic procedures; or extended length of hospital stay; or increased nursing care and/or monitoring. 23 Other Diagnosis 24 Might these not be an excellent proactive way to paint a picture as to why two hospice patients with the same terminal illness have much different levels of care on the ub-04 hospice claims submitted this month? 4

5 ICD-9: 10 Steps to Correct Coding 25 Step 1: Identify the reason for the visit (e.g., sign, symptom, diagnosis, condition to be coded). Physicians describe the patient's condition using terminology that includes specific diagnoses as well as symptoms, problems or reasons for the encounter. If symptoms are present but a definitive diagnosis has not yet been determined, code the symptoms. Do not code conditions that are referred to as rule out, suspected, probable or questionable. ICD-9: 10 Steps to Correct Coding 26 Step 2: Always consult the Alphabetic Index, Volume 2, before turning to the Tabular List. The most critical rule is to begin a code search in the index. Never turn first to the Tabular List (Volume 1), as this will lead to coding errors and less specificity in code assignments. To prevent coding errors, use both the Alphabetic Index and the Tabular List when locating and assigning a code. ICD-9: 10 Steps to Correct Coding Step 3: Locate the main entry term. 27 The Alphabetic Index is arranged by condition. Conditions may be expressed as nouns, adjectives and eponyms. Some conditions have multiple entries under their synonyms. Main terms are identified using boldface type. Step 4: Read and interpret any notes listed with the main term. Notes are identified using italicized type. ICD-9: 10 Steps to Correct Coding Step 5: Review entries for modifiers. Nonessential modifiers are in parentheses. These parenthetical terms are supplementary words or explanatory information that may either be present or absent in the diagnostic statement and do not affect code assignment. 28 ICD-9: 10 Steps to Correct Coding 29 Step 6: Interpret abbreviations, cross-references, symbols and brackets. Cross-references used are see, see category, or see also. The abbreviation NEC may follow main terms or subterms. NEC (not elsewhere classified) indicates that there is no specific code for the condition even though the medical documentation may be very specific. The box indicates the code requires an additional digit. If the appropriate digits are not found in the index, in a box beneath the main term, you MUST refer to the Tabular List. Italicized brackets [ ], are used to enclose a second code number that must be used with the code immediately preceding it and in that sequence. ICD-9: 10 Steps to Correct Coding 30 Step 7: Choose a tentative code and locate it in the Tabular List. Be guided by any inclusion or exclusion terms, notes or other instructions, such as code first and use additional code, that would direct the use of a different or additional code from that selected in the index for a particular diagnosis, condition or disease. 5

6 ICD-9: 10 Steps to Correct Coding 31 Step 8: Determine whether the code is at the highest level of specificity. Assign three-digit codes (category codes) if there are no four-digit codes within the code category. Assign four-digit codes (subcategory codes) if there are no five-digit codes for that category. Assign five-digit codes (fifth-digit subclassification codes) for those categories where they are available. ICD-9: 10 Steps to Correct Coding Step 9: Consult the color coding and reimbursement prompts, including the age and sex edits. Consult the official ICD-9-CM guidelines for coding and reporting, and refer to the AHA's Coding Clinic for ICD-9- CM for coding guidelines governing the use of specific codes. Step 10: Assign the code. 32 Some Additional Conventions Manifestation Codes 33 A manifestation code is not allowed to be reported as a first-listed diagnosis because each describes a manifestation of some other underlying disease, not the disease itself. This is referred to as mandatory multiple coding of etiology and manifestation. Code the underlying disease first. A Code first underlying disease instructional note will appear with underlying disease codes identified. Some Additional Conventions Manifestation Codes 34 A manifestation code is not allowed to be reported as a first-listed diagnosis because each describes a manifestation of some other underlying disease, not the disease itself. This is referred to as mandatory multiple coding of etiology and manifestation. Code the underlying disease first. A Code first underlying disease instructional note will appear with underlying disease codes identified. Late Effects Some Additional Conventions 35 A late effect is the residual effect (condition produced) after the acute phase of an illness or injury has terminated. There is no time limit on when a late effect code can be used. The residual may be apparent early, such as in cerebrovascular accident cases, or it may occur months or years later, such as that due to a previous injury. Coding of late effects generally requires two codes sequenced in the following order: The condition or nature of the late effect is sequenced first. The late effect code is sequenced second. Some Additional Conventions Unspecified Code 36 Use these codes when the neither the diagnostic statement nor the documentation provides enough information to assign a more specified diagnosis code. These codes may be stated as Unspecified or Not otherwise specified (NOS). Note: Do not assign these codes when a more specific diagnosis has been determined. 6

7 Palmetto GBA Article (09/24/2010) 37 Going Beyond Diagnosis: ICD-9-CM Debility, Unspecified: The guidelines encouraged hospice providers to document how multiple conditions were contributing to the beneficiary s medical prognosis of six months or less. this was to be accomplished by specifically identifying the impairments, activity limitations, and disability associated with the principal diagnosis identified by the hospice provider (i.e., the condition that was impacting most acutely on the beneficiary s clinical course). Palmetto s Going Beyond Diagnosis Description of ESRD Case ICD-9-CM End stage renal disease Comorbid Conditions Vascular dementia with delirium Dysphagia Pneumonitis due to solids and liquids Mitral valve insufficiency and aortic stenosis Aortic aneurysm Abdominal, without rupture Chronic ischemic heart disease, unspecified ICD-9 and Palliative Care And, from CMS s FAQs W I L L C M S B E A S K I N G F O R A D D I T I O N A L C L A I M S I N F O R M A T I O N I N T H E F U T U R E? A N S W E R Y E S. G I V E N T H E R E C E N T G R O W T H I N T H E M E D I C A R E H O S P I C E B E N E F I T A S W E L L A S T H E R E C O M M E N D A T I O N S F R O M T H E M E D I C A R E P A Y M E N T A D V I S O R Y C O M M I S S I O N ( M E D P A C ) A N D O T H E R S, C M S W I L L C O N T I N U E T O E V A L U A T E T H E N E E D F O R A D D I T I O N A L I N F O R M A T I O N O N T H E H O S P I C E C L A I M. A N Y A D D I T I O N A L R E Q U I R E M E N T S W I L L B E I S S U E D T H R O U G H P R O G R A M T R A N S M I T T A L S. R E F E R E N C E : W W W. C M S. H H S. G O V / T R A N S M I T T A L S / D O W N L O A D S / R C P. P D F Code for the diagnosis, condition, problem, or other reason for encounter/visit List first the ICD-9-CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided. List additional codes that describe any coexisting conditions. In some cases the first-listed diagnosis may be a symptom when a diagnosis has not been established (confirmed) by the physician Claim up to 8 ICD-9 codes 40 Question Received by NHPCO. There is some discussion as to how CMS wants hospice to code for Dementia. Do we code it Vascular Dementia if the patient has vascular dementia secondary to CVA? Or do we code it with the CVA diagnosis? The dementia will be the cause of death, however the dementia in this case is secondary to the CVA. Here s the easy question: Should the cause of death drive the diagnosis code? Dementias The Answer Code first the associated neurological condition Excludes dementia due to alcohol ( ) dementia due to drugs (292.82) 42 dementia not classified as senile, presenile, or arteriosclerotic ( ) psychoses classifiable to occurring in the senium without dementia or delirium ( ) senility with mental changes of nonpsychotic severity (310.1) transient organic psychotic conditions ( ) So, code the underlying neurological condition as primary 7

8 5th The Answer, cont d Vascular dementia Multi-infarct dementia or psychosis Use additional code to identify cerebral atherosclerosis (437.0) Excludes suspected cases with no clear evidence of arteriosclerosis (290.9) 43 1)Have to code to the 5 th digit 2)Must code the underlying vascular condition That 5 th digit. The Answer, cont d Vascular dementia, uncomplicated Arteriosclerotic dementia: NOS Simple type Vascular dementia with delirium Arteriosclerotic dementia with acute confusional state Vascular dementia with delusions Arteriosclerotic dementia, paranoid type Vascular dementia with depressed mood Arteriosclerotic dementia, depressed type 44 The Answer, cont d Use additional code to identify cerebral atherosclerosis (437.0) 4th 437 Other and ill-defined cerebrovascular disease Cerebral artherosclerosis Atheroma of cerebral arteries Cerebral arteriosclerosis other generalized ischemic cerebrovascular disease Acute cerebrovascular insufficiency NOS Cerebral ischemia (chronic) hypertensive encephalopathy 45 The Answer, cont d cerebral aneurysm, nonruptured Internal carotid artery, intracranial portion Internal carotid artery NOS cerebral arteritis Moyamoya disease Nonpyogenic thrombosis of intracranial venous sinus Transient global amnesia Other Unspecified Cerebrovascular disease or lesion NOS 46 Final Answer Not enough information to code correctly! 47 What we do know: 1. If you read the guidelines you can code correctly, but 2. Only if you have sufficient documentation Question Received by NHPCO. 48 If the patient s H&P states brain mass, but we have no pathology report, can we use brain Ca as a diagnosis? Based on everything we ve heard we should not and we have not. We re getting so many referrals for patients who have not had a biopsy because of their age, physical status or their desire not to pursue the diagnostic testing. We ve been using debility and coding mass secondary but we re concerned about using debility so often. NOTE: Question received 2 days prior to publication of the 2014 Wage Index rule! 8

9 The Answer How does debility look in ICD10? Unspecified debility 49 ICD-9 50 ICD Swelling, mass, or lump in head and neck Instructional notes: ( )~This section includes symptoms, signs, abnormal results of laboratory or other investigative procedures, and ill-defined conditions regarding which no diagnosis classifiable elsewhere is recorded.~ The conditions and signs or symptoms included in categories consist of: (a) cases for which no more specific diagnosis can be made even after all facts bearing on the case have been investigated; (b) signs or symptoms existing at the time of initial encounter that proved to be transient and whose causes could not be determined; (c) provisional diagnoses in a patient who failed to return for further investigation or care; (d) cases referred elsewhere for investigation or treatment before the diagnosis was made; (e) cases in which a more precise diagnosis was not available for any other reason; Unspecified debility 5th R53 Malaise & Fatigue R53.81 Other malaise Chronic debility Debility NOS General physical deterioration Malaise NOS Nervous debility Do not lose sight of our priorities! 52 Now for the clinical perspective on all this Top priority should remain caring for patients who can benefit from hospice care Doing the coding thing properly should not be a barrier to accessing hospice Even CMS stated this, in the final rule Proper care includes proper documentation Following these processes has the potential to actually improve the care provided to our patients Throughout this process, remember: Before we start definitions 54 Hospice eligibility is not based on diagnosis. Hospice eligibility is based on PROGNOSIS! A useful way of defining terms: Terminal diagnosis = Primary or Principal diagnosis Related diagnosis = Any other diagnosis related to terminal prognosis (sometimes called secondary conditions) Unrelated diagnosis = Any other diagnosis not related to terminal prognosis (sometimes called coexisting or comorbid conditions) HMD = Hospice Medical Director or Physician 9

10 CMS final rule (8/2/2013) Emphasis on Diagnosis Coding: Need to properly report on hospice claims: Terminal diagnosis Other Related diagnoses Use diagnosis codes according to ICD-9 coding rules Expressed concerns over use of: Symptom & Nonspecific codes Especially, but not limited to Debility and AFTT Some behavioral dementia codes 55 CMS says it is requiring this because: Rise in use of non-specific diagnosis codes Complicates analysis of hospice industry because of lack of diagnostic specificity Most hospices report only one diagnosis code Too focused on one problem, impairing the ability to properly provide holistic care 56 Most hospices don t report related diagnosis codes Complicates ability to determine and appropriately assign relatedness for other diagnoses medication/treatment coverage CMS response to these issues Mandate hospital-based coding rules Coding of terminal diagnosis by these rules ICD-9 codes or for the terminal diagnosis appear potentially problematic These codes are acceptable for related diagnoses CMS rules also require that hospices Document all diagnoses in the hospice record 57 List all related diagnosis codes on the hospice claim Explain why unrelated diagnoses are unrelated Isn t this just about Debility & AFTT? In a word: NO! Many in the hospice industry have focused only on the Debility / AFTT aspect of the CMS rule The scope of the rule is much broader than that Debility / AFTT are among the codes So are many other traditional hospice diagnoses Some have suggested: Changing to other possibly problematic codes Not admitting or discharging eligible patients 58 Several coding-related requirements 59 All diagnoses should be in the clinical record HMD, with input from the IDT, is to select the terminal diagnosis HMD, with input from the IDT, must designate if any diagnoses are unrelated HMD must document reasons for being unrelated Terminal & related diagnoses should be ICD-9 coded Terminal & related diagnosis codes should be entered on the hospice billing claim (We re going to step through each of these) Document all diagnoses 60 Necessary to list all diagnoses from clinical records, examinations and discussions Should be listed for care planning purposes Even when not related Not a new CoPs requirement No specific requirement for to do this Some suggest a stand-alone diagnosis list form 10

11 Choosing the terminal diagnosis 61 HMD determines terminal diagnosis, based on similar sources as for determining prognosis: Records review Input from IDG Discussions with referral sources/attending physician Clinical judgment And examination of patient (if applicable) Rule of thumb: The diagnosis that will most likely be listed as the cause of death on the death certificate, is likely the best terminal diagnosis But remember! There are some codes we should not use for the terminal diagnosis (More on this in upcoming slides) Terminal diagnosis codes that may be used will come from ICD-9 resource materials ICD-9-CM coding manuals Online coding guides 62 When documenting diagnoses Need to document each of the following: Terminal diagnosis Related diagnoses Unrelated diagnoses Terminal & Related diagnoses should have ICD-9 codes assigned Terminal & Related diagnosis codes are to be submitted on the billing claim 63 Determining relatedness CMS says the default is that diagnoses are related unless the hospice physician documents why they are not related HMD should document why an unrelated diagnosis is unrelated 64 This is a new way of documenting practices that many have already been informally doing Seems reasonable to develop a formal process to do this consistently (Possibly on a new diagnosis list form?) Documenting un-relatedness So how does one actually document un-relatedness? For most diagnoses, it is usually obvious to any clinician which diagnoses are and are not related Documentation should be individualized CMS says this must be done by the hospice physician Example explanations: 65 Glaucoma involves a different organ system than dementia, and is not contributing to the terminal prognosis. Patient s nasal allergies are not contributing to the patient s expected death from her ovarian cancer. Assigning related ICD-9 codes 66 Once terminal & related diagnoses identified: Identify local coder for office Preferably, someone with coding experience (consider physician or experienced nurse, if no one else) Coder should assign ICD-9 code for terminal diagnosis and each related diagnosis Remember: all related diagnoses must have ICD-9 codes listed on hospice billing claim No need to code unrelated diagnoses Listing ICD-9 codes on billing claim signals CMS that these diagnoses are related 11

12 Some codes have limited use 68 The upcoming discussion is about the critical thinking needed to assign the appropriate terminal diagnosis Not about barriers to admission or about discharging eligible patients Terminal Diagnosis: should generally not use the following codes ICD-9 Codes 290 through 319 (Mental, Behavioral, and Neurodevelopment Disorders) ICD-9 Codes 780 through 799 (Symptoms, Signs, and Ill-defined Conditions) Related Diagnoses: may use the above codes 67 Problem: ICD-9 codes 290 to 319 The following common hospice codes should be avoided as the terminal diagnosis: Senile dementia, uncomplicated Presenile dementia (& all subcodes) Senile dementia with delusional or depressive features Senile dementia with delirium Vascular dementia (& all sub-codes) Dementia in conditions classified elsewhere (& all subcodes) Dementia, unspecified (& all subcodes) Along with any other code in the 290 through 319 range Even if these worked before, they will likely be RTP d These codes may be used for related diagnoses 69 Which dementia codes are okay? Disease specific dementia ICD-9 codes that are acceptable include, but are not limited to the following: Alzheimer s disease (331.0) Pick s disease (331.11) Other frontotemporal dementia (331.19) Senile degeneration of the brain (331.2) Corticobasal degeneration (331.6) Dementia with Lewy bodies (331.82) The appropriate 290 series codes should be used as related diagnoses to provide additional information about the terminal diagnosis 70 Current patients with dementia as their terminal diagnosis 71 Having a 290 to 319 code today doesn t mean eligible dementia patients need to be discharged Such patients need to have their diagnoses clarified with a more disease-specific terminal diagnosis code Ex: Dementia in CCE might be changed to Alzheimer Dz Review ICD-9 codes of current dementia patients If an acceptable code nothing needs to be done If a problematic code review with HMD, get clarification order for disease-based diagnosis, then document new terminal diagnosis code, along with related diagnoses Since plan of care and documentation are for dementia, presumably nothing but the clarification order and diagnosis codes will change When specific dementia DX is lacking Often, the clinical records lack a specific diagnosis for the underlying cause of dementia HMDs can assign a diagnosis based on their clinical judgment HMDs do this for prognosis all the time Physician narrative would be the place to further explain this diagnosis Examples 72 Since Alzheimer s disease (331.0) is the most common dementia, one might assume previously undiagnosed cases are likely due to Alzheimer s Disease When the patient is >65 years old, then Senile degeneration of the brain (331.2) might be used, if appropriate 12

13 Vascular dementia is slightly different Vascular dementia (290.4) (a.k.a. multi-infarct dementia) is a problem terminal diagnosis code 73 Now that you re getting a feel for how this might work, let s move on to the non-specific codes, like Debility and Adult Failure to Thrive. The causative condition that led to vascular dementia is not neurodegenerative, but it still should be listed as the terminal diagnosis, such as perhaps: Cerebral atherosclerosis (437.0), or Cerebral embolism (434.1), or Essential hypertension, malignant (401.0), etc. For problematic codes, the proper causative condition is listed as the terminal diagnosis and other diagnoses are listed and coded as related diagnoses Problem: ICD-9 codes 780 to 799 The following common hospice codes are best avoided as a terminal diagnosis Abnormal weight loss Failure to thrive Adult failure to thrive Malaise and fatigue Debility, unspecified Other ill-defined conditions Other unknown & unspecified cause of morbidity or mortality Along with any other code in the 780 through 799 range The Debility Challenge Debility does not describe what is wrong with a patient Scope of the problem CMS, MACs, and hospice leaders have recognized Debility has been overused The challenge: 76 These may be used as related diagnoses 75 How do we eliminate the diagnosis while continuing our care of eligible patients? What is Debility, really? Definition: noun weakness or infirmity By this definition, virtually everyone in a nursing facility, almost everyone in a hospital, and almost everyone over the age of 80 has debility. Some, but not all not even most, of these people have a terminal prognosis! Debility is no better than simply using weakness as a diagnosis 77 Think of four ways to document hospice eligibility 78 Based on published guidelines (e.g. LCDs): Perfect Fit: Pt meets guideline elements of an LCD Close Fit + Supportive: Pt almost meets guideline elements of LCD, but also has supporting conditions indicating a terminal prognosis Close Fit + Rapid Decline: Pt almost meets guidelines elements of LCD, but also has rapid clinical decline indicating a terminal prognosis Clinical Judgment: There is no applicable LCD, but there is still evidence of terminal prognosis 13

14 How does this relate to debility? 79 Ask yourself the following three questions: 1. What condition(s) has made this patient debilitated or weak or infirm? 2. Is this a fit or close fit to one or more LCDs? 3. Is the patient likely to die within the next 6 months due to this? If the answers to #2 and #3 are Yes, then The answer to #1 is the terminal diagnosis If #1 has multiple answers, then the most predominant condition is the terminal diagnosis and the others are related diagnoses Explain all of this in the physician narrative What if questions #2 or #3 are No? 2. Is this a fit or close fit to one or more LCDs? If #2 is no, then it all depends on #3 3. Is the patient likely to die within the next 6 months? If #3 is yes, but #2 is no : 80 Document to whatever is leading to the terminal prognosis Code that diagnosis (as long as it is a permissible code) If #3 is no, then the patient is not hospice eligible, either: Quickly get more info, if that will change the decision, or Immediately begin discharge planning (Both of these can happen together) Debility specific DX example Pt with heart failure, COPD, and rapid weight loss leading to functional decline (PPS 50%) such that prognosis is for life expectancy of less than 6 months Heart failure is predominant because of difficulty with fluid retention, but is only NYHA Class 3 COPD has frequent exacerbations, making it difficult to tell what is COPD and what is CHF Unintentional weight loss of 25% over 6 months because is too tired/breathless to have appetite Also has glaucoma, osteoarthritis and hypothyroidism Physician narrative explains the combination together leads to terminal prognosis 81 Debility specific DX example narrative (close fit + supportive & rapid decline) year old female admitted for chronic heart failure secondary to ischemic cardiomyopathy complicated by COPD. Despite not meeting a clear picture of the LCD Guidelines for cardiac disease, it is my medical judgment that this patient does have a prognosis of less than six-month because of frequent exacerbations of her COPD and associated rapid decline in her nutritional status. She has had one hospitalization and two ED visits in the past four months. She is NYHA Class III and has chronic lower extremity edema. Her PPS is 50% and she has SOB with minimal activity despite continuous oxygen and optimal therapy. She suffers with dyspnea with minimal exertion. She had unintentional weight loss of 25% in the preceding six months with current wt - 132lbs & BMI If she continues on her current trajectory, her prognosis is less than six months. Debility specific DX example of old coding Terminal diagnosis: Debility, unspecified (799.3) (This code is no longer appropriate for terminal diagnosis. Consider: this patient s debility is clearly not unspecified since it is due to other conditions.) Related diagnoses: Congestive heart failure, unspecified (428.9) Abnormal weight loss (783.2) Unrelated diagnoses: Chronic airway obstruction, NEC (Contributes to the terminal prognosis, so should be related) Open-angle glaucoma, unspecified Unspecified hypothyroidism Osteoarthritis, multiple sites 83 Terminal diagnosis: Debility specific DX example of correct coding 84 Congestive heart failure, unspecified (428.9) Related diagnoses: Chronic airway obstruction, NEC (496.0) (In this case, we also cover COPD meds & treatments.) Abnormal weight loss (783.2) (This code is okay for related diagnosis, but not terminal.) Unrelated diagnoses: Open-angle glaucoma, unspecified Unspecified hypothyroidism Osteoarthritis, multiple sites (Remember: no ICD-9 codes are recorded for unrelated diagnoses, and the HMD must explain why these are unrelated.) 14

15 What about adult failure to thrive? Unlike Debility, AFTT is a well-defined geriatric syndrome associated with mortality Defined as PPS 40% and BMI < 22kg/m 2 due to unexplained or multiple causes Some hoped it would be an exception to the CMS rule, but they consider it the same as debility 85 Even so, AFTT is still handled a little differently While it cannot be listed as the terminal condition, AFTT can clearly be one of the related conditions Use AFTT with caution for non-geriatric patients Clarifying questions for AFTT Ask yourself the following three questions: 1. What condition(s) has made this geriatric patient fail to thrive? 2. Is this a fit or close fit to one or more LCDs? 3. Is the patient likely to die within the next 6 months due to this? If the answers to #2 and #3 are Yes, then The answer to #1 is the terminal diagnosis If #1 has multiple answers, then the most predominant condition is the terminal diagnosis and the others are related diagnoses AFTT cannot be the terminal diagnosis, but it can be a related diagnosis, especially since it has its own LCD Explain all of this in the physician narrative 86 What if questions #2 or #3 are No? Is this a fit or close fit to one or more LCDs? If #2 is no, then it all depends on #3 3. Is the patient likely to die within the next 6 months? If #3 is yes, but #2 is no : Document to whatever is leading to the terminal prognosis. Code that diagnosis (as long as it is a permissible code) If #3 is no, then the patient is not hospice eligible Either: Quickly get more info, if that will change the decision, or Immediately begin discharge planning (Both of these can happen together) AFTT specific DX example 88 Elderly patient has Alzheimer's disease with dementia FAST 6E incontinent, non-ambulatory, but still speaks more than 6 words / day Lost ability to do any ADLs except self-feed (PPS 40%) He has lost 8% of his body weight over the last four months to a current BMI of 18.5kg/m 2 He also has hypertension and osteoporosis 88 AFTT specific DX example narrative 89 This is an elderly patient with the diagnosis of Alzheimer's disease complicated by adult failure to thrive. Has a FAST of 6e, PPS of 40%, and BMI of 18.5 with documented weight loss of 8% over the preceding 4 months. It is my medical judgment that his diagnosis along with his trajectory of functional decline and associated poor nutritional status with irreversible weight loss will lead to his demise within the next six months. Terminal diagnosis AFTT specific DX example of old coding Adult failure to thrive (783.7) (Can no longer use for terminal diagnosis.) Related diagnoses Alzheimer s disease (331.0) (He is a close fit for the dementia LCD.) Unrelated diagnoses Essential hypertension, unspecified Osteoporosis

16 AFTT specific DX example of correct coding Terminal diagnosis o Alzheimer s disease (331.0) (Remember, we can still code a diagnosis that is only a close fit for an LCD, as long as there is other information supporting a terminal diagnosis.) Related diagnoses Adult failure to thrive (783.7) (While we cannot use this code for the terminal diagnosis, it is fine for a related diagnosis especially since it represents a perfect LCD fit. The physician narrative should explain this.) Unrelated diagnoses Essential hypertension, unspecified Osteoporosis (Remember: no ICD-9 codes for unrelated diagnoses, but the HMD must explain why these are unrelated.) 91 Adult failure to thrive dilemma 92 What about the occasional AFTT patient for whom no underlying contributing condition is apparent? This is sometimes because: There is no identifiable cause upon evaluation The patient / family decline evaluation CMS recognized this might rarely occur They recommend listing all related diagnoses, picking the predominant one as the terminal dx Do not use AFTT or debility as the terminal dx Whether other nonspecific codes might be accepted remains unclear Other 780 through 799 codes Ask yourself the following three questions: 1. What condition(s) has made this patient have <insert diagnosis>? 2. Is this a fit or close fit to one or more LCDs? 3. Is the patient likely to die within the next 6 months due to this? If the answers to #2 and #3 are Yes, then The answer to #1 is the terminal diagnosis (as long as it is not in the diagnosis code set If #1 has multiple answers, then the most predominant condition is the terminal diagnosis and the others are related diagnoses Explain all of this in the physician narrative 93 What if questions #2 or #3 are No? 2. Is this a fit or close fit to one or more LCDs? If #2 is no, then it all depends on #3 3. Is the patient likely to die within the next 6 months? If #3 is yes, but #2 is no : Document to whatever is leading to the terminal prognosis. Code that diagnosis (as long as it is a permissible code) If #3 is no, then the patient is not hospice eligible Either: Quickly get more info, if that will change the decision, or Immediately begin discharge planning (Both of these can happen together) 94 Relatedness 96 Now let s retrace our steps to that other topic we ve avoided CMS quotes the CoPs in stating the following: It is our general view that... hospices are required to provide virtually all the care that is needed by terminally ill patients. Therefore, unless there is clear evidence that a condition is unrelated to the terminal prognosis, all services would be considered related. It is also the responsibility of the hospice physician to document why a patient s medical need(s) would be unrelated to the terminal prognosis. [emphasis added] If a diagnosis contributes to the patient s terminal prognosis, then it should be considered related 16

17 General hospice relatedness guidance 97 Until now, there has been no standardized definition of hospice relatedness Discussion among experts revealed considerable variance in practice Part of CMS motivation for these proposed rules seems to be that some providers have used debility as a diagnosis in order to manage every other diagnosis as unrelated Recently related story from one MAC s medical director illustrates this: An HMD for an un-named hospice carefully explained during an ALJ appeal how a patient had a terminal prognosis due to debility, with comorbids of CHF, COPD, dementia, and weight loss. This HMD then stated that while these contributed to the patient s terminal state, his hospice felt none of these were related to the terminal diagnosis for coverage purposes. Something is clearly not right with that statement! Pain & symptom management CMS clearly states that pain & symptom management are always to be covered (seemingly regardless of relatedness) Explanations that pain or symptoms are due to unrelated diagnoses now appear to be moot Why? Presentation at MLC earlier this year discussed Medicare claims-data showing that almost 15% of analgesics for hospice patients were paid through Medicare Part D (not by hospice) Which symptoms, besides pain? CMS lists nausea, shortness of breath, anxiety, constipation, diarrhea, and depression, plus disease-specific medications 98 Other relatedness considerations What about medications and treatments that are related to the terminal condition, but are no longer beneficial or are not within the palliative plan of care for the patient? Ex: statins in someone with end-stage heart disease Ex: life-prolonging chemotherapy that does not treat any symptoms Such considerations are beyond the scope of today s presentations 99 Diagnosis changes Rarely, a patient s terminal diagnosis may change This is expected to happen in response to changes in patient s conditions, or when multiple diagnoses are identified and one becomes more predominant over time This is not necessarily a red flag This is likely to happen when changing from problematic to permissible codes Diagnosis change documentation What will need to be updated? List of diagnoses Relatedness determinations Unrelated diagnosis explanations Other documentation changes Physician order to change diagnosis Nursing documentation must reflect new diagnosis Physician narrative must reflect new diagnosis Update medication/treatment profiles & coverage Update Plan of Care 101 Diagnosis additions 102 As we care for our patients, additional diagnoses may be identified Such as urinary infections, respiratory infections, conjunctivitis, pressures ulcers, etc. Such diagnoses need inclusion in the record If related, document ICD-9 code to enter on claim and cover related treatments and medications If unrelated, must have HMD documentation of why the diagnosis is unrelated Remember: the default is related 17

18 ICD-10 Final Rule CMS-0013-F 104 ICD-10: What you should be doing now Published January 16, 2009 October 1, 2014 Compliance date for implementation of ICD-10-CM and ICD-10-PCS (no delays) No impact on Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPS) codes. ICD-10 CM New HIPAA standard for coding diagnoses Applies to all covered entities 14,025 ICD-9 codes versus 155,000 ICD-10 codes (and growing) Should reduce need for extra documentation Conducive to EHRs Mandated implementation date: 10/01/ ICD-10 Final Rule Issues 106 Single implementation date for all users Date of service for ambulatory and physician reporting Date of discharge for inpatient settings ICD-9-CM codes will not be accepted for services provided on or after October 1, 2014 For covered entities What about non-covered entities? ICD-9-CM claims for services prior to implementation date will continue to flow through systems for a period of time ICD-9 is 30 Years Old ICD- 9 CM in use since WHO developed based on medical knowledge at that time. WHO completed ICD-10 in Countries using ICD-10 UK ( 1995) France (1997) Australia (1998) Germany (200) Canada (2001) Languages >100 Countries ICD Developed almost 30 years ago, ICD-9 is now widely viewed as outdated because of its limited ability to accommodate new procedures and diagnoses. ICD-9 contains only 17,000 codes and is expected to start running out of available codes next year. By contrast, the ICD-10 code sets contain more than 155,000 codes and accommodate a host of new diagnoses and procedures. The additional codes will help to enable the implementation of electronic health records because they will provide more detail in the electronic transactions. This granularity will also help to improve efficiencies by helping to identify specific health conditions such as Methicillin-Resistant Staphylococcus Aureus (MRSA) and other conditions. U.S. Department of Health and Human Services, August 15,

19 ICD-10: The Benefits (MLN Matters SE1019) Much better data needed to: 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 Set health policy Support operational and strategic planning Design health care delivery systems Monitor resource utilization Improve clinical, financial and administrative performance Prevent and detect health care fraud and abuse Track public health and risks 109 Benefits of ICD-10 -CM 110 More detail more specific has 8000 categories, ICD categories and ambiguous. Provides standard coding convention that is flexible for future adaptation of new codes and future clinical protocols Organized- keeps body systems together. Laterality- has codes for Left and Right or the particular organ afflicted. Makes distinctions between ambulatory and managed care encounters. Improved coding for primary care encounters, external causes of injury, mental disorders, neoplasms, and preventive health. ICD-10 Payers Perspective* 111 As described herein, every area within a payor organization will be affected by the adoption of the ICD-10 codes. This is not simply a process of expanding field sizes and reprogramming logic. Business areas will be required to reevaluate their existing policies, procedures and processes. There will be extensive re-writing of reports. Provider contracting and communications with providers and other constituencies will be a significant effort. When all of that effort and the IT work is done, everything will have to be tested both internally and with trading partners to make sure all works as intended. *America s Health Insurance Plans impact report, 05/01/2006 ICD-10 Payers Costs 112 $432,000,000 to $913,000,000 The costs and Benefits of Moving to the ICD-10 Code Sets prepared for the Department of Health and Human Services by Martin Libicki and Irene Brahmakulam of the Rand Corporation (hereafter referred to as the Rand Report Replacing ICD-9-CM with ICD-10-CM and ICD-10-FCS Challenges, Estimated Costs and Potential Benefits prepared for Blue Cross and Blue Shield Association by Robert E. Nolan Company, October 2003 (hereafter referred to the Nolan Report ) ICD-10 WEDI s Perspective October 16, Diagnosis and procedures codes are integral to the treatment and payment process in today s healthcare industry. Although these codes change yearly, the changes are minor in nature to accommodate new medical conditions or treatment procedures. ICD-10, however, is a massive overhaul of the coding scheme and will require field size expansion, change to alphanumeric composition and complete redefinition of code values and their interpretation. In effect, this will be the most significant overhaul of the medical coding system since the advent of computers. A change to ICD-10 will impact providers, payers, software vendors, clearinghouses, laboratories, insured s and potentially many other entities. This paper highlights the considerations that must be taken into account before any new coding standard should be adopted. This paper does not address the impacts of removing local codes, migrating to National ICD-10 Palliative Care Costs 114 Nachimson Advisors estimates the cost-impact of an ICD-10 mandate on three different provider practices: A typical small practice, comprised of three physicians and two administrative staff A typical medium practice, comprised of 10 providers, one full-time coder and six administrative staff A typical large practice, comprised of 100 providers, with 64 coding staff comprised of 10 full-time coders and 54 medical records staff. The Impact of Implementing ICD-10 Oct 8, 2008 Nachimson Advisors 19

20 ICD-10 Providers Costs 115 Total Cost Impact of ICD-10 Mandate on Individual Provider Practices For a typical small practice, Nachimson Advisors estimates the total cost impact of the ICD-10 mandate as $83,290 per small practice For a typical medium practice, Nachimson Advisors estimates the total cost impact of the ICD-10 mandate as $285,195 per practice For a typical large practice, Nachimson Advisors estimates the total cost impact of the ICD-10 mandate as $2.7 million per practice Costs Attributable to Staff/Physician Education and Training Process Analysis Changes to Charge Tickets/Superbills IT System Changes 116 Increased Documentation Costs Cash Flow Disruption The Impact of Implementing ICD-10 Oct 8, 2008 Nachimson Advisors ICD-10 Providers Costs 117 Typical Small Provider Typical Medium Practice Typical Large Practice Education $2,405 $4,745 $46,280 Process Analysts $6,900 $12,000 $48,000 Changes to Charge Tickets $2,985 $9,950 $99,500 IT Costs $7,500 $15,000 $100,000 Increased Documentation Costs $44,000 $178,500 $1,785,000 Cash Flow Disruption $19,500 $65,000 $650,000 ICD-10: What s the big deal? TOTAL $83,290 $285,195 $2,728,780 The Impact of Implementing ICD-10 Oct 8, 2008 Nachimson Advisors Tabular List- chronological list of codes divided into chapters based on body system or condition 119 The ICD-10 CM Tabular List contains categories, subcategories and codes. All codes are alphanumeric All categories are 3 characters Subcategories are either 4 or 5 characters Codes range from 4 to 7 characters. A code that has an applicable 7 th character is invalid without the 7 th character. V and E codes are no longer supplemental classifications V codes replaced by Z codes in Chapter 21 External factors causes of injury found in Chapter 19 and causes of morbidity and mortality in Chapter 20. Full code titles Laterality Left v. Right Structural Differences 120 Combines common associated conditions Clinical concepts that have not been available in ICD-9 20

21 Other Changes 121 Injuries grouped by anatomical site rather than type of injury Certain diseases have been reclassified to different chapters to reflect current medical knowledge New code definitions E.g.: definition of an acute MI is now 4 weeks rather than 8 weeks Codes corresponding to V and E codes are incorporated into the main classification rather than as supplementary classifications Several more Includes New Clinical Concepts 122 T45.526D Under-dosing of antithrombotic drugs, subsequent encounter Z67.40 Type O blood, Rh Positive Y90.6 Blood alcohol level of mg/100mg Some Mapping is Easy 123 Lung cancer Diagnosis ICD-9 ICD-10 Description Heart Failure I50.0 Acute Kidney Failure Intestinal Obstruction N K56.60 Heart Failure, Unspecified Acute Kidney Failure, Unspecified Unspecified Intestinal Obstruction ICD-10 C34.00 Malignant neoplasm of unspecified main bronchus C34.01 Malignant neoplasm of right main bronchus C34.02 Malignant neoplasm of left main bronchus C34.10 Malignant neoplasm of upper lobe, unspecified bronchus or lung C34.11 Malignant neoplasm of upper lobe, right bronchus or lung C34.12 Malignant neoplasm of upper lobe, left bronchus or lung C34.2 Malignant neoplasm of middle lobe, bronchus or lung A 1:11 Ratio C34.30 Malignant neoplasm of lower lobe, unspecified bronchus or lung C34.31 Malignant neoplasm of lower lobe, right bronchus or lung C34.32 Malignant neoplasm of lower lobe, left bronchus or lung C34.80 Malignant neoplasm of overlapping sites of unspecified bronchus and lung C34.90 Malignant neoplasm of unspecified part of unspecified bronchus or lung CHF ICD-10 CHF 126 ICD-9 CHF Just for A 1:12 Ratio Congestive heart failure, unspecified Left heart failure Systolic heart failure, unspecified Acute systolic heart failure Chronic systolic heart failure Acute on chronic systolic heart failure Diastolic heart failure, unspecified Acute diastolic heart failure Chronic diastolic heart failure I50.1 Left ventricular failure 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 (congestive) and diastolic (congestive) heart failure I50.41 Acute combined systolic (congestive) and diastolic (congestive) heart failure I50.42 Chronic combined systolic (congestive) and diastolic (congestive) heart failure I50.43 Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure 21

22 Muscular Dystrophy a 1:1 Crosswalk 127 Chronic Kidney Disease; End Stage 128 ICD-9 ICD-10 ICD-9 ICD Congenital hereditary muscular dystrophy Hereditary progressive muscular dystrophy Myotonic muscular dystrophy G71.2 Congenital myopathies G71.0 Muscular dystrophy G71.11 Myotonic muscular dystrophy End stage renal disease N End stage renal disease Cirrhosis 129 Failure to Thrive 130 ICD-9 ICD-10 ICD-9 ICD Alcoholic cirrhosis of liver Cirrhosis of liver without mention of alcohol K Alcoholic cirrhosis of liver without ascites K70.31 Alcoholic cirrhosis of liver with ascites K74.0 Hepatic fibrosis K74.60 Unspecified cirrhosis of liver K74.69 Other cirrhosis of liver Adult failure to thrive R Adult failure to thrive Code Information: delayed puberty (E30.0) gonadal dysgenesis (Q99.1) hypopituitarism (E23.0) Note: Will this even apply in hospice? Others, not so much Diagnosis ICD-9 ICD-10 Description Cirrhosis of the Liver, NOS Acute Respiratory Failure K74.0 Hepatic Fibrosis - K K J J96.90 Unspecified Cirrhosis of Liver Other Cirrhosis of Liver Acute respiratory failure, unspecified whether hypoxia or hypercapnia Respiratory failure, unspecified, whether with hypoxia or hypercapnia ICD-10 The WJS s Perspective September 13, It s not clear how many klutzes want to notify their insurers that a doctor s visit was a W22.02XA walked into a lamppost, initial encounter (or, for that matter, W22.02XD, walked into a lamppost subsequent encounter ). Why are there codes for injuries received while W61.11XA: A code for injuries related to macaws sewing, ironing, playing a brass instrument, crocheting, doing handcrafts or knitting but not while shopping, wonders Rhonda Buckholtz, who does ICD-10 training for the American Academy of Professional Coders, a credentialing organization. Code V91.07XA, which involved a burn due to water-skis on fire (see codes) is another mystery she ponders: Is it work related? she asks. Is it a trick skier jumping through hoops of fire? How does it happen? 22

23 ICD-10 The WJS s Perspective September 13, Several codes involving drainage devices end in ooz. Then there are two of the codes describing sex-change operations that end in NoK1 and MoJo. You could see it ripple through the room as people said, nookie and mojo! says Kathryn DeVault, who has been teaching ICD-10 classes for the American Health Information Management Association. Was it purposeful? We don t know. No, it wasn t, says the Medicare agency s Ms. Brooks, who says the codes are built according to a consistent pattern in which each digit has a meaning. I couldn t if I wanted to insert a cute message, says Ms. Brooks, who admits that she could be described by Z73.1, Type A behavior pattern (see code). GEM General Equivalence Mappings (GEM) A tool developed to assist with conversion from ICD-9 to ICD-10 Also called a crosswalk, linking important information from one system to the other Found at Or, the AAPC s Code Translator found at: 10/codes/index.asp 134 ICD-10 What it means from an operational perspective Budgeting Resource Books Overtime Education 135 Staff will need to be trained Physicians will need to be trained Software, hardware, form revisions Mapping of old and new codes Doctors: Start now! ICD-10 Things to Think About 136 Will your [billing company] [contracted plans] be ready? Increased denials during learning curve and to-beexpected glitches Need for both ICD-9 and ICD-10 for at least 2 years Working old A/R Process, policy changes EMR templates will need to incorporate these ICD-10 concepts Progress Note templates will need to incorporate these ICD=10 concepts Implementation Effort 137 Enlist staff person (coder, biller, manager) to oversee effort who will be the key point person Prepare information to share with other providers and staff Identify work and scope for implementation Should be a team effort involving staff across departments Team Effort Across Departments 138 Collaboration necessary to identify systems impacted Across clinical, financial and IS areas Include HIM department heads and coders IT Department knows where databases exist, what software is available Administration support will be critical 23

24 Develop a Training Plan Who needs training? Physicians Coders and Billing staff Administrative staff Admissions Managed care authorization staff Clinical staff Required number of hours depends on their role What resources are available? When to start Purchasing materials Coding training 139 Develop a Training Plan Detailed training would have to be provided to specific staff involved in: Documentation of patient activities Coding of medical records and administrative records Information technology Health plan relations Contracts 140 Training* Begin 3 to 6 months prior to implementation Coders 16 hours of training, per AHIMA hours, per AAPC 8 hours Administrative and clinical staff Basics on how to code Where will admissions staff find the needed information? Additional time for physicians Perhaps 12 hours Understanding the codes Without an understanding, they won t know what to document How to document to support the codes 141 Develop a Training Plan Many professional organizations will have several mechanisms for training Distance learning Workshops Conferences Audio Conferences Webinars Books 142 *AHIMA, Rand, Nolan, AHIP Develop a Training Plan Determine if overtime will be necessary during training period What materials will the office need for ongoing support after training? Books Software (code look-up programs) Other? 143 Web Resources General ICD-10 information ICD-10-CM files, information, and General Equivalence Mappings (GEM) between ICD-10-CM and ICD-9-CM CMS Educational Tools American Academy of Professional Coders American Health Information Management Association 24

25 Questions? Jean Acevedo, LHRM, CPC,CHC, CENTC Acevedo Consulting Incorporated Ronald J Crossno, MD FAAHPM Senior National Hospice Medical Director Gentiva Health Services ronald.crossno@gentiva.com 25