icd 10 cm and home health - wedi · pdf file1|icd‐10 comes early to home health...

1 |ICD‐10 Comes Early To Home Health

ICD‐10‐CM and Home Health

Tricia A. Twombly BSN RN HCS‐D HCS‐O COS‐C CHCE AHIMA Approved ICD‐10 CM Trainer

AHIMA Ambassador

Senior DirectorDecisionHealth

Chief Executive OfficerBoard of Medical Specialty Coding and Compliance


First Things First


Implementation Date: Oct. 1, 2015

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Enough already! Let’s just transition


Home Health Readiness Survey


Answer Key Response

It already is a priority 79.34%

Q2 2015 12.40%

Q3 2015 7.85%

Q4 2015 0.00%

It will not become a priority 0.41%

When do you plan on making ICD‐10 a priority again?


Answer Key Response

It didn’t; we continued with our plan 21.49%

We reset the timeline but kept the same preparations

53.51%

We revised our plan 19.74%

We came up with an entirely new preparation plan

5.26%

How did the delay affect your agency’s preparation for ICD‐10?


Answer Key Response

Yes, but I’m still preparing as if it won’t be 12.50%

Yes, and therefore I won’t prepare for it 0.86%

No 86.64%

Do you believe ICD‐10 will be delayed again?


Answer Key Response

Finding the money to pay for it 3.60%

Reduced coder productivity 40.99%

Reduced clinician productivity 3.15%

Vendors won’t be ready 3.15%

Payers won’t be ready 6.76%

Claim delays and denials 42.34%

What is your top worry about the ICD‐10 transition?


Answer Key Response

None 42.52%

None, but our EHR vendor has 40.65%

CMS I‐10 acknowledgment testing week 7.48%

CMS I‐10 end to end testing week 4.21%

None, but our clearinghouse has 7.94%

With other payers 4.67%

What testing opportunities has your agency participated in?


Answer Key Response

Yes, and its work is complete 0.88%

Yes, and its work is ongoing 57.96%

No, we don’t plan to designate a transition team

20.35%

Not yet; we plan to during Q2 2015 13.27%



Has your agency designated an ICD‐10 transition team?


Answer Key Response

Already performed 24.77%

We aren’t going to perform one 20.72%



Not yet; we plan to during q4 2015 2.70%

When will your agency perform a gap analysis?


Answer Key Response

Training is completed 3.30%

Training began prior to Q2 2015 and is ongoing

33.49%

We began Q2 2015 31.13%

We will begin Q3 2015 24.06%


We cannot afford to train the clinicians 6.13%

We are not planning on training coders, we don’t believe ICD‐10 is coming

0.47%

When will your agency start training clinicians?


Answer Key Response

Training is completed 10.48%

Training began prior to Q2 2015 and is ongoing

60.95%

We began Q2 2015 15.71%

We will begin Q3 2015 7.62 %


We will not train coders; we don’t have coders

3.33%

We cannot afford to train our clinicians 0.95%

We are not planning on training, we don’t believe ICD‐10 is coming

0.00%

When will your agency start training coders?


Step Completed In Process Not Started Unaware of need to perform

Identify resources

48.58% 38.21% 9.43% 3.77%

Create project team

48.36% 27.23% 20.19% 4.23%

Assess the effects

20.66% 49.30% 25.35% 4.69%

Create a project plan

31.92% 43.19% 20.19% 4.69%

Secure a budget

30.48% 46.67% 18.57% 4.29%

Inform staff 38.50% 52.11% 6.57% 2.82%

Contact vendors

38.39% 40.76% 15.64% 5.21%

What readiness steps have been completed?


Step Completed In Process Not Started Unaware of need to perform

Contact payers 21.53% 50.24% 21.05% 7.18%

Monitor vendor preparation

20.83% 55.46% 16.59% 7.58%

High level test team training

11.43% 55.71% 26.67% 6.19%

Test internally 6.67% 51.90% 36.67% 4.76%

Test externally 6.76% 44.93% 42.03% 6.28%

Train clinicians 6.19% 68.10% 22.86% 2.86%

Train coders 9.57% 70.81% 16.27% 3.35%

Educate referral sources

2.84% 62.09% 30.81% 4.27%

What readiness steps have been completed?


Step 1 – Identify Resources

Step 2 – Create Project Team/Inform Staff

Step 3 – Assess Impact on Your Agency

Step 4 – Secure Budget

Step 5 – Identify Challenges & Develop Project Plan

Step 6 – Contact Vendors, Payers & Monitor Prep

Step 7 – High Level Training for Test Team

Step 8 – Comprehensive Training

Step 9 – Final Preparation

Step 10 – Monitor, Measure and Manage

Transition Steps


Step 8 Comprehensive Training

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Training

• 5 areas of training were considered by CMS

• Methodology

• Clinical specialty

• Number of coders

• Number of hours for coder training

• Cost per hour of training


Training

• CMS and AHIMA recommend training time line to be no sooner than 9 months prior to implementation (October 1, 2015)

• If training occurs sooner, the agency would need to retrain

• Note: This time line is not referencing the agency ICD‐10 trainer(s)


Training• CMS implementation estimate: • Coders = 16 hours training• Gap knowledge deficit = 8 hours additional • Total = 24 hours training time • CMS estimate $644 per coder

• Note: This estimated time frame and cost is for full time coders only – not other agency personnel who need an overall understanding (i.e. senior management, accounting, quality improvement staff)


• Canada’s implementation experience:

• Coders = 50 hours training

• Gap knowledge deficit = 15 additional hours

• Total = 65 hours training time

• Note: Participating U.S. test hospitals had a 20% decrease in case mix: 90% of the decrease were coding errors, not the result of revised Grouper case mix

Training


Home Health Organization

• Who is responsible for the coding?‐ Field clinician ‐ Centralized coder(s)‐ clinical‐non clinical‐ 56% non clinical ‐ 44% clinical

‐ Outsource coding • Does the coder also review the OASIS?


ICD‐9 Productivity

• Coding responsibility ONLY:

‐ 25 assessments per day

• Coding and OASIS review:

‐ 15 assessments per day

• Internal quarterly audit results:

‐ 90% > accuracy rating


Comparison

• Coder productivity first 12 months:

‐ 70% longer to code claims

‐ 54% decrease in productivity

Note: Data suggests initial productivity loss is never fully recovered

• Coder productivity in the long term:

‐ 20% decrease in productivity

‐Maintain a 90% > accuracy rating

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Productivity Comparison

ICD‐9Current

ICD‐10 First 12 months

ICD‐10Long term

Coding: Coding: Coding:

25 assessments daily 11.5 assessments daily 20 assessments daily

Coding and OASIS Review: Coding and OASIS Review: Coding and OASIS Review:

15 assessments daily 6.9 assessments daily 12 assessments daily

Internal audit Review: Internal audit Review: Internal audit Review:

90% > accuracy rating 90% > accuracy rating 90% > accuracy rating


Step 9 Final Preparation

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• How long are claims sitting in accounts receivable before being submitted to the payer?

• What percentage of your potential claims revenue is being written off due to timely filing deadlines?

• How long is your billing department taking to submit Medicare RAPs and claims?

Revenue Cycle Weaknesses


Suggested Revenue Cycle Performance1

Benchmark Poor Average Best

Medicare days in AR 45 days or more 35 days 25 days or less

Total days in AR 60 days or more 50 days 40 days or less

Medicare AR older than 120 days

10% or more 7% 3% or less

Total AR older than 120 days

15% or more 10% 7% or less

Collections Less than 100% 100% More than 100%

Medicare write‐offs 2% or more 1% 0%

Total write‐offs 3% or more 2% 1% or less

Days to bill RAPs More than 10 days 7 to 10 days Less than 7 days

Days to bill claims More than 10 days 7 to 10 days Less than 7 days

1 M. Aaron Little, CPA, ICD‐10 Administrator’s Boot Camp (DecisionHealth)


CMS and other industry leaders are recommending that agencies have available enough credit/cash to keep operating for 6 months with no revenue coming in.

This suggestion anticipates a “big bang” Y2K scenario, which we hope will not happen, but as always—better safe than sorry.

Revenue Preparation


• Expand existing line of credit

• Contact a bank/lender who understands the specialized financing requirements of healthcare practitioners

• Contact your Small Business Administration (SBA) office

• Know that banks are unlikely to approve new lines of credit for managing cash flow

Revenue Preparation


PPS Reimbursement

Base rate HHRGx =Case‐mix Adjusted Rate

HOME HEALTH PROSPECTIVE PAYMENT SYSTEM

Labor and Non‐

labor

Adjustment+ NRS Payment

Patient Clinical Information (OASIS)

Geographic Factors

Payment


Prospective Payment System

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Prospective Payment System

• All Medicare providers are paid on a prospective payment system based on a case mix score

• Hospitals are paid via discharge diagnoses and procedures = DRG

• Home Health is paid via certain OASIS responses in 3 different areas = HHRG

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Definitions

• OASIS is a core set of data elements integrated into a comprehensive assessment

• PPS uses OASIS as a method of determining payment according to the acuity and seriousness of the patient’s condition

• The current version of OASIS is ‘C1 ICD‐9’

• OASIS‐C1 ICD 10 will be implemented concurrently with the implementation of the ICD‐10 classification system.

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Definitions

• The OASIS payment questions are divided into 3 categories:

‐ Clinical severity

‐ Functional status

‐ Service utilization

• Resulting in 153 different possible payment scoring groups


Definitions

• An episode is a 60 day unit of payment for the home health prospective payment system

• The start of episode is determined by the date the first reimbursable service was delivered

• The episode end date is the 60th day after the start of episode date

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60 Day Episode

• To ensure adequate cash flow a split percentage payment is utilized

• Initial episode = 60/40 % split

‐ 60% paid at beginning of episode

‐ 40% paid at end of episode

• Subsequent episodes = 50/50 % split

‐ 50% paid at beginning of episode

‐ 50% will be paid at end of episode


Definitions

• HHA’s bill a request for anticipated payment (RAP) at the beginning of the episode

• HHA’s bill the end of episode payment (EOE) no sooner than the 60th day of the episode

• HHA’s will have episodic billing cycles spanning the ICD‐10 implementation date


Now It Gets Really Confusing


Episodes Spanning October 1st

SOC/ROC/Recerts

• CMS’ MLN Matters article released Feb. 24, 2014

• M0090 (Date assessment completed) determines assignment of ICD‐9 or ICD‐10

• It’s important to note that the M0090 date is a different date than the start of episode date



SOC/ROC/Recerts

• If both the date of the RAP and the M0090 date are before Oct.1

• ICD‐9 codes should be used on the OASIS‐C1‐I9

• The HIPPS code will be generated with ICD‐9 codes, even though the final claim will contain ICD‐10 codes



SOC/ROC/Recerts

• If the RAP date is before Oct. 1, but the M0090 date is after Oct. 1


• ICD‐9 codes are reported on the RAP

• The HIPPS code will be generated with ICD‐10 payment

• The ICD‐9 codes reported on the RAP are only necessary for it to be processed



SOC/ROC/Recerts

• If the M0090 date is before Oct. 1 but the RAP date is after Oct. 1 (patient is re‐assessed before the first billable visit and within the 5‐day window)


• ICD‐10 codes are reported on the RAP

• Though both the RAP and the final claim will contain ICD‐10 codes, the payment‐generating HIPPS code will be based on the ICD‐9 codes reported on the OASIS.


Summary TableOASIS

assessmentType

RAP “From

Through” Dates

M0090DateOASIS Version

EOEClaim

ThroughDate

DiagnosisCoding Used on OASIS

Diagnosis Coding Used on RAP

Diagnosis Coding Used on Claim (EOE)

SOC/ROC 9/28/2015 9/30/2015OASIS‐C1‐I9

11/26/2015 ICD‐9‐CM ICD‐9‐CM ICD‐10‐CM

Recert 9/28/2015 9/25/2015OASIS‐C1‐I9


SOC/ROC 9/28/2015 10/2/2015OASIS‐C1‐

I10


Recert 10/2/2015 9/28/2015OASIS‐C1‐I9



The REAL Beginning

Dual coding begins!


PPS Reimbursement

• Home health must begin dual coding 100% of claims starting August 3, 2015

• Rap will be billed with ICD‐9 codes

• EOE will be billed with ICD‐10 codes

• Reimbursement could be with ICD‐9 or ICD‐10 codes depending on the date the assessment was completed


Impact

• Required software changes will affect coding processes

• Testing with vendor and intermediary before the ‘go live’ date is a must

• Dual coding will be required for a period of time

• Lower payment structure for unspecified codes may result

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Impact

• New code set will produce a temporary increase in coding errors resulting in rejected claims

• Medicare expects a spike in rejected claims 3 to 6 months following introduction of code set, peaking at 10% of all claims submitted

• Productivity will be directly affected because of the need to learn new codes and definitions

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Impact

• Coding clinic guidance will be retired so ‘unlearning’ rules will be as important as learning the new code set

• In 2016, CMS estimates a 9.77 million dollar loss in coder productivity (based on each assessment requiring an additional 1.7 minutes to complete)

• CMS expects the Home Health industry to have an overall transition cost from ICD‐9 to ICD‐10 of 16.58 million dollars

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Impact

• Increased delay in processing claims

• Increased claim rejections and denials

• Improper claims payment

• Coding backlog

• Compliance anomalies

• Decreased cash flow


Take Away Points

• Preparation is the key

• Communication is vital

• Establish a team to implement the transition

• Payment in part, will be linked to precise coding

• Accurate coding depends on thorough documentation

• Both are critical to your organizational success in an ICD‐10 environment

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What questions do you have?


Presenter Information

Tricia A. Twombly BSN RN HCS‐D HCS‐O COS‐C CHCE

AHIMA Approved ICD‐10‐CM Trainer

AHIMA Ambassador

Senior Director

Decision Health

Chief Executive Officer

Board of Medical Specialty Coding and Compliance

www.decisionhealth.com

[email protected]

icd 10 cm and home health - wedi · pdf file1|icd‐10 comes early to home health...

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