Embed Size (px)
Citation preview
Page 1May 8, 2015
Prepared for GAHIMA
ICD-10 Effect on Alternative Payment Models
GAHIMAMay 8, 2015
Carine Leslie, RHIA, CCS, AHIMA-Approved ICD-10-CM/PCS Trainer
Kim Walker, CPC, CPMA, CCVTC, AHIMA-Approved ICD-10-CM Trainer
Page 2May 8, 2015
Prepared for GAHIMA
Learning Objectives• ICD-10 Update• ICD-10 Value in the World of New Payment
Models
– Patient Safety Indicator (PSI)– Hierarchical Condition Category (HCC)
• Mitigating ICD-10 Risk Through Physician Education
Page 3May 8, 2015
Prepared for GAHIMA
ICD-10 UpdateIn 2014, a last minute ICD-10 delay was slipped into SGR legislation that put off implementation of the new code set until October 1, 2015.
On late Tuesday, April 14, 2015, the Senate voted 92-8 to repeal the sustainable growth rate (“SGR”) formula that adjusts Medicare payments to physicians, legislation that has taken over a decade to pass. The bill, HR 2, the Medicare Access and CHIP Reauthorization Act, did not include any references to ICD-10 implementation or an ICD-10 delay.
Page 4May 8, 2015
Prepared for GAHIMA
Quality vs. Quantity• Value-based compensation• Healthcare is shifting from FFS model to pay-
for-performance methods• Payers will reward value and care
coordination, rather than volume and duplication
• HHS testing and expanding new health care payment models
Page 5May 8, 2015
Prepared for GAHIMA
Quality vs. Quantity (con’t.)• Pay-for-Performance
– Value-based purchasing, trends in quality measures and performance-based payment will continue to have a considerable impact on the healthcare delivery system. Changing the definition of the measures to be consistent with ICD-10 will considerably impact reporting of quality measures
– Inaccurate coding or changes in code-based measures under ICD-10 may make it difficult to achieve performance-based payment goals
• Capitation (Risk Adjustment)– Physician participation in Capitation (risk adjusted or condition
related) payment models could result in direct impacts to payment with the implementation of ICD-10
Page 6May 8, 2015
Prepared for GAHIMA
ICD-10 Value in the World of New Payment Models
Page 7May 8, 2015
Prepared for GAHIMA
Value-Based Purchasing and ICD-10 Coding
Patient Safety Indicator 3 – Pressure Ulcer RateICD-9-CM• 707.00 – 707.09: Pressure ulcer• 707.23 – 707.25: Pressure ulcer, stage III to un-stageable
ICD-10-CM • Due to the granularity of ICD-10-CM code set, the codes combined two
conditions: pressure ulcer and stage
Page 8May 8, 2015
Prepared for GAHIMA
Value-Based Purchasing and ICD-10 Coding (con’t)
Patient Safety Indicator 11 – Postoperative Respiratory Failure RateICD-9-CM• 518.51: Acute respiratory failure following trauma and surgery• 518.53: Acute and chronic respiratory failure following trauma and
surgery
ICD-10-CM • J95.821: Acute post-procedural respiratory failure• J95.822: Acute and chronic post-procedural respiratory failure
Page 9May 8, 2015
Prepared for GAHIMA
Value-Based Purchasing and ICD-10 Coding (con’t)
Patient Safety Indicator 11 – Postoperative Respiratory Failure RateICD-9-CM• 96.04: Insertion of endotracheal tube
ICD-10-CM • 0BH17EZ: Insertion of endotracheal airway
into trachea, via natural or artificial opening• 0BH18EZ: Insertion of endotracheal airway
into trachea, via natural or artificial opening endoscopic
Page 10May 8, 2015
Prepared for GAHIMA
Patient Safety Indicator 11 – Postoperative Respiratory Failure RateICD-9-CM• 96.70: Continuous invasive mechanical ventilation of unspecified duration• 96.71: Continuous invasive mechanical ventilation for less than 96 consecutive
hours• 96.72: Continuous invasive mechanical ventilation for 96 consecutive hours or
more
ICD-10-CM • 5A1935Z: Respiratory Ventilation, Less than 24 Consecutive Hours• 5A1945Z: Respiratory Ventilation, 24-96 Consecutive Hours• 5A1955Z: Respiratory Ventilation, Greater than 96 Consecutive Hours
Value-Based Purchasing and ICD-10 Coding (con’t)
Page 11May 8, 2015
Prepared for GAHIMA
Patient Safety Indicator 15 – Accidental Puncture or Laceration RateICD-9-CM• 998.2: Accidental puncture or laceration during a procedure, not elsewhere
classified
ICD-10-CM (Classified by affected body part)• D78.11: Accidental puncture and laceration of the spleen during a procedure on
the spleen• D78.12: Accidental puncture and laceration of the spleen during other procedure • E36.11: Accidental puncture and laceration of an endocrine system organ or
structure during an endocrine system procedure• E36.12: Accidental puncture and laceration of an endocrine system organ or
structure during other procedure
Value-Based Purchasing and ICD-10 Coding (con’t)
Page 12May 8, 2015
Prepared for GAHIMA
Risk Adjustment Models• Diagnosis based program
risk adjustment examples:– Chronic Illness and Disability
Payment Systems (“CDPS”) – Medicaid
– Hierarchical Co-Existing Conditions (“HCC-C”) – Medicare
– Diagnosis Related Groups (“DRG”) – Inpatient
– Adjusted Clinical Groups (“ACG”) – Outpatient
• Prescription based program risk adjustment examples:– MedicaidRx (“UCSD”)
– RxGroups (“DxCG”)
– Hierarchical Co-Existing Conditions (“HCC-D”)
Page 13May 8, 2015
Prepared for GAHIMA
What is HCC?• Initially, introduced by Centers for Medicare and Medicaid Services
(“CMS”) in 2004
• HCCs represent categories of health conditions, both chronic and acute, used to adjust payments to Medicare Advantage (MA) (Part C), health care plans and project healthcare costs for MA beneficiaries coming for an upcoming coverage period. The diagnosis codes are mapped to HCCs for conditions such as diabetes, congestive heart failure, etc.
• Accurate coding is the primary means to ensure accurate payments for the health plan and the participating providers
Page 14May 8, 2015
Prepared for GAHIMA
What is HCC? (con’t)• ICD-10, with its greatly expanded range of codes, will require careful
assignment in order to appropriately tie reimbursement to a patient’s medical condition
• Physician practices utilizing risk adjustment reimbursement will experience considerable impact because reimbursement funds will be defined differently in ICD-10. However, ICD-10 will provide better insight into patient risk and severity over time, if the provider is able to capture accurate ICD-10 data
Page 15May 8, 2015
Prepared for GAHIMA
HCC and ICD-10 Updates• Over 3,500 ICD-9-CM codes map to HCCs• On February 24, 2014, CMS posted a preliminary
ICD-10 HCC crosswalk– Approximately 10,100 diagnosis codes have been
identified as appropriate for Medicare risk adjustment, and are mapped to the various HCC models
• In April 2015, CMS is expected to release updated ICD-10 mappings that will go into effect on October 1, 2015
Page 16May 8, 2015
Prepared for GAHIMA
Physician Office ICD-10 HCC Coding and Documentation
• 250.40: Diabetes mellitus with renal manifestations, type II or unspecified type, not stated as uncontrolled
– V21 HCC 15; V22 HCC 18• 583.81: Nephritis and nephropathy in
diseases classified elsewhere (manifestation)
– V21 HCC 132; V22 HCC 0• 250.60: Diabetes mellitus with neurologic
manifestations, type II or unspecified type, not stated as uncontrolled
– V21 HCC 16; V22 HCC 18
• 357.2: Polyneuropathy in diabetes
(manifestation)– V21 HCC 71; 2014 HCC 18
• 250.70: Diabetes mellitus with peripheral circulatory disorder, type II or unspecified type, not stated as uncontrolled
– V21 HCC 15; V22 HCC 18
• 443.81: Peripheral angiopathy in diseases classified elsewhere (manifestation)
– V21 HCC 105; V22 HCC 108
The patient presented for follow-up of labs. The physician office note documents patient presented with diabetes mellitus type 2 with diabetic nephropathy, diabetes mellitus type 2 with diabetic polyneuropathy, diabetes mellitus type 2 with angiopathy.
In ICD-9-CM:
Page 17May 8, 2015
Prepared for GAHIMA
In ICD-10-CM:• E11.21: Type 2 diabetes mellitus with diabetic nephropathy
– V21 HCC 18; V22 HCC 18– V21 HCC 141
• E11.42: Type 2 diabetes mellitus with diabetic polyneuropathy– V21 HCC 18; V22 HCC 18– V21 75
• E11.51: Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene– V21 HCC 18; V22 HCC 18– V21 HCC 108; V22 HCC 108
Physician Office ICD-10 HCC Coding and Documentation (con’t)
Page 18May 8, 2015
Prepared for GAHIMA
Case Study: HCC Comparison
ICD-9 ICD-10
V21 HCC 15; V22 HCC 18 V21 HCC 18; V22 HCC 18
V21 HCC 132; V22 HCC 0 V21 HCC 141
V21 HCC 16; V22 HCC 18 V21 HCC 18; V22 HCC 18
V21 HCC 71; 2014 HCC 18 V21 75
V21 HCC 15; V22 HCC 18 V21 HCC 18; V22 HCC 18
V21 HCC 105; V22 HCC 108 V21 HCC 108; V22 HCC 108
The patient presented for follow-up of labs. The physician office note documents patient presented with diabetes mellitus type 2 with diabetic nephropathy, diabetes mellitus type 2 with diabetic polyneuropathy, diabetes mellitus type 2 with angiopathy.
Page 19May 8, 2015
Prepared for GAHIMA
Physician Office ICD-10 HCC Coding and Documentation
The patient presented for follow-up. The physician office note documents paroxysmal atrial tachycardia, peripheral vascular disease, and chronic bronchitis.
In ICD-9-CM:• 427.0: Paroxysmal supraventricular tachycardia
– V21 HCC 92; V22 HCC 96
• 443.9: Peripheral vascular disease, unspecified– V21 HCC 105; V22 HCC 108
• 491.9: Unspecified chronic bronchitis– V21 HCC 108; V22 HCC 111
Page 20May 8, 2015
Prepared for GAHIMA
Physician Office ICD-10 HCC Coding and Documentation (con’t)
In ICD-10-CM:• I47.1 Supraventricular tachycardia
– V21 HCC 96; V22 HCC 96
• I73.9 Peripheral vascular disease, unspecified– V21 HCC 108; V22 HCC 108
• J42 Unspecified chronic bronchitis– V21 HCC 111; V22 HCC 111
Page 21May 8, 2015
Prepared for GAHIMA
Case Study: HCC Comparison
ICD-9 ICD-10
V21 HCC 92; V22 HCC 96 V21 HCC 96; V22 HCC 96
V21 HCC 105; V22 HCC 108 V21 HCC 108; V22 HCC 108
V21 HCC 108; V22 HCC 111 V21 HCC 111; V22 HCC 111
The patient presented for follow-up. The physician office note documents paroxysmal atrial tachycardia, peripheral vascular disease, and chronic bronchitis.
Page 22May 8, 2015
Prepared for GAHIMA
Demand for Quality Documentation• Quality documentation promotes the ability to accurately capture the
acuity and severity for several healthcare initiatives:– Quality measures
– Reimbursement
– Risk adjustment profiles
– Provider performance profiles
• If encounters do not describe the conditions of its Medicare and/or Medicare Advantage members completely and accurately, there is the potential for a negative impact to reimbursement or a compliance related risk of overpayment
Page 23May 8, 2015
Prepared for GAHIMA
Mitigating ICD-10 Risk Through Physician Education
Page 24May 8, 2015
Prepared for GAHIMA
ICD-10 Transitions, Unless You Have Been Hiding…
• Many have completed their readiness assessment
• Identified ICD-10 leadership team and ICD-10 workgroups
• Planned coder, documentation specialist and other staff education
• Identified necessary IT infrastructure requirements
• Reviewed all internal processes where ICD-9-CM codes will be impacted by ICD-10 transition
Page 25May 8, 2015
Prepared for GAHIMA
Risk: Physician Documentation Education• Physician documentation behavior will not be specific
enough for ICD-10
– Unable to complete orders such as labs and diagnostic testing, if correct codes can’t be determined
– Coders are unable to complete coding of charts resulting in an increase in physician queries
• Higher scrutiny into ICD-10 coding from payers that have had to implement ICD-10 and whose intent is to curb improper payments
Page 26May 8, 2015
Prepared for GAHIMA
Risk: Physician Documentation Education (con’t)
• Claim denials will not strictly be a matter of clarification that can be handled by a nonclinical person in the billing office
• Denials will raise questions about medical necessity or the clarity of medical documentation supporting a code
Page 27May 8, 2015
Prepared for GAHIMA
What’s The Fix?• Ensuring clinical documentation contains accurate and
detailed information to assign the correct codes
• Making sure that that every code is justified by the data in the health record
• Physicians can modify their documentation behavior now, with the added benefit of improvement in ICD-9 coding
• Doing this well will not only ensure you are receiving accurate reimbursement for the care provided but also that your practice will avoid unnecessary penalties when an outside auditor wants to take a look
Page 28May 8, 2015
Prepared for GAHIMA
Priority Issues • Providers must understand the relationship between ICD-9
diagnosis and CPT codes
• Providers must know causes of payment denials
• Overcome intimidation - ICD-10 is “do-able” and makes sense
• Discharge the notion that Electronic Medical Records (“EMRs”) are the “magic bullet”
Page 29May 8, 2015
Prepared for GAHIMA
ICD-10 Readiness Testimony• Dr. William Terry, American
Urologic Association cited an AMA study that costs would be up to $250,000 for some small practices.
• Robert Averill, Director of Public Policy – 3M, stated that costs to small practices will be approximately $8,000 on average. “ICD-9 was implemented when you could still smoke in a room with the patient!”
Page 30May 8, 2015
Prepared for GAHIMA
Denial Management• Identify existing denial trends, including specific categorizing
and determining the reasons for denial• View denials from the physician’s perspective• Trace and fix issues with denial resolution processes• Work with your providers with a message of fixing the
problems before the claim goes out the door
Page 31May 8, 2015
Prepared for GAHIMA
Denial Management (con’t)• Physicians are life-long learners and are interested in better
documenting patients' clinical conditions, particularly when framed in regards to the effect on outcomes and their workflow and practice
• Shifting the attention to the front-end physician charting stage and reducing challenges at the back-end denial stage will help prepare for ICD-10 implementation
Page 32May 8, 2015
Prepared for GAHIMA
Denial Management (con’t)• Physician participation in denials management,
particularly surgeons, should be aware of the documentation they will need to provide before claims processing
• Adding that clinical perspective and input when denials occur, will help support medical necessity
Page 33May 8, 2015
Prepared for GAHIMA
TrainingClinicians• Physicians – focus on codes germane to their practice and typical
service offerings
• Review clinical documentation improvement efforts and develop new strategies
• Incorporate documentation improvement as a component to compliance training
• Ancillary staff – identify needs and level of training needed, nursing, financial services, quality, utilization, ancillary departments…
Information Technology• Training to ensure that codes are accurately cross-walked in
organization’s systems
Page 34May 8, 2015
Prepared for GAHIMA
Key Resources• Centers for Medicare and Medicaid Services (CMS) Preliminary ICD-
10-CM Mappings– http://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Risk-Adjustors.html
• “ICD-10 Implementation Guide for Small and Medium Practices” Official CMS Industry Resources for the ICD-10 Transition
• “Better Care. Smarter Spending. Healthier People: Paying Providers for Value, Not Volume”
– http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-01-26-3.html
• “SGR Repeal Bill Passes with No Mention of ICD-10” Journal of AHIMA
• Agency for Healthcare Research and Quality– http://www.qualityindicators.ahrq.gov
Page 35May 8, 2015
Prepared for GAHIMA
Questions?
Page 36May 8, 2015
Prepared for GAHIMA
Thank You!
Kim-Marie Walker CPC, CPMA, CCVTC,
AHIMA-Approved ICD-10-CM Trainer
Carine Leslie RHIA, CCS,
AHIMA-Approved ICD-10-CM/PCS Trainer
