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ICD-10: Checking in on ReadinessPeggi Ann Amstutz, MBA, CCS-P, CCSAHIMA Certified ICD-10-CM/PCS Trainer

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PRESENTER

Peggi Ann has been in the health care industry since 1986. Her focus is providing leadership to projects, developing and presenting seminars from basic coding to compliance, as well as coding compliance audits. Peggi Ann has an extensive background in program and policy development, with a proven ability to interpret Federal and state rules and regulations in a compliant manner. She has hands-on experience in managing daily clinic operations, provider scheduling, ER coverage, EMR functionality, preparing and monitoring annual revenue and expense budgets, and planning and implementing quality improvement initiatives. She also possesses an excellent understanding of CMS reimbursement methodologies, compliance standards, and HIPAA. Peggi Ann is a AHIMA Certified ICD10-CM/PCS Trainer. Peggi Ann is a past WA/AK HFMA Board Member and current co-chair of the Finance and Compliance Education Committee for WA/AK HFMA.

Peggi Ann Amstutz, MBA, CCS,CCS-PSenior Manager

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DISCUSSION OUTLINE

ICD-10: • The Why, What, WHEN?? and How• Impact analysis on Business processes and

Workflows , specifically Revenue Cycle issues• Future Outlook:

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QUESTION

How many of you have completed your vendorreadiness assessment?

YesNoHuh?

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CMS SAYS:

• February 23, 2012• “Keep on course” with ICD-10, Advises CMS

Director By Janis Oppelt• Don’t wait for the Centers for Medicare & Medicaid

Services (CMS) to make its decision about the implementation date for ICD-10, advises David Sayen, a CMS regulatory director. “Even if I-10 is delayed, keep on course,” he said, and make sure things are functioning properly. That’s the advice Sayen offers to providers and payers during this time of uncertainty.

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AHIMA SAYS:

• AHIMA: Remain Vigilant in ICD-10 Transition• Association Emphasizes Impact of Delay on

Costs, Progress Already Made• CHICAGO – Feb. 17, 2012 – The American

Health Information Management Association (AHIMA) said it will reach out to Department of Health and Human Services’ (HHS) leaders to emphasize that there should be no delay in the implementation and use of the ICD-10-CM and ICD-10-PCS classification systems.

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OVERVIEW

• 30 year old ICD-9 is being replacedo ICD-10-CM replaces ICD-9 volumes 1 and 2 for

diagnosiso ICD-10-PCS replaces ICD-9 volume 3 for hospital

inpatient procedure codes. o Original CMS deadline for all activity to be coded to

ICD-10 with a service date of October 1, 2013 or discharges on or after October 1, 2013 is now in limbo and we are now looking for some other date to be determined.

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World Class ServiceProductivity

StrategyGrowth Strategy

FinancialDrivers Customer / Patients

InternalProcesses

Learning &Growth

Improve Cost Structure

Increase Asset Utilization

Expand Revenue

Opportunities

Enhance Customer

Value

Price Quality Availability Selection Service Partnership Brand

Value Proposition

Organizational Capital

Human CapitalInformation Capital

Culture Leadership Alignment Teamwork

WorkflowReengineering Training Organizational

readiness Education

EHR Systems Interfaces Testing

ReportingAnalytics KPIs Dashboards Public Reporting

Value

Spectrum

Value

Spectrum

Functionality

OperationsPhysicians

NursesFacility Functions i.e.

Surgery, Radiology etc

Clinical & Care Management

Clinical InformaticsAmbulatory

Clinical Documentation

Managed CareContract Analysis

DRG AnalysisContract Negotiation

Reimbursement

ComplianceCoding

HIMOperations

Privacy & Security

Revenue CycleBilling

RegistrationCharge Data

Master

IICD10 Talking Points

WHAT IS THE VALUE PROPOSITION OF ICD-10?

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AUDIENCE QUESTION

How many ICD-10 diagnosis codes will be available when the system goes live?1. 550002. 790003. 360004. 68000

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OVERVIEW (CONT.)

• Issues with ICD-9o Doesn’t reflect current medical knowledge or

advances in technologyo Not detailed enough to support quality management

and reportingo Inhibits transition to interoperable health data

exchangeo US is the only industrialized country not using

ICD-10

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CODING STRUCTURES AND THE POTENTIALIMPACT ON REIMBURSEMENT

ICD-9 ICD-10

Diagnostic Codes

XXX . XX Category Etiology; Anatomic Site; Manifestation

250 . 61 Diabetes Mellitus, not stated as uncontrolled with Type 1 neurological complications

XXX . X X X X Category Etiology Anatomic Severity Extension

Site E10.40 DM w/ diabetic neuropathy, unspecified E10.41 DM w/ diabetic mononeuropathy E10.44 DM w/ Diabetic amyotrophy E10.49 DM w/ other neurological complications (7th character used to indicate initial or subsequent visit or sequela)

Procedure Codes XX . XX 31.99 Other operations on Trachea

X X X . X X X X Section Body Root Body Approach Device Qualifier System Operation Part 0B717DZ Dilation of trachea with intraluminal device via natural or artificial opening

MS-DRG 168 - Other respiratory system O.R. procedures w/o cc/mcc 165 - Major Chest procedures w/o cc/mcc

CMS weight 1.3026 1.7662

Reimbursement $6513 $8831 (note: Reimbursement risk can be significant depending on PCS code)

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ICD-10 EXAMPLES• Example: Laterality – Left versus Right

o C50.1 Malignant neoplasm, of central portion of breasto C50.111 Malignant neoplasm of central portion of right female breasto C50.112 Malignant neoplasm of central portion of left female breast

• Example: Angioplastyo 1,170 ICD-10-PCS angioplasty codes specifying body part, approach, and

device, including:� 047K04Z Dilation of right femoral artery with drug-eluting intraluminal device,

open approach� 047K0DZ Dilation of right femoral artery with intraluminal device, open

approach� 047K0ZZ Dilation of right femoral artery, open approach� 047K24Z Dilation of right femoral artery with drug-eluting intraluminal device,

open endoscopic approach� 047K2DZ Dilation of right femoral artery with intraluminal device, open

endoscopic approach

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MAPPING BETWEEN ICD-9 TO ICD-10

• There is no comprehensive mapo Many maps have been developed but they are not

precise

81.54 TOTAL KNEE REPLACEMENT in ICD-9, in ICD-10 there are 16 valid codes to chose from.

789.09 ABDMNAL PAIN OTH SPCF ST, in ICD-10 it is no longer “other specified” there are numerous codes to chose from to correctly specify

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• CMS developed General Equivalence Maps (GEMs) as interim step http://www.cms.gov/ICD10/11b14_2012_ICD10CM_and_GEMs.asp#TopOfPageo Backward and forward mapping between ICD-9 and

ICD-10o Maps are not exact reverse imageso Used by all stakeholders to convert:

� Payment systems� Payment and coverage edits� Risk Adjustment logic� Quality measures� Research applications

GEMS BETWEEN ICD-9 TO ICD-10

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CROSSWALKINGIN ORDER TO EFFECTIVELY INTERPRET DATA ACROSS PERIODS OF TIME, CROSSWALKS WILL BE NEEDED TO ASSOCIATE ICD-10 CODES WITH CORRESPONDING ICD-9 CODES (AND VICE VERSA).

• Crosswalks allow the retention of ICD-9 as the base scheme and enable organizations to convert from ICD-10 back to ICD-9, as well as ICD-9 to ICD-10. This helps:o Prevent loss of historical information for comparison

and analysis – possibly!o Make accurate claims payments – only where one of the

parties is not ready!o Continue fraud and abuse data audits and reviews

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CROSSWALKING (CONT.)

• Dual analysis and reporting systems will have to be written and maintained for many years

• Business analytics will be impacted because of the need to combine historical ICD-9 data with newer ICD-10 data

Major concern here is how to control wide range of reimbursement depending on which ICD-10 code is mapped to which ICD-9 code. This will require policy decisions to be made as part of the planning process.

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• Reimbursement Maps are a temporary but reliable solution to map ICD-10 to the “reimbursement equivalent” ICD-9 codeso Used to aid conversion of legacy systemso One to one mapping of “most representative”

ICD-9 and ICD-10 codeso Doesn’t account for clusters of ICD-9 codes

ICD-9 TO ICD-10

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CASE MIX INDEX – ONE OF THE MANY AREAS OF POTENTIAL IMPACT

• The file link below contains FY 2011 hospitals' case mix indexes (CMI) for discharges. A hospital's CMI represents the average diagnosis-related group (DRG) relative weight for that hospital. It is calculated by summing the DRG weights for all Medicare discharges and dividing by the number of discharges.

http://www.cms.gov/acuteinpatientpps/ipps2011/itemdetail.asp?itemid=CMS1237932

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AUDIENCE QUESTION

How many ICD-10 procedure codes will be available when we go live?

1. 140002. 870003. 490004. 56000

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BESIDE THE IMPACT ON REVENUE CYCLE MANAGEMENT RELATED SYSTEMS, THE IMPACT WILL BE FELT BY CLINICAL AND PERIPHERAL SYSTEMS TOO

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IMPACT ANALYSIS RESULTS - SYSTEMS

• Systems – technical impacto Field lengths are largero Using alpha-numeric codeso More storage spaceo Support for dual code setso Changes to program logic

• What to do with existing systems?o In-houseo Vended

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IMPACT ANALYSIS - DATA

• Need to support dual standards for significant period of timeo ICD-9 and ICD-10

• How to handle archived data and historic medical records?

• Potential for distorted or lost statistics• How to perform quality reporting across

historic and current datao Potential need for dual databases

• Need to ensure that Trading Partners are ready

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SAMPLE IT PLAN

• Upgrade, Remediate or Replace or Sunset, decision needed by application

• New software needed?• Interface upgrades or new interface(s)?• Hardware updates/replacements?• Timing of upgrades?• Timing of testing?

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DRILL IT DOWN FURTHER TO CLAIM SUBMISSION…

• Workflowo Patient Accesso Data Entryo HIMo Billing

• For each of these areas who owns the redesign, testing, training and roll out?

• And don’t forget Compliance/Revenue Integrity

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NEXT STEPS AND CONSIDERATIONS

• What should you be considering and planning for?o What is the impact based on your readiness

assessment?� Business processes and workflow� Trading Partner preparation� IT systems� Code analysis� Contract changes

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PLANNING BASED ON ANALYSIS

• What should you be considering and planning for?o Training and education – it is NOT just for coders!� Claims� Care management� Contract management� Business associates

o Possible contract re-negotiationo Lack of ICD-10 certified coderso Testing with partners

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FUTURE OUTLOOK

• Industry experience predicts (AHIMA & HIMSS):o Six-month learning curveo Decreased coding productivityo Increased provider querieso Increased claim rejections and denialso Increased delays in processing authorizationso Increased delays in reimbursemento Improper reimbursemento Discontinuity in data structures will impact related

analytics, trending and associated decision making

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FUTURE OUTLOOK (CONT.)

• Revenue cycle performance will likely experience:o Increase in unbilled receivableso Increase in accounts receivableo Slowed and/or reduced cash flow

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IMPACT OF ICD-10 ON BUSINESS FUNCTIONS

• Employeeso Many job functions will be impacted with varying

degree. Education and training, new processes and existing process remediation, re-certification, and internal/external reporting.

• Clinicalo Training and re-certification of coding staff. o Nurse practitioner, physician assistants and MDs

may modify or expand their problem list as ICD-10 maps become available.

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AUDIENCE QUESTION

How many hours of ICD-10 training does AHIMA estimate for coders performing inpatient coding?

1. 252. 403. 154. 50

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IMPACT OF ICD-10 ON BUSINESS FUNCTIONS (CONT.)

• Revenue Cycleo All aspects of revenue cycle will be impacted.

Documentation and coding, charge capture and other HIM functions will be significantly impacted. Other areas of significant impact are billing and reimbursement (payments and denials), and claims processing.

o Reporting including performance, operational, quantitative and qualitative measures.

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• Health Planso Significant impact on claims adjudication, benefits,

underwriting, actuarial and provider network functions.

• Registry Reportingo Significant impact on databases, multiple programs

which store, process and extract data that contains ICD codes and reports to CMS.

IMPACT OF ICD-10 ON BUSINESS FUNCTIONS (CONT.)

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• ITo Number of applications impacted may vary but

many will require a significant remediation or replacement effort to be compliant.

o Important to engage vendors to assess their readiness and transition plans and to identify any costs that may be incurred. Code upgrades may be included in support contracts; implementation costs may not.

IMPACT OF ICD-10 ON BUSINESS FUNCTIONS (CONT.)

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APPROACH: KEY QUESTIONS

• What are the risks and benefits?• What is the real scope of this effort?• How long will it take?• How should management oversight be organized?

Planning

• What business processes are affected – both internal and external?

• What are the policy/regulatory implications?• How many departments and people will be impacted?

Operational Impact

• What systems are impacted?• What does the conversion entail?• What other business/IT projects are competing or inter-

dependent?IT Impact

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APPROACH: KEY QUESTIONS (CONT.)

• What are the resource requirements to get this done?

• What tools are available?• Where can we go for specialized expertise?• How much will this cost?

Resourcing & Cost

Estimate

• How do we know when we are ready?• What are the critical success factors for

successful completion?• Is the organization ready?

Project Execution

If you haven’t started already… get started!

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AUDIENCE QUESTION

True or False:GEMs will map 1:1 ICD-9 codes to ICD-10 codes?

TrueFalse

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APPROACH: DETAILED EXECUTION PLAN AND SOLID PROJECT MANAGEMENT ARE KEY TO A SUCCESSFUL TRANSITION

• Business plan or Charter• Define a Project Manager and Steering

Committee to initiate governance processes and management oversight of the project

Planning• Identify and document impact on business

processes/procedures• Identify contracts to be modified• Forms!

Operational Impact

• Prepare hardware and software systems upgrade and testing timeline

• Outsourced systemsIT Impact

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• Source project team resources – internal and external

• Prepare training requirements and plan• Complete cost assessment and budget –

operational and capital

Resourcing & Cost

Estimate

• Prepare test plans and conduct testing• Plan conversion/migration and roll-out strategy• Complete system and data changes

Project Execution

APPROACH: DETAILED EXECUTION PLAN AND SOLID PROJECT MANAGEMENT ARE KEY TO A SUCCESSFUL TRANSITION

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KEY THOUGHTS

• Every organization is different.• If you do nothing else right now, you owe it to

your stakeholders to complete the impact assessment as soon as possible.

• Coder shortages and trainer shortages will be acute over the next three years.

• Educate everybody; train those that need training and certification.

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KEY THOUGHTS (CONT.)

• Don’t expect everyone to be ready; but do expect your trading partners to have a remediation plan.

• Many vendors think it is good enough to have their systems ready for 6 months before go live…

• This is not just for Medicare and Medicaid, it affects all claims for all HIPAA covered entities.

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REFERENCES

• Journal of AHIMA, AMIMA’s ICD-TEN newsletter, AHIMA’s CodeWrite newsletter, other resources available on AHIMA’s ICD-10 Web page (www.ahima.org/icd10)

• ICD-10 materials on the CMS Web site (https://www.cms.gov/ICD10)

• ICD-10 materials on the Centers for Disease Control and Prevention http://www.cdc.gov/nchs/icd/icd10cm.htm

• HIMSS: ICD10 Playbook http://www.himss.org/ASP/topics_icd10playbook.asp

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THANK YOU FOR ATTENDING!

Questions?

Peggi Ann Amstutz, MBA, CCS-P, CCSSenior Manger(253) 284-5299Peggi-Ann.Amstutz@mossadams.com