ahima icd-10-cm/pcs update august 2009
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© 2008
AHIMA ACEAHIMA ACEJuly 14, 2009July 14, 2009
ICD-10-CM/PCS UpdateICD-10-CM/PCS Update
© 2008
ICD-10-CM/PCS – the ACE Agenda ICD-10-CM/PCS – the ACE Agenda
Thumbnail Sketch of ICD-10-CM/PCS Requirements The Project(s): 5010 and ICD Project Steps Resources Discussion and Questions
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New Federal RegulationsNew Federal Regulations
Final Federal Regulations – January 16, 2009 HIPAA Modifications - Transactions
Medical Data Modifications Code Set Standards ICD-10-CM and ICD-10-PCS
Effective – March 17, 2009 Transaction Compliance Date – January 1, 2012* ICD-Code Set Standards – October 1, 2013
* January 1, 2011 – Testing for Transactions Begin? January 1, 2013 – Medicaid Rx Related
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New Federal RegulationsNew Federal Regulations
Transactions UpgradesTransactions Upgrades All HIPAA Entities All ASC X12 and NCPDP HIPAA transactions
Code Sets Adoption Code Sets Adoption ICD-9-CM diagnosis codes to ICD-10-CM All healthcare settings ICD-9-CM procedure codes to ICD-10-PCS All hospital inpatient services All other sites continue to us CPT® and HCPCS codes
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HIPAA Modification - TransactionsHIPAA Modification - Transactions
Transactions include: X12 837 – Claims (Dental, Professional, Institutional)
X12 837/D.0 – Retail Pharmacy (supplies and professional services)
X12 837 – Coordination of Benefits (DPI)
X12 270/271 – Eligibility for a Health Plan (DPI)
X12 276/277 – Healthcare Claim Status (DPI)
X12 834 – Enrollment and Disenrollment (HP) X12 835 – Healthcare Payment and Remit X12 278 – Referral Certification & Authorization NCPDP D.0 – Various Pharmacy
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HIPAA Modification - TransactionsHIPAA Modification - Transactions
Estimate over 800 changes (updates from over six years of use)
HIPAA testing will be a key to ICD-10-CM/PCS implementation ● Testing begins January 1, 2011 ● Providers and Payers ● Test scheduling and coordination
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Modifications to Medical Data Code SetModifications to Medical Data Code Set
Effective – March 17, 2009
Compliance – October 1, 2013 ICD-9-CM (V 1&2) ►ICD-10-CM – diagnoses ICD-9-CM (V 3) ► ICD-10-PCS* – procedures I/P No change to use of CPT® or HCPCS
Depend on HIPAA transaction updates
* Procedure Coding System
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Impact of Coding System ChangeImpact of Coding System Change
• Data trending challenges
– Maintenance of crosswalks among coding systems for longitudinal data analysis
– Potential for faulty decisions due to distorted, inaccurate, or misinterpreted data
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Impact – Other Healthcare ProvidersImpact – Other Healthcare Providers
• Non-inpatient facilities including physician offices will only use ICD-10-
CM, NOT ICD-10-PCS
• CPT® will continue to be used by Part B providers to describe procedures
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Mapping between Old & New SystemsMapping between Old & New Systems
10
GEMs Maps
GEMs Maps
= GEMs Crosswalks
• General equivalence maps (GEMs) between ICD-9-CM and ICD-10-CM/PCS have been developed
ICD-9-CM ICD-10-PCS via CMS web site
ICD-9-CM ICD-10-CM via CMS /NCHS web sites
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Mapping between Old & New SystemsMapping between Old & New Systems
• Reimbursement map added to CMS web site in 2009– Intended for use by payers – Temporary mechanism – Allows claims processing by legacy systems– Allows for data collection for reimbursement changes
• Maps should NOT be used for coding medical records
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Implications of the Transition – Who? Implications of the Transition – Who?
● Providers ● Hospitals ● Physicians ● Outpatient facilities ● Post-acute providers (home health agencies, skilled nursing facilities, etc.)
● Health Plans or Payers ● Third party administrators ● Employers
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Implications of the Transition – Who? Implications of the Transition – Who?
● Others ● Laboratories ● Free standing ancillaries ● Researchers ● Public health agencies et al. ● Data collection agencies/organizations (registries) ● Vendors ● Clearinghouses ● Business associates and partners
● ● Patients Patients
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Implementation – Two Systems, One or Implementation – Two Systems, One or three? three?
50105010
ICD-10-CM/PCS
01/012010
01/012011
01/012012
01/012013
10/012013
01/012014
ImplementationImplementationTestingTesting
Implementation Implementation TestingTesting
ARRAARRAMeaningful Use”
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X12/NCPDP HIPAA Transactions Implementation Testing Compliance
ICD-10-CM/ICD-10-PCS Implementation Testing Compliance
New Systems (RFIs & RFPs)
Implementation Implementation
Education &Education &TrainingTraining
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Remember Resources Key supporters and worker bees Systems and other resources Vendors and Consultants HIPAA transactions are important What can be done in parallel? Other systems needs Internal v external schedules New systems Business goes on as usual (?)
Implementation Implementation
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Impact of Coding System Change:Impact of Coding System Change: 7 Steps 7 Steps
1. Develop Strategy
2. Communicate
3. Assess Readiness
4. Inventory Process/ System Impact
5. Plan Training
6. Documentation Improvement
7. Develop Budget
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Phase 1 – Impact Assessment:Phase 1 – Impact Assessment:Develop StrategyDevelop Strategy
• Develop organizational implementation strategy
– Establish sponsors!! (Who for what?)– Establish a multi-disciplinary implementation
planning team and designate leader(s)– Develop internal timeline, including resources
required– Develop organization-wide implementation plan
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Phase 1 – Impact Assessment:Phase 1 – Impact Assessment:CommunicateCommunicate
• Communication management strategies
– Minimize “fear of change” factor– Communication is key– Facility-wide
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• Build awareness
– Orient key personnel – Basic familiarity with structure,
organization, and unique features of new systems
– Understand how ICD-10-CM/PCS fits into electronic health record and nationwide health information infrastructure
Phase 1 – Impact Assessment:Phase 1 – Impact Assessment:CommunicateCommunicate
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• Assess organizational readiness for electronic data standard changes (5010)
– Affected staff– Information systems– Documentation process and work flow (Where in the world
is ICD-9-CM?)
– Data availability and use (How is it used now – in the future?)
– Organizational capacity– Local, state, regional trading partners
Phase 1 – Impact Assessment:Phase 1 – Impact Assessment:Assess ReadinessAssess Readiness
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Reporting• Provider profiling• Quality measurement• Utilization
management• Disease management
registries• Other registries• State reporting
systems
• Fraud management• Aggregate data
reporting• Clinical systems• Patient assessment
data sets (e.g., MDS, PAI, OASIS)
• Managed care reporting system (HEDIS)
Phase 1 – Impact Assessment:Phase 1 – Impact Assessment:InventoryInventory
Support Systems•Case mix systems•Utilization management•Quality management•Case Management
Clinical Systems•Clinical protocols•Test ordering systems•Clinical reminder systems•Medical necessity software•Disease management systems•Decision support systems•Clinical systems•Pharmacy systems
Billing/ Financial•DRG grouper•Conversion of other payment methodologies•National and local coverage determinations•System logic and edits•Billing systems•Financial systems•Claim submission systems•Compliance checking systems
Registration•Registration and scheduling systems•Advance Beneficiary software•Performance measurement systems•Medical necessity edits
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Phase 1 – Impact Assessment: InventoryPhase 1 – Impact Assessment: Inventory
• Determine length of time for legacy and new coding systems*
• Determine which reports require modification • Forms redesign**• Budgetary implications hardware/software• Vendor readiness and timelines• Build flexibility for future upgrades
* Providers and Plans **Paper or ???
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Phase 1 – Impact Assessment: InventoryPhase 1 – Impact Assessment: Inventory
• Orient IS personnel on specifications of code sets
• Perform comprehensive systems audit– Inventory databases and systems– Screens and input– Map electronic data flow to inventory all
reports containing ICD-9-CM– Detailed analysis of system changes needed
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Phase 1 – Impact Assessment:Phase 1 – Impact Assessment:InventoryInventory
• Field size expansion
• Alphanumeric composition
• Use of decimals
• Redefinition of code values
• Longer code descriptions
• Edit and logic changes
• Modification of table structures
• Expansion of flat files containing diagnosis codes
• Systems interfaces
Determine required software changesDetermine required software changes
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• Assess educational needs and develop budget plan• Who will need education?• What type and level of education will they need?• How will the education be delivered?• Education for HIM and Coding
• Education on benefits • Overall electronic health record• Structure, organization and unique features• Monitor AHIMA ICD-10 web site• Reading articles• News/announcements
Phase 1 – Impact Assessment:Phase 1 – Impact Assessment:Plan TrainingPlan Training
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• Anatomy and Physiology
• Medical Terminology
• Official Coding Guidelines
• Attention to Documentation
• Reference look-up skills
• Education, Education, Education
Phase 1 – Impact Assessment:Phase 1 – Impact Assessment:Plan TrainingPlan Training
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Phase 1 – Impact Assessment: Phase 1 – Impact Assessment: Plan TrainingPlan Training
• Multiple categories of users of coded data will require varying levels of training
• Different categories of coders will require varying levels of training
• Coders working in settings that will not be using ICD-10-PCS will only require ICD-10-CM training
• Training for physician practice coders working in a medical specialty area can be focused on particular code categories
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Who Else Requires Education Within Your Organization?
• Coders
• Other HIM
• Clinicians
• Senior management
• Information systems
• Quality management
• Utilization management
• Accounting
• Business Office
• Auditors and consultants
• Patient access and registration
• Clinical department managers
• Ancillary departments
• Data analysts
• Researchers
• Epidemiologists
• Software vendors
• Performance improvement
• Compliance
• Data quality management
• Data security
• Data analysts
Phase 1 – Impact Assessment:Phase 1 – Impact Assessment:Plan TrainingPlan Training
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• Conduct gap analysis of coding and documentation practices
• Assess adequacy of staff knowledge• Measure coding professionals’ baseline knowledge of
anatomy, physiology, pharmacology, and medical terminology
• Identify areas of weakness and provide targeted education if necessary
• Assess adequacy of medical record documentation to support level of detail in new coding systems – implement documentation improvement strategies as needed
Phase 1 – Impact Assessment:Phase 1 – Impact Assessment:Documentation ImprovementDocumentation Improvement
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Phase 1 – Impact Assessment:Phase 1 – Impact Assessment:Develop BudgetDevelop Budget
• Develop budget• Departmental budget responsible for costs
• Systems, hardware, software, education• Increased staffing?
• Impact on productivity and accuracy– Short-term (during learning curve) and long-term– More sophisticated computer-assisted coding technologies and
advances in mapping from clinical terminologies will improve productivity and accuracy
• Consulting services– Backlogs– Monitoring coding accuracy– Other support
• Allocation over several year timeframe
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““Lessons Learned” from Other CountriesLessons Learned” from Other Countries
• Begin now – Don’t wait!
• Importance of planning and preparation
• Six-month learning curve
• Vendor readiness is extremely important
• Communication is critical
• Targeted significant ICD-9/ICD-10 comparability issues
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Bottom Line on Preparation (Goals)Bottom Line on Preparation (Goals)
• Maintain coding productivity
• Maintain coding accuracy
• Reduce claims rejections and denials
• Maintain account receivables
• Proper claims payment
• Reduce risk of compliance issues
• Decisions based on improved data
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Next StepsNext Steps
• Read the Final Rules and analysis
• Begin preparing for the transition to ICD-10-CM/PCS and new HIPAA electronic transactions standards NOW!
• Watch for more information from AHIMA
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Resources Resources
National Center for Health Statistics – CDC ICD-10-CM www.cdc.gov/nchs/about/otheract/icd9/icd10cm.htm
Centers for Medicare and Medicaid Services ICD-10-PCS www.cms.hhs.gov/ICD10
ICD-10 and HIPAA Federal Register Notices www.access.gpo.gov/su_docs/fedreg/a080822c.html
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Resources Resources
AHIMA ICD-Ten Webpage www.ahima.org/icd10
Analysis of Final Rule for the Adoption of the ICD-10-CM and ICD-10 PCS Code Sets www.ahima.org/dc (under analysis)
Analysis of the Final Rule Modifications to the HIPAA Electronic Transaction Standards www.ahima.org/dc (under analysis)
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Resources Resources
Publications eAlert Journal of AHIMA Advance ICD-Ten AHIMA Website: www.ahima.org ICD-10: www.ahima.org/icd10 Communities of Practice Education programs
© 2008
Dan Rode, MBA, CPHS, FHFMADan Rode, MBA, CPHS, FHFMAVice President, Policy and Government RelationsVice President, Policy and Government RelationsAmerican Health Information Management AssociationAmerican Health Information Management Association1730 M Street, NW, Suite 5021730 M Street, NW, Suite 502Washington, DC 20036Washington, DC 20036Telephone: (202) 659-9440Telephone: (202) 659-9440E-Mail: dan.rode@ahima.org E-Mail: dan.rode@ahima.org
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