ICD-10: What is the Impact on Physician Practices?

1. ICD-10:What is the Impact on Physician Practices? Presented by Julie Appleton, CCS-P, CPC, CPC-H, FCS, PCS

2. Disclaimer The materials utilized in this presentation are intended solely for use in conjunction with today’s seminar. Although great efforts have been taken in the preparation of today’s material, neither THIMA, the speakers, nor their employers assume responsibility for errors or omissions or for damages resulting from the use of the information contained therein. Advice is general, thus participants should consult professional counsel for specific legal, ethical, technical and clinical questions prior to claim submission. This lecture was prepared with information that was publicly available at this time. ICD-10 and MS-DRGs are constantly evolving. Please consult official guidance prior to code preparation or submission.

3. Introduction to THIMA • The Tennessee Health Information Management Association (THIMA) is an organization of health information management professionals that fosters the professional development of its members through education, representation, and lifelong learning. • THIMA is part of the American Health Information Management Association, one of the official ICD-10 Cooperating Parties responsibilefor maintaining this official HIPAA-compliant transaction set. • These commitments promote quality health information for the benefit of the public, healthcare consumers, providers, and other users of clinical data. Learn more at: http://www.thima.org

4. Under Development • Service Specific ICD-10 Training • First courses expected in January 2012 • Including: • Cardiology, • Orthopedics, • Primary Care • Other additional services • Practice specific and high level overview training for physician documentation

5. Objectives • Orient physicians and their practice management for the impending transition of ICD-9-CM to ICD-10-CM on October 1, 2013. • Develop a framework for ICD-10-CM planning and implementation strategies

6. ICD-10 – The Y2K of Healthcare • ICD-10 Implementation is believed to be the biggest data change ever for the healthcare industry. • It affects all aspects of healthcare- payers, providers, vendors etc.. • It affects systems, procedures, work flow throughout numerous departments “We believe ICD-10 will be the biggest cost impact to the healthcare industry in the last 30 years” - PWC

7. ICD-10 Implementation • October 1, 2013 – Compliance date for implementation of ICD-10-CM and ICD-10-PCS • No Delays • No Grace Periods- providers will not be able to submit ICD-9-CM codes for services provided on or after October 1, 2013

8. What is Changing? • ICD-10-CM • Diagnosis code sets • Impacts all settings including physician practices • ICD-10-PCS • Procedure coding • Impacts inpatient facility

9. Why The Need For Change ? ICD-9 CM ICD- 10 CM/PCS Greater coding accuracy and specificity Higher quality information for measuring healthcare service quality , safety, and efficiency Aligns the United States with coding systems worldwide Provides for recognition in advances in medicine and technology Has the space to accommodate future expansion • Lacks sufficient specificity and detail • It is 29 years old and becoming obsolete – no longer reflects the modern practice of medicine • Running out of space for new codes – it cannot accommodate advancements in medicine and medical technology • Cannot support the US transition to an interoperable health data exchange The United States will be the only country to use ICD-10 data for reimbursement

10. Reasons for Physicians To Learn ICD-10-CM • Accurate representation of patient’s condition in their coded database. • Trending of their patient populations • Medical necessity compliance • Diagnostic tests and treatments require specific codes to qualify for payment. • Illness of severity supporting E&M codes • Physician profiling • Medicare Physician Value-Based Purchasing • Private insurance profiling • BCBST • United Healthcare

11. Who Is Profiling Hospitals & Physicians? • Federal/state regulatory agencies • The Joint Commission • CMS – Center for Medicare & Medicaid Services • AHRQ – Agency for Health Research & Quality • University HealthSystem Consortium (UHC) • Peer Review Organizations -Q Source in Tennessee • Managed care payers • Third-party payers • Profiling agencies (i.e. US News & World reports) • Hospitals • Physician groups • State Health Departments • Employers – The Leapfrog Group • Consumers/General Public (via Internet)

12. Provider Profiling of Quality and Efficiency Patient Charter for Physician Performance Measurement, Reporting and Tiering Programs: Ensuring Transparency, Fairness and Independent Review - April 1, 2008 CMS has established a website whereby physicians cost efficiency and quality may be accessed. Must like Medicare’s Hospital, Dialysis, or Nursing Home Compare sites

13. ICD-10-CM/PCS Final Regulation Physician ICD-10-CM Behavioral Health ICD-10-CM CPT / HCPCS CPT / HCPCS Hospital ICD-10-CM ICD-10-PCS inpatient Laboratory ICD-10-CM ICD-10-CM ICD-10-CM All Other CPT / HCPCS outpatient CPT / HCPCS CPT / HCPCS Long Term Healthcare ICD-10-CM ICD-10 AHIMA CPT / HPCPS

14. Departments Impacted

15. There are More Codes and More Details

16. ICD-10-CM Diagnosis Code Comparisons ICD-9-CM 3 Characters – 486 4 Characters – 428.0 5 Characters – 427.31 3 Characters – C37 4 Characters – A18.4 5 Characters – B58.81 6 Characters – I69.042 7 Characters – S35.411A ICD-10 AHIMA

17. Code Structure Differences ICD-9 Example

18. Code Structure Differences ICD-10 Example

19. ICD-10-PCS - Structure Characters (Med/Surg) 1 2 3 4 5 6 7 Root Operation Qualifier Section Approach Body System Body Part Device Surgeons will have to be educated to be more descriptive of the anatomy and procedures they are performing. ICD-10 AHIMA

20. ICD-9-CM Procedure versus ICD-10-PCS hfma Healthcare financial management association

21. ICD-9-CM Suture of Artery: One code (39.31) ICD-10-PCS Repair of Artery: 183 codes ICD-10 AHIMA

22. ICD-9 Comparison to ICD-10 While hospitalized, a patient has a procedure done through an [endoscope] inserted [through the skin] to [bypass] the blood flow from the [abdominal aorta] to the [right] [renalartery] using a [synthetic material] ICD-9 Code Description 39.24Aorta-renal Bypass ICD-10 Code Description 04104J3Bypass Abdominal Aorta to Right Renal Artery with Synthetic Substitute, Percutaneous Endoscopic Approach

23. Logistical Issues in the transition from ICD-9 to ICD-10

24. ASC X12 Technical Reports Type 3(TR3), Version 005010 • Known as 5010 • This rule was released on the same day as the rule mandating ICD-10, January 9, 2009. • 5010 is a pre-requisite for the ICD-10 project • Deadlines • January 1, 2011 – Medicare began its transition to the 5010 standard • January 1, 2012 - All electronic claims must use the 5010 standard

25. What 5010Does and Does Not Do • What 5010 DOES: • Increases the field size for the ICD codes from 5 bytes to 7 bytes • Adds a one digit version indicator to the ICD code to indicate version 9 versus 10 • Increases the number of diagnosis codes allowed on a claim • Facilitates Present on Admission (POA) Reporting • What 5010 DOES NOT: • Add processing needed to use ICD-10 codes • Add a crosswalk of ICD-9 to ICD-10 codes • Require the use of ICD-10 codes Will your billing software be 5010 compliant by January 1, 2012?

26. ICD-10 Code Freeze • October 1, 2011 - last regular annual updates to ICD-9-CM and ICD-10-CM will be made. • After this date, code updates will be limited only to new diseases and technologies. • The ICD-10 Coordination and Maintenance Committee will continue to meet biannually. • On October 1, 2013, NO changes from the previous year will be made at all. • Therefore, the codes released in mid-2012 will last until October 1, 2014.

27. Available Tool for Converting ICD-9/ ICD-10 Codes • General Equivalence Mapping (GEMS) assist in converting data from ICD-9-CM to ICD-10 • GEMS provide forward and backward mapping • GEMS are not a substitute for learning how to code with ICD-10 or for using ICD-10 code books/encoders • It is better to use the Alphabetic Index followed by the Table to look up a code. • Available at: http://tinyurl.com/2011ICD10

28. Potential Problems with GEMs • A single ICD-9 code may now be represented by multiple ICD-10 codes • One to many • Multiple ICD-9 codes may map to only one ICD-10 code • Many to one • An ICD-10 code cannot be arbitrarily chosen from the GEMs • A code may not represent the complexity of the illness (e.g. unspecified code) – this could result in underpayments • A code may overstate the complexity of the illness – this could result in audits and retrospective recovery of payments.

29. Time Line for Implementation

30. Strategies for ICD-10 Communication and Collaboration must include at a minimum the following key people at your physician practices: • Finance - Contracting • Information Technology (IT) • Coding/Billing • Providers

31. Finance Cash flow reserves • Transition will create coding and claims processing delays • Enough reserves to keep organization afloat financially • Prepare for any unexpected costs • Potential reduced revenue due to delayed reimbursement

32. Organizational Self-Assessment • Contracting – Physician Profiling • Information Systems • Documentation • Encounter Form • Medical record - EMR • Current provider and staff knowledge gaps and opportunities AHIMA has a free assessment tool available at the following website http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_046380.xls

33. Contracting – Physician Profiling • Absolutely crucial to know how ICD-10-CM diagnoses will affect medical necessity and fee schedules • What codes support medical necessity for the services rendered? • The mapping of ICD-9-CM to ICD-10-CM is NOT perfect. • Medicare has not yet published NCDs with ICD-10-CM codes yet • Stay tuned • Wouldn’t hurt to learn more about provider profiling • Medicare Value-Based Purchasing https://www.cms.gov/physicianfeedbackprogram/ • Check with BCBST and United Healthcare about their programs • If your IPA or group has a strategy to implement an Accountable Care Organization, consider how ICD-10-CM will affect the risk-adjustment methodology.

34. Information Systems

35. Information Systems • Contact System Vendors • Confirm that your vendors is on track with ICD-10 and 5010. • Identify potential vendor costs for example hardware upgrades, customization, staffing, and OT. • Determine if the upgrades are included in the current contract or if there will be additional costs to upgrade.

36. Information Systems • How are ICD-9 CM codes currently used in information systems? • Which vendor software applications are being used? • Can the system handle alphanumeric structure? • Can the current system house both ICD-9 and ICD-10 codes simultaneously?

37. Information Systems - Inventory • Create list of all systems using ICD-9-CM • Create vendor readiness assessment list • Use list to contact all vendors • Keep data base showing what you need to do for each vendor • Assign staff member to each vendor to follow through with I-10 readiness for this vendor • Target date for completing initial readiness assessment

38. Documentation Infrastructure • Inventory all forms that use ICD-9 diagnosis codes. • Encounter Forms may become quite lengthy • May require innovative (or computerized) approaches, especially with laterality and episodes of care. • Assess whether documentation currently in your medical records will support the level of specificity for ICD-10. • Ascertain that coding is based on provider documentation, not just what’s on the Encounter Form • Ascertain congruence between the codes indicated on the Encounter Form and what’s documented in the medical record.

39. Documentation Infrastructure • GEM’s – cannot substitute for coding • Download top codes you use now and use GEM’s to crosswalk • Help determine if continuation of paper form is possible (most likely not) • Give you an idea of key areas impacted by ICD-10 change for your specialty

40. Documentation Example • Displaced transverse fracture of shaft of humerus, right arm initial encounter for closed fracture. • ICD-9: 812.2 • ICD-10: S42.321A

41. An ICD-10-CM Superbill Example

42. Educational Needs • Coders and frontline staff • Recognize that most do not know ICD-10. • Areas of greatest need: • Code structure, additions, revisions, and deletions • Primarily anatomy; however clinical pathophysiology and disease nomenclature is a plus, especially in recognizing nonspecific codes adversely affecting physician severity and risk adjustment. • Medical necessity requirements and changes. • Physicians • Impact of lack of specificity upon their profiles • What terms and/or codes more aptly or congruently reflect their patient’s conditions. • Don’t forget that hospital billing affects this as well. • How to use the new Superbills or documentation templates • How to work collaboratively with the office and hospital coding and frontline staff to reduce denials

43. Educational Needs • ICD-10-CM/PCS Final Rule estimates that inpatient coders will need a minimum of 50 hours training • Assuming they know A&P • Once training needs are identified, make sure to budget for the training. • Dual coding support during the transition. • Experience in Canada and Australia found coding takes longer.

44. Awareness Education • Senior Management, IT staff, Department Managers, and Medical Staff need awareness education regarding: • Regulatory requirements (5010, implementation dates) • Overview of the differences between ICD-9 and ICD-10 • Value of new code sets • How ICD-10 fits with other internal and external initiatives • Budgetary implications • Impact on documentation and need for more specificity

45. WORDS of WISDOM “Acquiring knowledge months or years before it’s applied is not efficient, as this inevitably results in varying amounts of follow-up and retraining that consumes additional training resources.” Sue Bowman, RHIA, CCS, Director of coding policy and compliance AHIMA

46. Impact of Transition • Presents both opportunities and challenges • Scope and complexity are significant • Coded data is more widely used than when the US transitioned to ICD-9-CM • Transition will require substantial changes affecting many systems, processes and people • Definite impact on coding and billing productivity • This is a team effort and will require many players working together for a common goal • Physicians need to be advised of increased query activity • Don’t delay getting started!

47. Consequences of Poor Preparation • Increased claims rejections and denials • Increased delays in processing authorizations and reimbursement claims • Improper claims payment • Significant coding backlogs • Compliance issues • Decisions based on inaccurate data • Severity of illness and Risk of Mortality data may be inaccurate (Benchmarking Data) • Accounts Receivables may drop significantly • IT systems may not be ready • AVOID THESE ISSUES BY BEING PREPARED!

48. Where are you with ICD-10 Implementation?

49. Implementation • After establishing your project team, now its time to organize and manage the implementation.

50. Conclusion • Create Implementation Team • Assess your physician practice where ICD-9 diagnosis codes are currently being used. • Analyze your current information systems and contact your vendors. • Evaluate current documentation practices. • Educate, Educate, and Educate your office staff and providers. • Be prepared!