2014 Webinar Series #4 ICD- 10: What to do with the gi, of.me?

Transcription

1 2014 Webinar Series #4 ICD- 10: What to do with the gi, of.me? May 19,

2 ICD- 10: What to do with the gi, of.me? Denny Flint Complete Prac.ce Resources 2

3 Latest News and View from the Road Latest ICD- 10 project News Another delay Now what? Timeline? CMS estimates a 15 to 18 month project WEDI feedback - Payers will be ready (testing?) No. Carolina Test project worse results than anticipated View from the road The additional delay does a disservice to our doctors Uncertainty, Paralysis, Inactivity What to do? How to begin? Why do we have to do this?!

4 Background Published by WHO in 1992 (CM released 7 years later) HIPAA mandate v.5010 data format change + no new ICD- 9 updates They ve burned the boats! CMS/DHHS blindsided by this third delay

5 Insurance Reimbursement Impact Current Insurance Reimbursement Issues will carry over to ICD- 10 Medical Necessity Denials Value- based reimbursement and PQRS ACO s? Unspeci_ied = Unpaid?

6 Unspecified = Unpaid Physicians may be ICD- 10 compliant, but if they abuse the other or unspeci>ied codes, payment will not occur if a more speci>ic alternative exists. Dennis Winkler Blue Cross Blue Shield of Michigan Director of Technical Program Management Justifying medically necessary procedures and services depends on speci5icity of diagnosis coding!

7 ProducQvity Impact More documentation v. Patient Scheduling Coding Productivity Denied Claims Increase the ripple effect Training Impact on ability to maintain work_low

8 OperaQons Impact EHR pick/problem lists and Superbills Order Entry Pre- Authorization/Pre- Certi_ication Referrals Reporting

9

10 Prevailing Provider AUtudes It s the government either won t happen or it will be delayed again. It s just an IT and a coding issue. What s the big deal? RAC audits, Meaningful Use, ACO s and now ICD- 10? I don t care. I m retiring. We know it s coming, we just don t have a clear sense of what to do or where to begin.

11 The 5 Phases of the ICD- 10 TransiQon 1. Engaging and educating Physicians and Staff 2. Organizing your implementation effort 3. Creating your Timeline and Transition Plan 4. Implementing your Transition Plan 5. Post Transition Analysis and Reporting Each phase is the prerequisite for the next. Most practices are still in Phase 1.

12 Top PrioriQes during the Delay Demystify ICD- 10 and >ind your personal ICD- 10 reality 1. Convert your top 20 codes, identify new documentation elements, 2. Create training tools 3. Conduct simple chart reviews that reveal current documentation shortfalls and adjust your habits 4. Engage your software vendors and payers 5. Test, Test, Test - Internal and External (where possible) 6. Assess ICD- 10 impact on value- based/evidence- based reimbursement models, HCC impact for chronic disease, risk adjusted plans, PCMH and ACO s

13 Clinical Documentation Improvement should be your number one priority during this additional delay (Immediate bene9its!)

14 Reimbursement Paradigm is ShiXing Shifting away from fee- for- service payment Rapid proliferation of dx- based models ACO s, HCC, PCMH, Capitation, Chronic Disease Burden Management Documentation driving speci_icity is key

15 Medicare Risk Adjustment Diagnosis Coding The objective of CMS risk based payment is to calculate and correlate payment levels with member health risk Accurate payments ensure physicians are paid appropriately for services provided Risk adjustment relies on accurate assignment of diagnosis codes Providers must report the diagnosis code to the highest level of speci_icity 15

16 The HCC Model Hierarchy Conditions Categories Also known as Hierarchical Co- existing Conditions More severe or complicated illnesses in a category will trump others Allows CMS to calculate a member s risk score from information received via claim data RAF adjusted score identi_ies member s health status or severity of illness for the current year, as well as the cost of their care Calculation = Advantage Plan payment 16

17 The HCC Model Factors that drive the risk score Most severe manifestation The more severe or complex the diagnosis the higher the value ( risk score ) Similar to RVU concept applied to CPT codes Currently 3,000 diagnosis codes which group into 70 HCC s 17

18 Example of Risk Adjustment 18

19 67 y/o F Patient is seen for six month checkup Documentation states DM and peripheral vascular disease ; (Type II DM without complications (PVD unspeci_ied) If provider had documented PVD due to diabetes ; (Type II DM with peripheral (peripheral angiopathy in other diseases) 19

20 Example of Incorrect Code Assignment Condition ICD- 9 Code CMS Risk Score Demographic Score Type II DM w/ o Complications Total RAF Score Calculation (based on $800) $ PVD unspec Example of Accurate Code Assignment Based on Documentation Condition ICD- 9 Code CMS Risk Score Demographic Score Type II DM w/ peripheral Peripheral Angiopathy Total RAF Score Calculation (based on $800) $

21 Chronic Disease - Data Capture Document and report at least once per calendar year (MEAT): Chronic conditions (CHF,COPD,DM) Active status conditions (amputations, colostomy) Pertinent past conditions (previous MI) All conditions requiring medication (A- _ib) Conditions that affect the patient s day- to- day life 21

22 COPD 496 COPD CHF Top Ten HCC Groups Asthma w/chronic COPD (Chronic Obstructive Asthma) Chronic Bronchitis Emphysema CHF Primary Cardiomyopathy (Ischemic is not an HCC) Hypertensive Heart Disease w/heart failure Vascular Disease Peripheral Vascular Disease PVD in other diseases (diabetes) Acute DVT Atherosclerosis of Aorta Abdominal Aortic Aneurysm 22

23 Cancer All malignant neoplasms including Melanoma but not skin cancer All secondary malignant neoplasms - highest HCC if site is documented Ischemic Heart Disease Unstable Angina Speci5ied Heart Arrhythmia Complete AV block Atrial Fibrillation Sick Sinus Syndrome Diabetes All diabetes (250.XX) and most of the manifestations 23

24 Ischemic or Unspeci5ied Stroke 436 CVA Unspeci_ied cerebral artery occlusion, w/infarction Angina/Old MI Angina 412 Old MI Rheumatoid Arthritis & In5lammatory Connective Tissue Disease Rheumatoid Arthritis SLE 725 Polymyalgia Rheumatica Sacroiliitis 24

25 Sample ICD-9 Quick Code HCC Codes in BOLD 25

26 HCC Data Capture and ICD- 10 The conversion from ICD- 9 to ICD- 10 will provide better quality data 14,000 ICD- 9 codes will increase to 69,000 ICD- 10 codes Quantity of HCC data will increase; one ICD- 9 code may crosswalk to several ICD- 10 codes For example, Rheumatoid Arthritis (ICD ) crosswalks to 20 ICD- 10 codes (M05.40 M05.471) For calendar year 2015 which set of codes to use or both? 26

27 Clinical DocumentaQon Improvement Identify and begin utilizing HCC Codes appropriate for your specialty Create a strategy in your practice for reporting any additional chronic diseases that you must consider when treating your patients Conduct chart reviews to identify your ICD- 9 diagnosis coding documentation de_iciencies. Use the same chart reviews to identify your ICD- 10 diagnosis coding documentation de_iciencies 27

28 Clinical DocumentaQon Improvement Identify increased ICD- 10 documentation requirements and create a plan for learning to use them Documentation for ICD- 10 is relatively simple It improves ICD- 9 documentation and coding It s bene_icial in the move to DBR It will make the transition to ICD- 10 far easier and less impactful when it does happen Engage in specialty speci_ic CDI education for DX coding guidelines 28

29 Providers hold the key to ICD- 10 success and the key to their own data- driven survival Without you, all project efforts are fruitless Documentation is the cornerstone Your future _inancial health depends on it Jerry McGuire approach

30 The Bo^om Line Don t squander the gift of time CDI and physician engagement - #1 Vendor templates and testing Fee for service is dying DATA is KING! 30

31 Ques.ons Denny Flint

32 Next Steps Today s recording posted by 5/23/

33 * Working for you!