Billing Plan for Restructuring WMU School of Medicine’s Billing Department

1. Billing Plan for Restructuring WMU School of Medicine’sBilling Department By: Heather Smith LDR 609

2. Executive Summary On January 15, 2009, the Department of Health and Human Services (HHS) released the final regulation to move from the current ICD-9-CM coding system to the ICD-10-CM coding system in October 1, 2013 (HHS, 2009). On August 24, 2012, the HHS announced changes to the final rule that changed the deadline for compliance to October 1, 2014 (AHIMA, 2012). WMU School of Medicine must be prepared for this transition to ensure that our cash flow is not disrupted or delayed. Quality improvements to chart documentation will be essential in obtaining reimbursement from insurance carriers once ICD-10 is implemented. ICD-10 requires more detail and a clearer clinical description to justify the medical necessity for services provided. Provider readiness assessments must occur to evaluate their documentation and to educate them on deficiencies found to prepare for this transition. A steering committee must be established to meet the challenges we face in preparing for ICD-10 implementation. Due to past issues with provider compliance audits and to effectively prepare for this transition, we are recommending the addition of a second full time auditor, and a change to the structure and set up of the billing department. In addition, we will internally prepare to train and educate our organization on ICD-10’s code structure, conventions, and guidelines.

3. Objective The transition to ICD-10-CM could present significant challenges to WMU School of Medicine, and if not properly implemented, could have an adverse impact on clinical and financial performance. With the October 1, 2014 deadline, it is important that to WMU School of Medicine begin planning an implementation strategy that will ensure a smooth transition. Planning is the key to success; our key objectives are outlined below: • Create a steering committee that will provide strategic guidance • Define each person’s role and responsibility in achieving a successful transition • Set deadlines to achieve results • Plan the Budget • Hire a second auditor and define the roles for each • Reorganize the billing department to perform prospective billing reviews to • Support medical necessity, code to highest level of specificity, and ensure claim accuracy for proper reimburseent • Identify the systems that will be affected within the entire organization • Discuss with vendors as to when software updates will occur and when we will be able to begin testing • Perform chart reviews to determine current areas where documentation must be improved • Review the impact and expectations on documentation • Begin to communicate the transition to providers, coders, and billers • Create a training module to perform in-house training • Train practitioners, coders, billing staff, and other identified staff affected by this transition • Coders will be required to pass an ICD-10-CM proficiency test to maintain AAPC certification • Identify weaknesses where additional education would be beneficial • Test • Transition operation October 1, 2014

4. Financial Analysis Personnel Expenses: Current $753,920 Proposed Change $829,666 Variance $75,746 Operating Expenses Current $41,700 Proposed Change $43,600 Variance $1,900 Total Expenses Current $795,620 Proposed Change $873,265 Variance $77,645

5. Gap Analysis • Strengths: All coders and physicians currently receive training based on compliance in the organization and are up to date on coding issues. We have an internal auditing process in place to continuously assess and monitor compliance and provide education for all providers falling below the 90% standard. Our organization has converted to 5010 transaction sets in preparation for ICD-10. We review our insurance contracts bi-annually and will pull all contract and review against medical policies as health plans publish their ICD-10 changes. • Weaknesses: Upon initial review of documentation there appears to be an issue with meeting the new ICD-10 standards of specificity, granularity, and laterality. We must convert to eCW’s version 10 to be able to load and accommodate ICD-10-CM. Currently short staffed; need to reorganize billing department to transition an AR member to the coding side and post an additional auditor to help with pre- and post- implementation and provider documentation readiness reviews. Funding of training is not accounted for in the budget for providers and other staff. Need to expand education and training for documentation and compliance accuracy for providers and coders.

6. Gap Analysis • Opportunities: Will begin focused quarterly auditing and monitoring reviews geared towards using ICD-10-CM codes and review provider documentation to ensure compliance. It will set a date with our software and system vendor to upgrade to version 10 by February 1st, 2014. We will expand budget to include addition of software upgrade which was not previously budgeted for. All coders will attend education for ICD-10 code sets through the AAPC as well as through the organization. All providers and remaining staff will obtain scheduled education through the organizational training sessions. We will work with project team to ensure readiness. • Threats: Must find the time and resources to review all carrier medical policies for ICD-10. Work with the reluctant physicians to change documentation practices relative to ICD-10 and get all residents trained and audited on ICD-10 documentation to ensure all providers are ready. Providers feel their documentation is sufficient now so we need to obtain additional time to educate providers to get them better prepared and help them understand the significant differences and changes necessary to be compliant. Learning a new code set will slow down the productivity of the providers and coding staff that must bounce back within three months of the transition. There are also unknown factors as to what new regulations will be enacted and with health care reform, not certain how this will impact or affect the overall process and medical practices

7. Monitoring and Review The first 30 days after go live, claims processing will be monitored daily for rejections or denials. Any claims issues will be resolved and resubmitted within 24 hours. Coder productivity will be reviewed over the first six months and a temp agency will be on stand-by if additional resources are needed to maintain revenue expectations. Both auditors will pull random samples of provider documentation to continue reviews on quality, specificity, and accuracy for the first three months. I will monitor our benchmark reports closely during the first six months of transition looking for problem areas, inadequacies or weak areas within the process. Identified areas will be fixed immediately to prevent reimbursement delays. During the first several months we will revisit the new policies and procedures to ensure that nothing was missed and that no improvements are necessary. Once it is established that all the objectives were attained and the transition phase is complete, we will continue to monitor productivity and performance benchmarks monthly.

8. References • AHIMA. (2012). HHS Announces: ICD-10 delayed one year. Retrieved from: http://journal.ahima.org/2012/08/24/hhs-announces-icd-10-delayed-one-year/ • Longest, Jr., B.B., & Darr, K. (2008). Managing health services organizations and systems, 5th ed. Baltimore, Maryland: Health Professions Press • US Department of Health & Human Services (HHS). (2009). HHS issues final ICD-10 code sets and updated electronic transaction standards rules. Retrieved from: http://www.hhs.gov/news/press/2009pres/01/20090115f.html

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