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A Practical Guide to Navigating the ICD-10 Waters

A Practical Guide to Navigating the ICD-10 Waters. Northeast Ohio HFMA July 28, 2011. Agenda. Introductions The Visible Clinical Aspects of ICD-10 ICD-10 Imperative and Call to Action Impact of ICD-10 Among Stakeholders Summary Q&A. The Speakers.

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A Practical Guide to Navigating the ICD-10 Waters

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  1. A Practical Guide to Navigating the ICD-10 Waters Northeast Ohio HFMA July 28, 2011

  2. Agenda • Introductions • The Visible Clinical Aspects of ICD-10 • ICD-10 Imperative and Call to Action • Impact of ICD-10 Among Stakeholders • Summary • Q&A

  3. The Speakers • Nabil Chehade, MD, MSBS, CPCAssistant Medical Director, Medical SpecialtiesChief Medical Informatics OfficerOhio Permanente Medical Group • Lynn Eckendorf, MBA, CCPSenior Associate Gap Consulting • Gail Kovacs, RN, MBA,CLNC Healthcare Business Advisor Kovacs and Associates

  4. The Visible Clinical Aspects of ICD-10

  5. Overview of Kaiser Permanente • Founded 1945 • Serves > 8.7 Million Members • 8 Regions Across the United States: • Colorado, • Georgia, • Hawaii, • Mid-Atlantic States (VA, MD, DC), • Northern California, • Northwest (Oregon/Washington), • Ohio and • Southern California • 35 Hospitals • 454 Medical Offices, • 15,129 Physicians, • 64,098 Employees • Total Revenue for 2010 = $44.2B Courtesy of: Kaiser Foundation Health Plan of Ohio Ohio Permanente Medical Group

  6. According to the American Association of Professional Coders Courtesy of: Kaiser Foundation Health Plan of Ohio Ohio Permanente Medical Group

  7. Kaiser’s Organizational Imperative • Kaiser Permanente As a Complex Organization: • Insurer, Care Delivery, Hospital System, IT, Vendor Relationship • Kaiser Permanente as a Leader in Integrated Care Delivery • Kaiser Permanente As the Largest Non-Governmental Deployment of EMR in the World Kaiser Permanente Will Have to Take a Multi-Year and Multi-Disciplinary Approach for ICD-10 Readiness Courtesy of: Kaiser Foundation Health Plan of Ohio Ohio Permanente Medical Group

  8. Kaiser Permanente’s Approach Organization Wide 10/1/2013 ICD-10 compliance 5010 Systems identified to size impact Refine plan. Remediate, retire, replace applications in line with compliance approach. Testing/ Deployment / Transition Draft systems approach IT Multi-year plan framework Business Review: impacted apps, processes and policies Readiness for business-supported apps; revision of policies and procedures; organizational readiness National and Regional Governance structures Business General awareness, communications and training CoP: Curriculum and approach Prerequisites training Role-specific training Coordination with and tracking of vendor readiness activities Coordinated vendor testing; risk mitigation Vendor Readiness survey Program 2009 2010 2011 2012 2013 Complete systems readiness Assess impact Plan approach Execute plan Courtesy of: Kaiser Foundation Health Plan of Ohio Ohio Permanente Medical Group

  9. Example ICD-9 to ICD-10 Courtesy of: Kaiser Foundation Health Plan of Ohio Ohio Permanente Medical Group

  10. Comparisons of the Diagnosis Code Sets Courtesy of: Kaiser Foundation Health Plan of Ohio Ohio Permanente Medical Group

  11. ICD-10 Code Structure • ICD-10-CM • CM = Clinical Modification of the WHO Diagnostic System for the US • Characters 1-3 – Category • Characters 4-6 – Etiology, anatomic site, severity, or other clinical detail • Characters 7 – Extension • ICD-10-PCS • PCS = Procedural Coding System (Inpatient Hospital Use) • Only the US Uses PCS • Character 1- Name of Section • Character 2- Body System • Character 3- Root Operation • Character 4- Body Part • Character 5- Approach • Character 6- Device • Character 7- Qualifier Courtesy of: Kaiser Foundation Health Plan of Ohio Ohio Permanente Medical Group

  12. Clinical Example, ICD-10-CM A Provider Sees a Patient in a Subsequent Encounterfor an Age Related Pathological Fractureto LeftHumeruswith Delayed Healing: • ICD-9-CM Code: One Code 733.11 PATHOLOGICAL FRACTURE OF HUMERUS • ICD-10-CM Takes into Account Several Elements to Get More Granular Code M80.022.G: • In ICD-10-CM Many Choices for the First 3 Characters Depending on the Category (M80) • Osteoporosis with current pathological fracture • ICD-10-CM Presents Several Other Choices Dependent on the Clinical Information (022): • M80.021 Aged related osteoporosis with current pathological fracture, humerus, right • M80.022 Aged related osteoporosis with current pathological fracture, humerus Left • M80.029 unspecified • ICD-10-CM must identify encounter and healing status, this is the extension code (G) • A) initial encounter for fracture • D) subsequent encounter for fracture with routine healing • G) subsequent encounter for fracture with delayed healing • K) subsequent encounter for fracture with non-union healing • P) subsequent encounter for fracture with malunion healing • S) sequela Courtesy of: Kaiser Foundation Health Plan of Ohio Ohio Permanente Medical Group

  13. ICD-9-CM Vs. ICD-10-CM 13 Courtesy of: Kaiser Foundation Health Plan of Ohio Ohio Permanente Medical Group • Prior Example of Age Related Pathologic Fracture Yields 18 codes in ICD-10-CM Vs. One Code Available in ICD-9-CM • If We Were to Compare and Code for Traumatic Fracture Instead of Pathologic Fracture: • 26 Codes in ICD-9-CM Vs. 966 Codes in ICD-10-CM 26 codes (13 closed fracture and 13 open fracture) in ICD-9 - 812.x 966 codes (138 codes x 7 alpha extensions includes Initial Open and Initial Closed) in ICD-10 - S42.2xx to S42.49xx

  14. Impact on Documentation by the Clinician 14 Courtesy of: Kaiser Foundation Health Plan of Ohio Ohio Permanente Medical Group • How Specific Do We Need to Be When Documenting in ICD-10? • Is More Specific Better for Patient Care, Quality Initiatives or Revenue Impact? • Can Extreme Request for Specificity Backfire and Lead to Vague Data and Sometimes Outright Incorrect or Erroneous Data? What Would the Impact Be on Provider Productivity?

  15. Impact and Optimization of EMR • Mapping for ICD-10 and Making Display Names and Synonyms Available for Easy Retrieval • Implementation of New Coding Tools in EMR to Help Selecting Correct Codes • Remediation and Mapping of: • Structured Data (Problem List, PMH, Decision Support Tools) • Existing Documentation Tools • Quality Reports • Utilization Management Reports • Clinical Protocols • Population Registries

  16. Kaiser’s Expectations • Kaiser Permanente, Kaiser Hospitals and Permanente Medical Group Will Be Ready for an October 2013 Transition to ICD-10 • All Impacted Systems Will Be Remediated • People Impact Will Be Minimized • Training and Workflows Will Be Optimized For a Smooth Transition with a Minimal Disruption • Progress to Date: • Completed Inventory of Impacted System Program Wide • Significant Progress on People Impact and Training Program Wide • System Remediation, Mapping and Crosswalk of Codes Already in Progress Courtesy of: Kaiser Foundation Health Plan of Ohio Ohio Permanente Medical Group

  17. ICD-10 Imperative and Call to Action

  18. Where It All Came Together…

  19. Timeline/State of Readiness • Key Dates • 9/30/13: Last date to use ICD-9 • 10/1/13: Effective Date ICD-10 • Delay potential due to MU Stage 2 delay? • Coordination with 5010 (Comply with 5010 First) • Preparation / Assessment • EHR Upgrade Synchronization • Workflow Improvements • Benefits of ICD-10 • Data Precision • Discrete Cost Analysis • Improved Payer / Provider Discussions / Negotiations • Improved Portfolio Management

  20. Benefitsof ICD-10 • More Specific Coding / More Accurate Reimbursement • Faster Reimbursement / Fewer Denials (Long-Term) • Able to Accommodate Treatments Post-ICD-9 • Better EMR Support • Improved Safety, Medical Management and Quality of Care • Improved Portfolio Management • Redesign Clinical and Administrative Operations • Enhance Integration with Payers and Providers Source: Accenture: “Preparing Payers for ICD-10”

  21. Industry Benefits of ICD-10 Source: “The Cost and Benefits of Moving to ICD-10 Code Sets” by Rand Science and Technology

  22. Potential Provider Business Opportunities BusinessBenefits • Improved portfolio management • Improvement opportunity - Clinical and Operational Redesign • Improvement opportunity - Clinical Documentation by Physicians • Increased patient/provider loyalty • Improved payer/provider integration • None to minimal impact to bottom line Courtesy of: 3M

  23. Potential Payer Business Opportunities BusinessBenefits • Improved qualityof care • Reduced costof claims • Increased member satisfaction • Increased provider satisfaction • Improved administrative cost Source: Trizetto Presentation 2010 Courtesy of: 3M

  24. ICD-10 Projected Impact The Move to ICD-10 Is Expected to Cost $1.64 Billion Dollars • The Centers for Medicare & Medicaid Services Estimate That the Transition from ICD-9 to ICD-10 Will Cost the Healthcare Industry $1.64 Billion • Also in 2008, Nachimson Advisors, LLC Estimated These Impacts of ICD-10: • Typical Small Practice: Total Cost Impact $83,290 Per Practice • Typical Medium Practice: Total Cost Impact $285,195 Per Practice • Typical Large Practice: Total Cost Impact $2.7 Million Per Practice Courtesy of: Kaiser Foundation Health Plan of Ohio Ohio Permanente Medical Group

  25. Date Impacts • Claims That Cross the 10/1/13 Boundary • Discharges • Services Provided Prior to 10/1/13: No Change • Services Provided On or After 10/1/13: All Use ICD-10; Convert from ICD-9 • Code Freezes • 10/1/11: Last Regular, Annual Updates to Both ICD-9-CM and ICD-10 • 10/1/12: Only Limited Code Updates to Both ICD-9-CM & ICD-10 Code Sets To Capture New Technology And New Diseases • 10/1/13: Only Limited Code Updates to ICD-10 Code Sets to Capture New Technology And New Diseases • Define Your Approach Organization-Wide

  26. Where Are You with ICD-10 Planning? • ICD-10 Steering Committee • Comprehensive Assessment Completed with Issues Identified • 5010 Readiness • IT Systems-System Inventory • Decision Support • Case Management • Utilization Review • Managed Care/Payer Contracts • Quality Department • Functional Areas That Use ICD-9 Codes Today That Need Translation • Educational Needs Within Organization • Documentation Assessment • Claims Analysis to Identify Top Specialties Impacted the Most • Vendor Readiness • Testing Schedule • Managed Care/Payer Contract Readiness • Implemented Education Plan • Implemented Documentation Improvement Plan for ICD-10 • CDI Program w/ I-10 Concepts • Identified Top Specialties and Education to Physicians • Roadmap Completed for Implementation Courtesy of: 3M

  27. Implementation of ICD-10 • HIMSS ICD-10 Playbook http://www.himss.org/ASP/topics_ICD10Playbook.asp • Reviews Known Risks—Direct/Avoidable • Reviews Hidden Risks—Indirect and Complex: Can Cause Irreversible Damage • Payer Readiness Variability • Necessary Payer Conservatism • Assume Miscoding—Increased Denials • More Diligent In Validating Appeals—Cash Flow Delays • Evaluate Contracts Based on Assumptive Trend Data • Inevitable Lender Uncertainty • Delays in Cash Flow Will Result in Decreased Net Revenue, Results in More Scrutiny of Margin • Get Approved Lines of Credit In Place Now • Payer Will Need Extensive Modeling, Will Adjust Rules as They Gain Experience • Configuration Mistakes Will Lead to Re-Billing 2013 Is Just The Beginning. If You Get Behind, You Stay Behind!

  28. What You Need to Be Addressing Today • Comprehensive Assessment of Functional Areas Impacted • Vendor/Payer Gap Analysis • Identify Functional Areas and Processes That Will be Impacted • Develop Roadmap for Successful Implementation • Begin Translation Process • Translate Lists of Codes for Appropriate Applications (Software/ Paper) • Assess Payer Contract Implications and Begin Translating/Working with Payer Regarding Future Contractual Agreement for Transition to ICD-10 • Documentation and Current Claims Assessment • Review of Claim/Code Volume of Codes that Cannot be Translated • Identify High Volume Trends (Codes, Specificity, etc.) • Documentation Review of These Codes for Accuracy and Specificity • Begin Process of Changing Physician Documentation Behavior • Utilize Trends from Documentation and Claims Assessment to Begin to Educate and Change Physician Behavior Now Courtesy of: 3M,

  29. ICD-10 Implementation: Critical Success Factors • Knowledge Transfer/EducationProvided to Key Leadership/Teams Staged According to Fully Integrated Program Plan Development and Execution. • Fully Integrated IT And Other SystemsCurrently Containing ICD-9 Codes Across All Hospital, Vendor, Payer and Other Integrated Systems (Electronic and Other) • Comprehensive Internal And External CommunicationStrategy/Plan • Detailed Contracts with Other Providers, Payers and Vendorswith Clear Identification of Timing, Integration and Conversion/Translation Applications • Comprehensive Modeling and Integrated Functional TestingPlan Across the Continuum of Care Courtesy of: 3M

  30. Tools: Conversion / Crosswalk Activities • General Equivalence Mappings (GEMs) Assist in Converting Data from ICD-9-CM to ICD-10 • Forward and Backward Mappings • Information on GEMs and Their Use – http://www.cms.gov/ICD10(Click on ICD-10-CM or ICD-10-PCS to Find Most Recent GEMs) • Description of MS-DRG Conversion Project http://www.cms.gov/ICD10/17_ICD10_MS_DRG_Conversion_Project.asp

  31. Best Methods To Reduce Claims And Coding Errors • Increased Specificity Makes Accurate Documentation Critical Garri Garrison, 3M • ICD-10 Could Turn Revenue Cycle Management Upside Down Doug Brilbrey , SSI Group • There Are 2 Reasons Mistakes Happen Greg Larson, TriZetto • Info Is Missing or Inconsistent; • Diagnosis & Procedural Codes Are Inappropriate for Type/ Level of Care • Successful Transition Requires Planning and Collaboration Lisa Nolan, PatientKeeper • Key to Reducing Errors Is Education Ken Bradley, Navicure • Control the Accuracy of Coding Where It Matters Kimberly Labow, Navinet • Correct Coding Begins with Thorough Documentation Kristen Weinberger, Edifecs • Need to Evaluate the CAC (Computer Assisted Coding) Mark Morsch, A-Life Systems Medical, part of Ingenix • Key is Remediation Ray Desrtochers, HealthEdge • Must Have Detailed Contracting Arrangements Ravi Sabharwal, Infosys Technologies

  32. Best Methods To Reduce Claims And Coding Errors • Mobile Solutions Are Important Paul Adkison, IQMax • Whole Practice Must Embrace the Challenge Rex Stanley, Unicor Medical • Important to Identify Early Opportunities to Optimize William Shea Systems Cognizant Business Consulting • Best Approach Will Start with an Impact Assessment Rob Culbert, Culbert Health Solutions • Education, Training and Support Are Keys to Avoiding Steve Sabino, DST Costly Errors Health Solutions • Create an Acceptance Test that Defines the Expected Sal Novin, Health Care Outcome ProductivityAutomation • Education Will Remove Barriers to ICD-10 Success Deborah Nevill, Elsevier

  33. Impact of ICD-10 Among Stakeholders

  34. According to the American Association of Professional Coders Courtesy of: Kaiser Foundation Health Plan of Ohio Ohio Permanente Medical Group

  35. Steering Committee • Components Executive Sponsor : Often the CFO • Governance • Leadership: • IT / HIM/ CMO / CNO • Broad Stakeholder Participation • PMO Office • Message: High Level Engagement and Commitment of Senior Management • Consider: Payer Perspective as a Stakeholder

  36. Steering Committee Role / Responsibilities: • Develop / Implement • Goals • Schedule / Milestones • Assign Tasks / Resources • Oversee Organization-Wide Training • Assess Impact/Modify Course • Of Implementation • On Functional / Other Areas • Communications (e.g., Awareness, Status)

  37. Kaiser Permanente’s Approach National vs. Regional Reg. Business Lead(s) Compliance National Lead(s) For Each Functional Area PMO Org Readiness Reg. IT Lead Executive Sponsors (Regional) Executive Sponsors (National) Steering Group (Regional) Steering Group (National) Additional team structures to be determined by each region Courtesy of: Kaiser Foundation Health Plan of Ohio Ohio Permanente Medical Group

  38. Sample Organization Structure

  39. Physician Impact • Appreciate Time, Complexity, & Level of Difficulty • Documentation Will Change • Will Take Longer; May Need To Be Repeated; Delinquent Charts • Also Being Impacted At The Office Level AND • Need To Take Care Of Patients!! • Engage & Train Physicians On Importance Of Changes • Address Adoption Issues, Training Sessions, Tools • Conduct Workflow Analysis • Potential Gaps • Redesign Workflows And Documentation Products • Prepare To Minimize Impact • Consider Preparation Of Billing Under Both Coding Systems

  40. Nursing Impact • Appreciate Time, Complexity, & Level of Difficulty • Same Organizational Change Issues as Physicians • Awareness of Impact Initiative in Other Departments • Physicians, Utilization & QA Review, Agency Personnel!! • Training Needs • Forms & Orders Will Change; Documentation Will Need to Be More Specific: • EG. Pressure Ulcers: ICD 9 = 9 codes; ICD 10 > 125 codes • Don’t Underestimate the Value of a Nurse • Critical to engage: understand A & P, disease process, can read surgical reports and can explain what happened/how treated • Can serve as translators between Physicians and HIM • Consider Role for Nursing Specialists/Informaticists, RN-Coders: :http://community.advanceweb.com/blogs/nurses_18/archive/2011/04/25/nursing-s-role-in-icd-10-meaningful-use.aspx

  41. Operational / Functional Impact Productivity will be effected in Real $$ • Productivity Decreases Expected, Beyond Transition • Cash Flow Impact Resulting from Lowered Productivity: • Claims Submissions • Reimbursements • Slowed Revenue Stream • A/R Drop • Audit Impact of Changes in Documentation • Increase in Cost Per Case for a Period of Time • Delays in Chart Completion Secondary to Physician Documentation • Charge capture Processes May Need Modifications • Utilization Review / Case Management Impact • Stop Loss Initiatives Needed? • Collaborate with Payers as Well

  42. Productivity Impact on Coding • Canada Implemented ICD-10 in 2001 • Coders Did Not Return to Post Implementation Productivity Levels • Use of Pre-defined Coding Lists Within Ambulatory Care Settings Mitigated Drop • Sample of Canadian Coding Productivity Pre- and Post-ICD-10 • Expressed as Charts Completed Per Hour Courtesy of: Kaiser Foundation Health Plan of Ohio Ohio Permanente Medical Group

  43. Technology Impact • Software Programs & Testing Efforts • Clinical Documentation Programs will need Review • Required to Support Accuracy • Lead to Enhanced Reimbursement and Severity-Adjusted Clinical Outcome Measures1 • Multiple Sites • May Each Have Locally Customized Software ( Even If Using the Same Applications) • Forms Will Likely Change

  44. Who Requires Training? • Accounting • Business Office • Auditors & Consultants • Patient Access & Registration • Clinical Department Managers • Ancillary Departments • Coders • Other HIM • Clinicians (Physicians, Nurses) • Senior Management • Information Systems • Quality Management • Utilization Management • Claims Analyst • Performance Improvement • Compliance • Data Quality Management • Data Security • Data Analysts Courtesy of: Kaiser Foundation Health Plan of Ohio Ohio Permanente Medical Group

  45. Impact on Software Programs • HIM • DRG Grouper -Encoding Software • Abstract Systems -Compliance Software • Medical Necessity -Support Systems • Case Mix Systems -Utilization Management • Quality Management -Case Management • Performance Management

  46. Impact on Software Programs • Financial • Billing • Financials • Claim Submission • Compliance Checking • National And Local Coverage • Determinations • Reporting • Provider Profiling • Quality Management • Utilization Management • Disease Management Registries / Other Registries • State Reporting Systems • Fraud Management • Patient Assessment Data • Data Sets • Aggregate Data Reporting • Managed Care Reporting

  47. Impact on Software Programs • Clinical Systems • Clinical Protocols • Test Ordering Systems • Clinical Reminder Systems • Decision Support Systems • Disease Management Systems • Internal Home Grown-Systems and Customizations • Clinical Systems • Pharmacy Systems • Lab System • Radiology Systems • EKG • Registration • Registration/Scheduling • Advance Beneficiary Software • Medical Necessity Edits • Anywhere a Code or Diagnosis Resides or is Utilized • WILL be Effected!!

  48. Ancillary /Other Impact • Ancillary • Pharmacy (V and E Codes Will Still Be Alphanumeric) • Lab (Codes Change) • Quality Measures and Reporting • Public Health / Compliance Impact • Data Is More Clearly Defined • Potential to Improve ACO Data • Reporting

  49. Vendor Interface Impact • Create Inventory of Systems • Define Those Impacted (Systems, Vendors) • Coding Vendor • Compliance / Readiness of 5010 & ICD-10 • Release / Implementation of System Updates • Costs • Testing Interfaces (Bidirectional) • Affected Systems and Third-Party Recipients / Providers • Claims, Clearinghouses, Reference Labs, Affiliated Physicians, Etc. • Costs

  50. Payer Impact Consider: • Testing with Payers and Clearinghouses • Effects That ICD-10 Will Have on Explanation of Benefits (EOB) Statements • Changes to Submitted Claims • Changes in Communications to Patients • Handling of Questions / Calls from Patients • Who will they view as the cause of their anxiety and frustration ?

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