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Peggi Ann Amstutz, MBA, CCS, CCS-P
AHIMA Approved ICD-10 CM/PCS TrainerVice President Revenue Cycle & HIM
Confluence Health
ICD-10
RegulationIs the Driver
Customer / Patients
InternalProcesses
Learning &Growth
HIPAA requirement
Documentation Driven
Expanded Reporting
Opportunities
Enhanced Specificity
Price Quality Availability Selection Service Partnership Brand
Organizational Capital
Human Capital
Information Capital
Culture Leadership Alignment Teamwork
ProcessReengineering
TrainingOrganizational
readinessEducation
EHR Systems Interfaces Testing
ReportingAnalytics KPIs Dashboards Public Reporting
Functionality
Operations
PhysiciansNurses
Facility Functions i.e. surgery,
radiology etc
Clinical & Care Management
Clinical InformaticsAmbulatory
Clinical Documentation
Managed Care
Contract AnalysisDRG’s Analysis
Contracts Negotiation
Reimbursements
Compliance
Coding HIM
OperationsPrivacy & Security
Revenue Cycle
BillingRegistrationCharge Data
Master
Proprietary & Confidential
What is the value of ICD-10? The improved clinical detail, better capture of medical technology, up-to-date
terminology, and more flexible structure will result in: Higher quality information for measuring healthcare service quality, safety, and
efficiency Greater coding accuracy and specificity Recognition of advances in clinical practice and technology Improved ability to measure outcomes, efficacy, and costs of new medical technology Enhanced review of medical necessity and fewer claims denials Improved ability to determine disease severity for risk and severity adjustment Global healthcare data comparability Improved ability to track and respond to public health threats Reduced need for manual review of health records to perform research and data
mining and adjudicate reimbursement claims Reduced need for supporting documentations to support information reported on
claims Reduced opportunities for fraud and improved fraud detection capabilities Development of expanded computer-assisted coding technologies that will facilitate
more accurate and efficient coding and alleviate the coder shortage Space to accommodate future code expansion
We are here today because… ICD-10 is only 67 Days away
ICD-10 appears to be happening whether we agree or not
ICD-10 is not just a coder / coding thing
ICD-10 impacts (not a complete list!)
•Scheduling •Policy & Procedures
•Registration •Coding
•Authorization •Billing
•Charge tickets •Reimbursement
•Medical Necessity •Reporting
•Registries •Forms
•Cash Flow •Staff Morale
Scheduling Do we currently use ICD-9 information in any of our
scheduling systems…….
Clinic Visits
OR Scheduling
PT/OT Scheduling
Imaging Scheduling
Cath Lab Scheduling
IR
Why do we ask? Many scripts in scheduling rely on diagnosis
information as they drives the time, equipment, space etc.
Medical Necessity checking for coverage (ABN)
Diagnosis may also direct ‘who’ a patient is scheduled to see
Diagnosis often drives additional work – i.e. a lab test might be needed prior to another service.
Registration & Authorization Insurance says…….
This service is only covered for XX condition
Prior Authorization…..
Some request codes
Some will request additional diagnoses
Who has a cheat sheet for staff?
Is it updated
Do you know where to look?
Health PlanICD10 code/description required on pre-auth requests submitted on or after*1:
ICD10 code/description can
be sent as early as
AsurisL&IRegenceCigna 07-01 07-01First Choice 07-03 07-03CHPW 08-01 08-01GHC 09-01 09-01Aetna 10-01 07-01AIM 10-01 10-01HCA-Medicaid 10-01 10-01Molina 10-01 08-05Premera 10-01 07-01United Health Care 10-01 10-01
Pre-Authorization RequestsDate Required for ICD10 Code/Description
On Pre-Authorization Requests submitted for services scheduled for 10-1-2015 and later …*1 – ICD9 codes/descriptions for services scheduled on & after 10-1 can be used before this date
Charge Tickets All paper tickets rounded up and revised?
What about ‘pre-printed’ orders for Imagining?
What about the lab?
DME
What will you do about the hoarders?
Have you checked to see if ICD-9 codes are ‘hidden’ within order ‘sets’?
Medical Necessity - CMS http://www.cms.gov/medicare-coverage-
database/overview-and-quick-search.aspx?list_type=ncd
Advanced Search: If searching by ICD-10, make sure that the date criteria field indicates a date of service after 10/01/2015 in order to receive valid results.
http://www.cms.gov/medicare-coverage-database/downloads/downloadable-databases.aspx
Medical Necessity - Payers http://www.onehealthport.com/icd10-information-
central
Direct Links to Health Plan ICD-10 Information Referrals
Lists, Clinical Guidelines & Forms!
Crossing the 10/01/2015 Boundary
Claims Processing
Contract Implications
Mapping
Outreach & Testing
Example of what is there… Is your pre-authorization policy AND/OR your
guidelines for requesting pre-authorizations now set for the implementation of ICD-10. If no, how will they change and when will the revised policy/guidelines be published?
Yes, Molina’s prior authorization policies and guidelines are set for the ICD10 implementation. Molina will begin accepting prior authorization requests with ICD9 OR ICD10 codes beginning in August. Only ICD10 codes will be accepted after the compliance date.
Registry and other Reporting Trauma -
http://www.doh.wa.gov/DataandStatisticalReports/InjuryViolenceandPoisoning/TraumaRegistry
Birth Defects – See Attachment
CHARS -http://www.doh.wa.gov/DataandStatisticalReports/HealthcareinWashington/HospitalandPatientData/HospitalDischargeDataCHARS
Notifiable Conditions – See Attachment
The questions to ask…. Have we identified all of our ‘outbound’ reports using
ICD-9 data?
Have we updated/cross walked this data?
Have we tested it up and down stream?
Have we verified our ‘triggers’?
Example, if a physician documents a phrase such as Cleft Palate – do ‘we’ have something automated based on this phrase which pulls the patient information into a report?
CMS developed General Equivalence Maps (GEMs) as interim step http://www.cms.gov/ICD10/11b14_2012_ICD10CM_and_GEMs.asp#TopOfPage
Backward and forward mapping between ICD-9 and ICD-10
Maps are not exact reverse images
Used by all stakeholders to convert: Payment systems
Payment and coverage edits
Risk Adjustment logic
Quality measures
Research applications
GEMs between ICD-9 to ICD-10
ICD-10 Examples Example: Laterality – Left versus Right
C50.1 Malignant neoplasm, of central portion of breast
C50.111 Malignant neoplasm of central portion of right female breast
C50.112 Malignant neoplasm of central portion of left female breast
• Example: Angioplasty
o 1,170 ICD-10-PCS angioplasty codes specifying body part, approach, and
device, including:
047K04Z Dilation of right femoral artery with drug-eluting intraluminal device,
open approach
047K0DZ Dilation of right femoral artery with intraluminal device, open
approach
047K0ZZ Dilation of right femoral artery, open approach
047K24Z Dilation of right femoral artery with drug-eluting intraluminal device,
open endoscopic approach
047K2DZ Dilation of right femoral artery with intraluminal device, open
endoscopic approach
Mapping between ICD-9 to ICD-10 There is no comprehensive map
Many maps have been developed but they are not precise
81.54 TOTAL KNEE REPLACEMENT in ICD-9, in ICD-10 there are 16 valid codes to chose from.
789.09 ABDMNAL PAIN OTH SPCF ST, in ICD-10 it is no longer “other specified” there are numerous codes to chose from to correctly specify
GEM example
Glossary of GEM Terms Approximate flag—attribute in a GEM that when turned on indicates
that the entry is not considered equivalent
No map flag—attribute in a GEM that when turned on indicates that a code in the source system is not linked to any code in the target system
Combination flag—attribute in a GEM that when turned on indicates that more than one code in the target system is required to satisfy the full equivalent meaning of a code in the source system
Scenario—in a combination entry, a collection of codes from the target system containing the necessary codes that when combined as directed will satisfy the equivalent meaning of a code in the source system
Choice list—in a combination entry, a list of one or more codes in the target system from which one code must be chosen to satisfy the equivalent meaning of a code in the source system
Source: Diagnosis Code Set General Equivalent Mapper (National Center for Health Statistics (NCHS))
CrosswalkingIn order to effectively interpret data across periods of time, crosswalks will be needed to associate ICD-10 codes with corresponding ICD-9 codes (and vice versa).
Crosswalks allow the retention of ICD-9 as the base scheme and enable organizations to convert from ICD-10 back to ICD-9, as well as ICD-9 to ICD-10. This helps:
Prevent loss of historical information for comparison and analysis – possibly!
Make accurate claims payments – only where one of the parties is not ready!
Continue fraud and abuse data audits and reviews
Crosswalking (cont.) Dual analysis and reporting systems will have to be
written and maintained for many years
Business analytics will be impacted because of the need to combine historical ICD-9 data with newer ICD-10 data
Major concern here is how to control wide range of reimbursement depending on which ICD-10 code is mapped to which ICD-9 code. This will require policy decisions to be made as part of the planning process.
Reimbursement Maps are a temporary but reliablesolution to map ICD-10 to the “reimbursement equivalent” ICD-9 codes
Used to aid conversion of legacy systems
One to one mapping of “most representative” ICD-9 and ICD-10 codes
Doesn’t account for clusters of ICD-9 codes
ICD-9 to ICD-10
Other places to review & x-walk Coding Summary
These are often exported
Physician Query
These are often tracked and trended
May also have “smart” text or phrases
Physician Attestation
Case Mix Reporting
LOS Reporting
DRG Reporting
About the CDM It contains thousands of individual charges and
procedures across all hospital departments
Each charge code is then associated with a revenue code
Every chargeable item in the hospital must be part of the CDM in order for a hospital to track and bill a patient, payer, or another healthcare provider
CDM includes a unique item number, technical description, CPT/HCPCS/ICD-9PX and revenue codes, the assigned price, and several other elements.
More details A percutaneous transhepatic cholangiogram for biliary drainage with low
osmolar contrast agent and radiological supervision and interpretation (S&I)
The CDM charges would include four separate CPT code components: 47500 – Injection for Percutaneous Transhepatic Cholangiogram 74320 – Cholangiography, Percutaneous transhepatic, S&I 47510 – Intro of Percutaneous Transhepatic catheter for biliary drainage 75980 – Percutaneous transhepatic biliary drainage with contrast monitoring,
S&I
Under ICD-10-PCS, only two codes—with very different descriptions—would be assigned; BF101ZZ – Fluoroscopy of Bile Ducts using Low Osmolar Contrast 0F9930Z – Drainage of Bile Duct, with Drainage Device, Percutaneous approach
The complexities of accurate charging and coding make thorough and precise clinical documentation.
Appreciating the Complexity In ICD-10-PCS, every detail of a surgical procedure must be
documented and coded, making coding exponentially more difficult. Several aspects of ICD-10 introduce additional complexity compared with ICD-9: A multitude of approaches, devices, episodes of care, and
major and minor body systems are all represented as digits within a single ICD-10-PCS code
Surgeries that were grouped together in ICD-9 must be broken out into multiple procedure codes for ICD-10
Outpatient procedure codes and quality indicator reporting will continue to use CPT, while inpatient procedures and all diagnosis codes must be in ICD-10-PCS
In the OR One of the most difficult steps in preparing operating
rooms (ORs) for ICD-10 is readying perioperativeclinical documentation. Assessments, template updates, and education are all required.
OR scheduling personnel depend on physician office staff for information and a complete medical diagnosis prior to surgery. Integrating physician office personnel into ICD-10 education and preparedness is essential to help prevent medical necessity denials and revenue take-backs.
OR Perioperative information systems typically allow each
member of the care team (pre-admission testing, pre-op, nursing, anesthesia, recovery, etc.) to document within the same system.
All perioperative charges must be captured, correlated with chargemasters, and correctly applied to the associated procedure codes.
Additional documentation from the surgical system may be needed across the charge interface and revenue cycle system to create correct “super-bills” under ICD-10.
Hot Spots Blood transfusions. Blood transfusions are essentially organ
transplants, and in ICD-10, the coding of them is far more specific.
Coding for the transfusion of packed red blood cells (PRCs) in ICD-9 is relatively simple: It consists of one code. However, ICD-10 requires that coders specify not only whether the red blood cells transfused were frozen, but also what specific site (peripheral or central vein or artery) and approach was used for the transfusion. Physicians and CDI and coding staff now must consider a total of eight codes for each transfusion event.
And Shifts in DRGs One example is Major Depression. Under ICD-9, the
principal diagnosis of Major Depression, unspecified, groups to MS-DRG 885. Under ICD-10, Major Depression groups to MS-DRG 881, which is a lower-weighted MS-DRG.
Two distinct types of patients—those diagnosed with major depression and those diagnosed with unspecified depression—will be captured with the same ICD-10 code, even though these conditions are different and involve different symptoms.
More Shifts
Discussion – Homework What reports need to be ‘re-done” at your facility?
_____________________________
_____________________________
Is payer testing complete and was it successful?
_____________________________
Chart tickets / Order forms
Reviewed? ____________
Revised? ____________
Distributed? __________
Discussion – Homework What data is sent to others electronically?
_____________________________
_____________________________
Is training complete and was it successful?
_____________________________
Policies
Reviewed? ____________
Revised? ____________
Distributed? __________
Discussion – Homework Back up plan?
_____________________________
_____________________________
Known reimbursement increase / decrease? _____________________________
Cash Flow Forecasted? ____________
DNFB Plan for keeping it low?
Productivity Known drop – what are you doing for backfill?
Thoughts? ___________________________________
___________________________________
___________________________________
The better prepared for the transition and the ‘what ifs’ the better your outcome will be!
Thank you!
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