ACO Lunch & Learn ICD 10.Are you ready? March 18, 2015
ACO Announcements GPRO CMS reviews have come to a close! Reminders: ACO Notifications PQRS
ICD-10-CM The importance of complete and accurate documentation Presented by Laurel Kropski CMBS, CPC-A Accessium Billing & Consulting, Inc 2821 Wehrle Dr Ste 12 Williamsville, NY 14221
So why is documentation important? Supports proper payment and reduces denials Ensures accurate measures of quality and efficiency Ensures accountability and transparency Captures levels of risk and severity Supports clinical research and public health reporting Enhances communication and enables significant improvements in care management
Importance of Documentation (cont.) Clinical modifications to ICD-10 offer a higher level of specificity by including separate codes for laterality and additional characters/extensions for expanded detail. Other changes include combining etiology and manifestations, poisoning and external cause, or diagnosis and symptoms into a single code. ICD-10-CM codes will reveal more about quality of care so that data can be used to better understand complications, design clinical process, and better track the outcomes of care.
More Documentation Details To reflect current medical knowledge, certain diseases have been reclassified/reassigned to a more appropriate chapter. In contrast to ICD-9-CM which classifies injuries by type, ICD-10-CM groups injuries first by specific site (head, arm, leg) and then by type of injury (fracture, open wound, etc.) Timeframe is also important to record for all injuries or onset of symptoms. E.g.. Trimester information in pregnancy codes, initial, subsequent or sequelae encounters
Changes in the number of codes ICD-9 vs ICD-10 Clinical area ICD-9 Codes ICD-10 Codes Fractures 747 17099 Poisoning & toxic effects 244 4662 Brain injury 292 574 Diabetes 69 239 Bleeding disorders 26 29 Hypertensive disease 33 14 End-stage renal disease 11 5
ICD-9-CM vs ICD-10-CM ICD-9-CM ICD-10-CM 3-5 digits 3-7 digits 1st digit is numeric (chapters 1-17) or alpha (E or V) (supplemental chapters) 1st digit is alpha (all letters except U) 2nd, 3rd, 4th and 5th digits are numeric 2nd and 3rd digits are numeric; 4th, 5th, 6th and 7th digits can be alpha or numeric Decimal after first 3 characters Decimal after first 3 characters
Coding Examples ICD-9-CM Diabetes Mellitus ICD-10-CM 250.00 Diabetes Mellitus E11 Type II Diabetes E11.3 Type II DM with ophthalmic complications E11.31 Type II DM with unspecified diabetic retinopathy Additionally, if the patient is insulin dependent requires specificity E11.311 Z79.4 Type II DM with unspecified diabetic retinopathy with macular edema Long-term (current) use of insulin
Coding Examples ICD-9-CM Obesity, morbid ICD-10-CM 278.01 Obesity, morbid E66.9 E66.01 Obesity, unspecified Obesity, morbid (severe) due to excess calories E66.2 Obesity, morbid with alveolar hypoventilation Additionally, the BMI requires specificity E66.01 Obesity, morbid with alveolar hypoventilation due to excess calories Z68.4 Body mass index 40 or greater, adult
Coding Examples ICD-9-CM Fracture ICD-10-CM 813.22 Fracture of Upper End of ulna, closed shaft S52.242 D Displaced spiral fracture of shaft of ulna, left arm, subsequent encounter for closed fracture with routine healing. ** 7 th character is the extension for type of encounter A-initial encounter, D- subsequent encounter or S-sequelae
Helpful tool to help transition from one code to another CMS has created a mapping between ICD-9-CM and ICD-10-CM known as the road to 10 which can be found on the following website: http://www.roadto10.org
HCC Coding & 2015 Insurance Initiatives What is the purpose? How can this benefit your practice? Tami Kaczmarek, CPC, CMOM, CBO & Partner Accessium Billing & Consulting, Inc 2821 Wehrle Drive Suite 12 Williamsville, NY 14221 716-262-8663
HCC Coding (Hierarchical Condition Categories) Medicare implemented an HCC model in 2004 Last couple of years -CMP has worked with practices to improve coding accuracy, provided patient reports for audits and tip sheets for reference CMS measures the disease burden to determine appropriate Health Risk Scores, coding correctly can increase the payment to Medicare Advantage plans by more than 2-3 times the amount Precise diagnostic coding is necessary to capture the complexity of the patient population you serve. Accessium Billing & Consulting, Inc
HCC scores must be captured every year for CMS to reimburse plans for those higher, more complex patients. Appropriate Health Risk Scores = more money to take care of the patient Average 65+ patient = 250.01 DM I w/o Complications =$10,000 verses More accurate coding = 250.60 DM w/complications; 2078.01 Morbid Obesity, 585.X Chronic Kidney Disease (X stage) = $25,000 Health insurance costs for your employees: Monthly premium $430.00 = $5,160.00 Deductible = $1,000.00 Total out of pocket (employee/employer) - before the insurance contributes any amount toward claims - $6,160.00 Accessium Billing & Consulting, Inc
What is the Benefit to you. Medicare Managed Patient Medicare provides more funding to the managed plans to manage those patients based on their complexity (yearly audits looking through the patients chart to identify additional diagnosis codes by your or other providers that have not been included on claims.) Additional submission of diagnosis codes submitting CPT code 99080 ACO (Medicare FFS) our organization would have more funding toward the budget which is based on how sick our patient population is. This allows a greater margin for improving expenses. Shared Savings Model 1. High clinical quality measures this is the easy part 2. Reduce expenses more difficult (If we have more money allocated to our budget based on the complexity of our patients (driven by appropriate HCC codes) it is easier to have a higher quantity of dollars saved in expenses) Consider this thought in your Business Model Your coding and documentation not only effects your reimbursement per patient visit but also ensures accurate calculation of current and future CMP incentives that will be distributed to you. Accessium Billing & Consulting, Inc
IHA Enhanced Visit 1. Annual Preventative Visit Document standard visit elements: vital signs, interval history, past history, family history, medication reconciliation, review of systems, physical exam, update medications, problem and health Maintenance list, impression/assessment, plan and counseling of patient, Document the status of each and every medical condition, including goals for treatment and management plan for each active problems, update problem list, discuss any changes you might recommend in specialty physician referrals, note games in care 2. Annual Wellness Visit Document patient s medical, surgical and family histories, depression screening, functional ability and safety, list of current providers, cognitive function assessment and many duplications from the annual preventative visit criteria 3. Health Risk Assessment (provided by IHA) Review the patient s HRA and make it part of the chart, document discussions related to issues noted by patient Fax provider documentation and HRA to IHA QM Department This is an opportunity to increase (more than double) your revenue based on services that your practice already provides to your patients. Accessium Billing & Consulting, Inc
Blue Cross Blue Shield Vatica tool Claims data dump to the Vatica tool allowing the provider to have a full picture of the patient health Provides a history of diagnosis codes used by all provides The tool provides testing and procedure notifications that are due Accessium Billing & Consulting, Inc
Revenue opportunities IHA G8496 Enhanced visit (Preventative & Annual Wellness Visit) $ 300.00 BCBS - This tool will also notify you if the patient is due for any addition tests, procedures etc. which would be billed in addition to the below CPT codes G0439 (Annual Wellness Visit) $ 200.00 Modifier GC = incentive for using the Vatica tool $ 150.00 99397 Preventative $ 50.00 --------------------------------------------- Total reimbursement $ 400.00 If you choose to only provide the Annual Wellness Visit utilizing the Vatica tool on one date of service and schedule the Preventative Visit on another day, you will receive the full reimbursement of $ 135.47 for the 99397 which will then be a total revenue amount of $ 485.47 for these services. Accessium Billing & Consulting, Inc
Thank You
Announcements Next ACO Lunch & Learn 4/15/2015. Improving Patient Experiences Reminders: ACO Notifications, PQRS Sheree M Arnold ACO Clinical Transformation Specialist sarnold@chsbuffalo.org (716)862-2453