Keeping ICD-10 Relevant Amidst Change RVHIMA April 10, 2015 John Stearman, RHIA, MS Ellen Arnold, RHIA
John Overview Why do I care? How Congress works How a federal bill becomes law How ICD10 was derailed last year How everyone can be involved in the process Keeping an eye on Congress Influencing your leaders
Why do I care? ICD-9 is a 1974 Ford Pinto in a Ferrari world We as individuals and collectively as HIM professionals can influence the process. Time, money, effort, and most importantly - our sanity is at risk.
How a federal bill becomes law aka Welcome back to high school civics Creating bills is the job of the House of Representatives Once the bill passes the House it then goes to the Senate If the bill passes the Senate, it then goes to the president for signature If all the above happens successfully the bill becomes law http://kids.clerk.house.gov/grade-school/lesson.html?intid=17
Vetoes Throwing a Wrench in the Process Over-riding a veto Presidential pocket veto Riders How ICD-10 got derailed last time H.R. 4302 Protecting Access to Medicare Act of 2014 The ICD10 part was a rider passed the Senate 03/31/2014 and was signed into law by the president the next day
Throwing a Wrench in the Process - continued There was speculation killing ICD-10 would be tacked onto the spending bill to keep the Federal government moving in December 2014 it did not The bill left the House and was confirmed by the Senate
Influencing the Process All of us have the right / obligation to influence bills How? VOTE! Contact your Representatives John Yarmuth Contact your Senator Mitch McConnell Senate Majority Leader Rand Paul running for President Phone calls, emails, snail-mail letters
Influencing the Process - continued Lobbyists Party Politics Mailing lists For example, Meaningful Use Stage 3 Proposed rule is announced comment period The Federal Register If we don t make ourselves heard we get what we get!
Useful Websites Who is my Congressman? http://www.contactingthecongress.org/ What is going on with a bill? https://www.govtrack.us/ The Federal Register https://www.federalregister.gov/
Where Do We Stand Now? T 6 Months and Counting
WEDI ICD-10 Readiness Survey Results WEDI ICD-10 Readiness Survey conducted in February 2015 1,174 participants Healthcare providers Vendors Health Plans Conclusions ICD-10 readiness is not what it should be Healthcare organizations were wary to put resources into ICD-10 preparation There are concerns that the ICD-10 deadline would be delayed again Although the latest delay was meant to give more time to prepare for ICD-10 implementation not enough healthcare organizations took advantage of the time
WEDI ICD-10 Readiness Survey Results Healthcare Providers 1/3 of healthcare providers report completion of ICD-10 impact assessments Hospital systems were ahead of physicians by a margin of 3 to 1 50% of hospitals report external testing has started 10% of physician practices report external testing has started 25% plan to start external testing in second or third quarter of 2015 Vendors All have started product development Only 60% were ready and available for testing This is down from the same survey conducted in August, 2014 Health Plans Progress on finishing their impact assessments 50% report external testing has begun 25% plan to test with most of their healthcare providers 60% plan to just test with a sample of healthcare providers 10% plan to test with just clearinghouses
Priorities Planning Testing and resources needs Dual Coding plan Payer testing Coder review and training Education and communication System remediation and testing Post Implementation and follow up
Where Do We Stand Now? Education
Coder Education Coder retention of ICD-10 knowledge Evaluate current coder knowledge and capabilities Coders trained to meet the previous 10/1/2014 ICD-10 deadline may have forgotten much of what they learned Keep coders engaged with ICD-10 as much as possible Refresher courses (online, instructor led) Boot camps Dual coding
Coder Education Dual coding strategy Ongoing practice and feedback is essential If unable to implement dual coding other avenues for practice must be explored Metrics gathered during the dual coding process have multiple benefits An estimate of the amount of productivity loss from the ICD-10 implementation An estimate of the areas of concern with regard to clinical documentation An estimate of potential revenue loss DRG Shift gains and losses Productivity loss = increase in AR days
Coder Education Dual coding strategy questions to answer What is the impact that a diagnosis like hypertension will have on DRGs and CMI after 10/1/2015? Which medical records are un-codable in ICD-10 today without some form of query or other intervention? How are common CCs and MCCs that were applied in ICD-9 not applicable in ICD-10 causing a DRG shift? How many coders and CDI specialists will be needed to deal with increased numbers of queries, concurrent or retrospective, for ICD-10 documentation issues? Will CMI go up, down, or remain the same when ICD-10 is implemented?
Coder Education Dual coding strategy What approach works best for your organization? Create a workflow diagram of how the process will work What are your feedback mechanisms? Communication is key Regular meetings for coders to discuss issues Coding staff will need to be supplemented
Physician/Provider Education ICD-10 is really a clinical documentation improvement initiative Active, committed physician participation, starting with the chief medical officer (CMO) and chief medical informatics officer (CMIO) is critical to the success of every ICD-10 implementation project Resistance from physicians makes progress in the ICD-10 implementation slow and painful
Physician/Provider Education Why are physicians so resistant? Healthcare industry interest groups have generated mixed messages about the value of ICD-10 if its so important why all the delays? Physicians aren t convinced that ICD-10 offers any value in making improvements to treating patients Physicians seem to hear only a narrowly focused message about coding Its just for billing
Physician/Provider Education How do we manage this change? Strong executive support is essential Identify a committed, influential physician who will enthusiastically help sponsor the ICD-10 conversion effort Consider how to make ICD-10 assistance part of a larger physician engagement strategy Offer physician education online, peer-to-peer/elbow-to-elbow, specialty specific Work with office staff and educate them as well Incorporate ICD-10 into the clinical documentation improvement (CDI) process Focus on the pros and outlaw the cons
Physician/Provider Education Greater documentation specificity requirements Communicate and direct providers to education venues Provide tools to make the transitions Extensive online education programs that offer CMEs Documentation tip sheets/tent cards Laminated pocket cards Communicate new specificity required for top diagnoses and procedures Offer specialty specific education tracks
Physician/Provider Education Best avenues of communication? Tap into existing meetings Physician leadership meetings Standing department meetings Online through existing physician communication avenues CDI Queries Coder Queries
Physician/Provider Education Some things to keep in mind Physician productivity, just like coder productivity, will drop Update documentation templates to support greater specificity Physicians and other providers using an online tool to assign ICD-10 codes may not be offered the best code in the top five to 10 codes that are displayed It takes time to look through potentially hundreds of codes to find the best fit Order placement for ICD-10 compliant orders
Other Areas Where Education is Necessary Define the lifecycle of a diagnosis and/or procedure code Patient Access Scheduling Verification Advance Beneficiary Notification CDI Coordinators EMR Team Patient Financial Services
Where Do We Stand Now? Systems Remediation and Testing
Testing Resources Testing is a team effort IT Patient Access E.M.R. Team HIM/CDI Patient Financial Services
What To Test
Systems Remediation and Testing
Are Your Systems Really Ready? An integrated test system must be in place so that all ICD-10 affected applications can be tested in tandem All ICD-10 affected IT applications must be at keystone release The release that will be supported by the vendor going forward (this is not necessarily the first ICD-10 compliant release) Be sure that a current test set of ICD-10 codes has been loaded into each application s test system Be sure that application analysts are aware of the parameters that must be set up with correct dates for ICD-10 testing Have a clear plan for identifying problems and retesting
Parting Words Things to Keep in Mind
Things to Keep in Mind During the Transition Even if all your systems are tested and ready, it will take vendors just as much time to release the regulatory changes for Fiscal Year 2016 as it does every year General timeline - regulatory updates go out to customers in mid to late September All updates must then be applied to all affected applications and retested This rarely if ever happens by October 1 st Productivity in all areas will decrease so be prepared and staff up AR days will increase Bill to payment days will increase so be prepared Insurance companies may say they re ready for ICD-10 but a large number of them will be mapping your ICD-10 codes back to some version of ICD-9
According to CMS Conversion Project Results Slightly more than 99% of the cases showed no change in MS-DRG when coded in ICD-10 Of the 1% of the cases with MS-DRG shifts, 45% of those shifted to higher weight MS-DRGs and 55% shifted to lower weight MS-DRGs The aggregate weight change of the 6 cases that shifted to higher weight MS-DRGs was 0.10% (one tenth of one percent or an approximate increase of 1/1000th of the ICD-9 reimbursement) The aggregate weight change of the cases that shifted to lower weight MS- DRGs was -0.14% (an approximate reduction of 14/10,000th of the ICD-9 reimbursement) The net weight change of all MS-DRG shifts in the analysis was -0.04% (4 one-hundredths of a percent, or an approximate reduction of 4/10,000th of the ICD-9 reimbursement) This is equivalent to a loss of four pennies (.04) per $100 paid under ICD-9 That s $99.96 to every $100.00 earned today
According to CMS Conversion Project Results Top 10 DRG Shifts 1. MS-DRG 812, Red blood cell disorders w/o MCC - HIGHER 2. MS-DRG 981, Extensive O.R. procedure unrelated to principal diagnosis w/mcc LOWER 3. MS-DRG 391, Esophagitis, gastroent & misc digest disorders w MCC LOWER 4. MS-DRG 885, Psychoses LOWER 5. MS-DRG 066, Intracranial hemorrhage or cerebral infarction w/o CC/MCC HIGHER 6. MS-DRG 191, Chronic obstructive pulmonary disease with CC LOWER 7. MS-DRG 011, Tracheostomy for face, mouth and neck diagnoses with MCC - HIGHER 8. MS-DRG 974, HIV with major related condition and MCC - LOWER 9. MS-DRG 292, Heart failure and shock with CC - LOWER 10. MS-DRG 037, Extracranial procedures with MCC - LOWER
Remember, there is an ICD-10 code for nearly everything www.youtube.com/watch?v=htq6gw31p3e
Remember, there is an ICD-10 code for nearly everything X61.112 Fall Into Grave, Vacated Likely by Zombie See Injury by Zombie (ZA0-ZA5) if Zombie was encountered and secondary injury occurred ICD-10-CM FY2015 Version Draft Exposure to Paranormal Forces